Dermatology Weekly

Consider poor adherence rather than recalcitrant disease in psoriasis patients who do not respond to topical treatment. Dr. Vincent DeLeo talks with Dr. Nwanneka Okwundu and Dr. Steven Feldman about strategies to promote better treatment adherence. They discuss factors that contribute to poor adherence and offer tips to motivate patients to stick to their treatment regimens. "There's a lot we can do to get people to use their medicine better. ... Our job is to get people well. And to do that, we have to make the right diagnosis, prescribe the right therapy, and do those things that need to be done to get patients to put the medicine on," explains Dr. Feldman.

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

1. Coronavirus outbreak prompts cancellation of AAD annual meetingThe American Academy of Dermatology annual meeting is the latest large medical conference to be canceled because of the coronavirus disease 2019 (COVID-19) outbreak.

2. Antifungal drug terbinafine appears safe for pregnancyTreatment with terbinafine during pregnancy does not appear to increase the risk of major malformations or spontaneous abortions.

3. Toys may be the culprit for children with contact allergiesA variety of toys such as video game controllers, tablets, dolls, bikes, and toy cars, can cause contact dermatitis in children because of the nature of their respective ingredients.

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Things you will learn in this episode:

• A recent study evaluated whether psoriasis patients who were resistant to topical corticosteroids responded under conditions designed to promote treatment adherence, which included telephone reminders, frequent study visits, and use of a spray vehicle vs. an ointment.
• Most participants improved in all measurement parameters, but the randomized group of patients who received telephone calls showed more improvement in disease severity than those who did not receive telephone calls. "This idea that topical therapy doesn't work, I think, is based on a misconception. It's based on our observations that it doesn't work, but we're not seeing how poorly compliant patients are. If we take people who fail topical therapy and do things to really get them to use their topical medication well, their skin disease clears up," Dr. Feldman explains.
• In addition to making the diagnosis and prescribing treatment, dermatologists play an important role in getting psoriasis patients to use their medications: "If you tell people, 'Here, put this topical therapy on. It's messy, I'll see you in 3 months,' you'll be like a piano teacher saying, 'Here's a really complicated piece of music, practice it every day, I'll see you at the recital in 3 months.' It's just not going to sound like a very good recital," Dr. Feldman notes.
• Practical alternatives to frequent office visits that dermatologists can use to answer patient questions and promote treatment adherence include virtual visits (teledermatology) and electronic interactions (telephone calls, email correspondence).
• It is important to prescribe therapies that are consistent with a patient's preferred vehicle. "If the patient prefers a spray, give them a spray. If they want an ointment, give them an ointment. They are more likely to use it that way," Dr. Okwundu recommends.
• When starting patients on a new treatment, hold them accountable by having them check in with you to let you know how they are doing. "Maybe we don't need to see people every 3 days, but we need to make sure patients realize we care about them, because they don't want to let us down if we have the kind of strong human relationship with them and then we have to hold them accountable," Dr. Feldman advises.

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Hosts: Nick Andrews; Vincent A. DeLeo, MD (University of Southern California, Los Angeles)

Guests: Nwanneka Okwundu, DO; Steven R. Feldman, MD, PhD (both are with Wake Forest University, Winston-Salem, N.C.).

Show notes by: Alicia Sonners, Melissa Sears, Elizabeth Mechcatie

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Hyperbaric oxygen therapy (HOT) is an effective second-line treatment option anytime there is a chronic complicated wound or tissue with vascular compromise. Dr. Josephine Nguyen, president of the Association of Military Dermatologists, talks with Dr. Emily Wong and Dr. Jonathan Jeter about how dermatologists can use HOT. "The most common scenario ... would be a situation where you have a compromised flap or graft after a surgery," says Dr. Jeter "[The site is] not getting enough blood flow that's threatening it to necrose ... hyperbaric oxygen therapy can come in [and] can increase the oxygen delivery to those sites," says Dr. Jeter. They discuss the mechanism of action for HOT, tips for treatment, and potential complications.

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

1. What medical conferences are being canceled by coronavirus? Despite COVID-19, most U.S. medical conferences are moving forward as planned.

2. Nemolizumab tames itching in prurigo nodularis patients in phase 2 study Adults with moderate to severe prurigo nodularis who were treated with the investigational drug nemolizumab showed significant improvement in itching, compared with patients who received placebo.

3. Esophageal stricture signals urgent treatment in kids with butterfly skin A quarter of urgent contacts in 20 children with generalized severe recessive dystrophic epidermolysis bullosa were tied to esophageal narrowing.

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Things you will learn in this episode:

• Hyperbaric oxygen therapy is best known for treating decompression sickness (e.g., "the bends" in scuba divers or aircrew members) and carbon monoxide poisoning. "[HOT] occurs in a specialized chamber that gradually becomes pressurized in order to increase the ambient pressure," Dr. Wong explains. "Then the pressure can return to atmospheric pressure in a controlled, slow manner."
• In addition to persistent wounds and compromised grafts and flaps, other dermatologic applications for HOT include radiation-induced ulceration, vasculitis/vasculopathy, and autoimmune reactions.
• Patients may inquire about HOT for anti-inflammatory conditions such as psoriasis, but there currently is no evidence to support its effectiveness. Only published dermatologic indications for HOT are recommended until more research is conducted.
• According to the Undersea & Hyperbaric Medical Society, there currently are nearly 200 accredited HOT locations in the United States. Hyperbaric oxygen therapy is most likely to be available within large medical centers and is less common in rural areas.
• In cases in which tissue is threatened, it is important to refer patients for HOT sooner rather than later. "The longer it goes since the initial injury or loss of blood flow, the less likely [HOT is] going to be effective," notes Dr. Jeter.
• Dermatologists typically need to refer patients to large academic medical centers with wound care centers to receive HOT.
• Potential complications of HOT include fire, middle ear barotrauma, and reversible myopathy. More severe but rare complications include central nervous system symptoms, seizures, and pulmonary toxicity.
• The only absolute contraindication for HOT is an untreated pneumothorax.
• Treatment sessions can last anywhere from a few minutes up to several hours. "The longer [the sessions] get, the more likely you are to have complications, but generally around an hour to an hour and a half is a pretty reasonable time period," Dr. Jeter recommends.
• In a hyperbaric oxygen chamber, the patient sits or lays down and breathes in pressurized 100% oxygen through a mask or a tight-fitting hood, and the affected skin stays covered with a bandage or the patient's clothing. "Ultimately, it is the increased level of systemic oxygen that promotes wound healing and graft or flap survival. The systemic oxygen improves the fibroblast function, blood flow, vascularity, and mitigates the ischemia-reperfusion injury," explains Dr. Wong.

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Hosts: Nick Andrews; Josephine Nguyen, MD

Guests: Emily B. Wong, MD; Jonathan P. Jeter, MD (San Antonio Uniformed Services Health Education Consortium, Joint Base San Antonio–Lackland, Tex.)

Show notes by: Alicia Sonners, Melissa Sears, Elizabeth Mechcatie

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Low-dose naltrexone can suppress inflammatory markers, making it a potential therapy for some inflammatory skin conditions with a pruritic component. In this resident takeover, Dr. Daniel Mazori talks to Dr. Nadine Shabeeb about the benefits of off-label low-dose naltrexone (LDN) for the treatment of inflammatory skin conditions. "These anti-inflammatory effects aren't seen at the higher doses of naltrexone; they're only seen at the lower dose," Dr. Shabeeb notes. She provides a practical perspective on prescribing LDN in the dermatology setting and discusses how to counsel patients about potential side effects, including concerns about its abuse potential.

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

1. Advising patients on morning and evening skin protectionMDedge Dermatology Editor Elizabeth Mechcatie speaks with Dr. Brooke C. Sikora about what clinicians can recommend for their patients for skin protection, both in the morning and in the evening.

2. Patient counseling about expectations with noninvasive skin tightening is key Dr. Nazanin Saedi advised that it is important to counsel patients about the degree of improvement to expect with noninvasive skin-tightening procedures.

3. Banning indoor tanning devices could save lives and money Banning indoor tanning devices outright in the United States, Canada, and Europe could prevent as many as 448,000 melanomas and save billions of dollars.

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Things you will learn in this episode:

• Naltrexone is approved by the U.S. Food and Drug Administration to treat alcohol and opioid addiction. At its approved dose of 50-100 mg/day, naltrexone blocks opioid effects for 24 hours. In dermatology, naltrexone is used off-label at lower doses of 1.5-4.5 mg/day. "At this dose, naltrexone only binds partially to the opioid receptors, so this ends up leading to a temporary opioid blockade and ultimately increases endogenous endorphins."
• Dermatologic conditions that may benefit from LDN include Hailey-Hailey disease, lichen planopilaris, psoriasis, and pruritus.
• Low-dose naltrexone has a favorable side-effect profile. Known adverse effects include sleep disturbances with vivid dreams and gastrointestinal tract upset.
• Low-dose naltrexone can alter thyroid hormone levels, especially in patients with a history of thyroid disease. "If they haven't had a normal TSH [thyroid-stimulating hormone test] in the past year, then you can consider checking one at baseline and then check every 3 or 4 months for patients who do have a history of thyroid disease while they're on treatment," Dr. Shabeeb advises. "I'd also recommend counseling patients about symptoms related to hyper- and hypothyroidism so that they're aware of symptoms to look out for."
• There is no known abuse potential for LDN, but it is important to ask patients if they are using any opiates or opioid blockers before prescribing it. "If [LDN is] taken with an opiate, it can cause withdrawal symptoms and also decrease the effectiveness of the opiate, and if it's taken with other opioid blockers, there's also a higher risk for opioid withdrawal," Dr. Shabeeb explains.
• Patients should be counseled that the cost of LDN will not be covered by insurance because it has no FDA-approved dermatologic indications.
• There is a lot of potential for LDN in the treatment of inflammatory skin diseases, but current research is limited to case report and case series; therefore, more data is needed.

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Hosts: Nick Andrews; Daniel R. Mazori, MD (State University of New York, Brooklyn)

Guests: Nadine Shabeeb, MD, MPH (University of Wisconsin Hospital and Clinics, Madison); Brooke C. Sikora, MD, is in private practice in Chestnut Hill, Pa.; Nazanin Saedi, MD (Jefferson University Hospitals, Philadelphia

Show notes by: Alicia Sonners, Melissa Sears, Elizabeth Mechcatie

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

Email the show: [email protected]

Interact with us on Twitter: @MDedgeDerm

Phototherapy is a viable option for many patients with psoriasis. Dr. George Han speaks with Dr. Jashin Wu about the recent national guidelines from the American Academy of Dermatology and the National Psoriasis Foundation on phototherapy, particularly narrowband UVB. They discuss treatment advantages, potential side effects, combination regimens, and patient reimbursement for at-home phototherapy. "Phototherapy serves as a reasonable and effective treatment option for [psoriasis] patients requiring more than topical treatments but also wishing to avoid systemic medications or if they are simply seeking an adjuvant to a failing regimen," advises Dr. Wu.

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

1. How the mutant selection window could reshape antibiotic use

Dr. Hilary Baldwin describes a concept in the infectious disease literature that could help dermatologists strike a careful balance between treatment and resistance.

2. What oral therapies work best for hyperhidrosis

Dr. Jashin Wu examines the nondevice options for treating patients with the condition.

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Things you will learn in this episode:

• Narrowband UVB is the primary type of phototherapy used in dermatology. It acts by three major pathways: alteration of the cytokine profile, apoptosis (programmed cell death), and UV-induced immunosuppression of epidermal Langerhans cells.
• Phototherapy offers advantages for a wide range of patients. "If a patient has failed topical treatment but they may not be interested in systemic therapy -- they don't want a biologic or they don't want an oral therapy --phototherapy still is a good option for these patients. In particular, I like it for patients with moderate disease ... between 3% and 10% body surface area," Dr. Wu explains.
• Phototherapy also is a good option for pregnant women who may be concerned about potential fetal side effects associated with most systemic agents.
• Acitretin (Soriatane) is one of the most common agents used in combination with phototherapy: "In theory, phototherapy could increase the risk of skin cancer, especially if [the patient has] several hundreds of episodes of phototherapy," Dr. Wu notes. "Acitretin in theory may improve the risk of skin cancer, so actually this has a protective effect and also may reduce the number and length of phototherapy [treatment sessions] that [are] needed."
• It is recommended that patients undergoing phototherapy use genital shielding to reduce the risk of skin cancers in the genital area and wear goggles to reduce the risk of cataracts.
• Skin cancer risk in patients treated with both narrowband and broadband UVB has been correlated with the number of treatments received, but the risk has not shown to be significantly greater than in the general population. "If [the patient has] had a prior history of skin cancers, I probably wouldn't be choosing phototherapy as one of my first-line agents," Dr. Wu says.
• Home phototherapy is a good option for patients who are not able to come to the office for treatment two or three times per week. "Sometimes the insurance carriers would actually prefer this," Dr. Wu explains.
• Some patients may request to stop treatment temporarily during warmer months when they are more likely to get exposure to natural sunlight. When resuming phototherapy, these patients will need to repeat the induction phase before returning to a maintenance regimen.

Hosts: Nick Andrews; George Han, MD, PhD (Icahn School of Medicine at Mount Sinai, New York, New York)

Guests: Hilary E. Baldwin, MD (State University of New York, Brooklyn); Jashin J. Wu, MD (Dermatology Research and Education Foundation, Irvine, California)

Show notes by: Alicia Sonners, Melissa Sears, 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

At the 2020 ODAC Dermatology, Aesthetic & Surgical Conference in Orlando, Angelo Landriscina, MD, revealed how dermatologists can help their LGBTQ+ patients. Dr. Landriscina, and MDedge reporter Jeff Craven join producer Nick Andrews to discuss how dermatologists are uniquely suited to treat sexual- and gender-minority patients.

As patients are becoming more involved in their own care, physicians must stay up to date on trends such as the ketogenic (keto) diet to encourage better health and steer patients away from dangerous online advice. Dr. Vincent DeLeo spoke with Dr. Daren Fomin about benefits of the ketogenic diet for dermatologic conditions such as acne, diabetic skin diseases, and cutaneous malignancies. Dr. Fomin also provided tips for safely and effectively implementing this diet. "Coming alongside [patients] as more than just a diagnoser and treater of disease but [as a] promoter of health, I think that's very valuable, and honestly I think that's where medicine is moving," Dr. Fomin said.

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Things you will learn in this episode:

• Ketosis is the state of producing ketones, which is necessary to maintain proper organ function in the absence of sufficient dietary carbohydrates.
• Ketosis can be achieved through fasting; prolonged aerobic activity; certain physiologic states (e.g., pregnancy or the neonatal period); and processes such as the ketogenic diet, which tricks the body into a low glucose state that results in metabolic and cellular benefits without famine or fasting.
• Some dermatologic conditions might theoretically respond to a ketogenic diet. "From our reading of the literature, we think potential candidates would be acne, hidradenitis suppurativa, autoinflammatory syndromes, definitely diabetic skin diseases, melanoma, and perhaps other skin cancers, psoriasis, morphea, and ... obesity-related skin disease," Dr. Fomin explained.
• Ketogenesis may provide a multiangle approach to acne treatment. Beta-hydroxybutyrate, the main ketone produced during ketogenesis, can potentially decrease or inhibit the inflammatory response in acne vulgaris. Ketogenesis also helps prevent the hyperproliferation of keratinocytes seen in acne and optimizes androgens to reduce sebum production.
• Low-carbohydrate regimens such as the ketogenic diet have been associated with risk reduction of such diabetic skin diseases as diabetic peripheral neuropathy, ulcers, acanthosis nigricans, microangiopathy, and cutaneous infections: "This is due to several known mechanisms," Dr. Fomin noted. "Less glucose entering the body and less fat deposition as a product of that, less end-product glycation, less free radical production, enhanced fat loss and metabolic efficiency, increased insulin sensitivity, and then decreased inflammation, as well."
• Because cancer cells from melanoma and other malignancies survive only in the presence of glycogen, there is serious potential that cancer could be "starved out" by feeding normal tissues with ketones. "Honestly, it's my hope and kind of my optimistic thought that in 10-20 years, maybe we'll see an increase in the number of patients being put on some sort of either endogenous or exogenous ketone therapy as an adjunct to their cancer treatments," Dr. Fomin said. "I'd be curious to see if we can start adding this on to adjunctive melanoma therapy and see if there's an improved outcome in our patients."
• The ketogenic diet generally is well tolerated, but potential transient adverse effects include dehydration, acidosis, lethargy, hypoglycemia, dyslipidemia, prurigo pigmentosa, and gastrointestinal distress. Chronic side effects include nephrolithiasis and unintended weight loss.
• The ketogenic diet approach to managing skin disease takes a lot of self-motivation and work from patients. It is important to make sure patients know to expect a few days to weeks of potentially noticeable physiologic effects (e.g., hyperglycemia, lethargy) before they become adapted to the diet.
• When working with patients to initiate the ketogenic diet, dermatologists are encouraged to involve educated nutritionists if they have access to them.

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

Guests: Angelo Landriscina, MD (George Washington University, Washington); Daren A. Fomin, DO (Walter Reed National Military Medical Center, Bethesda, Md.).

Show notes by: Alicia Sonners, Melissa Sears, Elizabeth Mechcatie

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

Email the show: [email protected] Interact with us on Twitter: @MDedgeDerm

Dermatologists had concerns about the maintenance of certification (MOC) program and the American Board of Dermatology (ABD) listened. Dr. Vincent DeLeo speaks with Dr. Erik Stratman about how CertLink, the ABD's new web-based assessment platform, makes continuing certification activities more accessible and more meaningful to clinical practice. Dr. Stratman notes, "We [ABD] recognized that the program [MOC] had faults. In 2015, after our first 10 years of experiences, we decided to take a hard look at the program. . . . The American Board of Dermatology decided to take on some of the education on its own shoulders and create activities that could be made more affordable, more meaningful, less time, and that's where ideas such as CertLink . . . came to be."

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We bring you the latest in dermatology news and research:

1. Social media may negatively influence acne treatment Patients follow advice found on social media that doesn't match up with AAD guidelines.
2. High cost of wound dressings for epidermolysis bullosa highlightedDressing and bandage costs were highest for study participants with the generalized severe subtype, at about $112,450 per patient annually.
3. New Barbie lineup includes a doll with vitiligoThe doll debuts much to the delight of clinicians who treat children and adolescents with the condition.

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Things you will learn in this episode:

• CertLink is a web-based longitudinal assessment platform designed as an alternative to the high-stakes sit-down examination.
• Rather than generating questions on random medical knowledge, CertLink allows dermatologists to tailor the test to highlight specific subspecialties that are more relevant to their individual areas of clinical practice. "It allows the diplomate to tailor the assessment to be more relevant to what they do in practice every day," advises Dr. Stratman. "And that's one of the ways that we've tried to tackle the question of relevance so that [diplomates are] maximizing the kinds of questions that reflect their practice."
• Once ABD diplomates start the CertLink program, they are issued a set of 13 questions every quarter for the rest of their active board-certified lives. The questions can be accessed all at once or one at a time, depending on how the dermatologist wants to take the assessment.
• Questions come in 3 varieties: core questions (general dermatology); concentration, vignette-based questions (subspecialties); and article-based questions (eg, new guidelines, therapies, side effects).
• Because the new assessment program is designed to be taken continuously throughout one's career, all diplomates are permitted to take 1 quarter off each year as a break from the testing.
• Larger-scale participation in the CertLink program over time will be necessary to develop accurate measures of performance for the new test. "We want to get as many diplomates as possible on board with this testing platform so that they can gain experience, and we recognize that within these early years there's going to be a nonuniform uptake of joining on to CertLink, so there's basically a 2-year onboarding window that we anticipate," Dr. Stratman notes.
• CertLink includes a learn-to-competence element that allows diplomates to learn from wrong answers without penalty. "When you first see a question in a particular quarter and you answer that question and you happen to get it wrong . . . you will get an explanation of why was that right answer right and why were each of the wrong answers wrong, so there's a little opportunity for learning," Dr. Stratman explains. The diplomate then will receive a very similar question in the following quarter, and only then will the response count toward the assessment grade.
• The CertLink platform launched on January 6, 2020, to a cohort of more than 4500 board-certified dermatologists. In the first week, more than 800 dermatologists answered test questions with a correct response rate of more than 97%.
• The next sign-on period for CertLink is in May 2020. "When you see an inbox email from the [ABD], it's worth opening and reading. We don't try and sell you products, we aren't spamming you. If there's something from the [ABD], it's worth the read," Dr. Stratman advises.

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

Guests: Erik J. Stratman, MD (Marshfield Clinic Health System, Wisconsin)

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Show notes by: Alicia Sonners, Melissa Sears, 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 resident takeover, three dermatology residents -- Dr. Daniel Mazori, Dr. Elisabeth Tracey, and Dr. Julie Croley—recap some of the dermatology issues and controversies that made headlines in 2019. They provide an overview of noteworthy topics such as chemical sunscreen safety, measles and vaccinations, drug approvals, and recalls of popular over-the-counter products and discuss how they have addressed these issues with their patients.

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We bring you the latest in dermatology news and research:

1. European marketing of Picato suspended while skin cancer risk reviewed The Food and Drug Administration is gathering information to investigate the safety concern raised in Europe.

2. Frequent lab testing is common, but low-yield, for isotretinoin patients Low rates of abnormalities can inform clinicians looking for an optimal testing strategy.

3. Celebrating 50 years of Dermatology News

   Click the above headline to read our debut issue from January 1970!

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   Things you will learn in this episode:

   • Laws restricting the sale of chemical sunscreens containing organic UV filters such as oxybenzone were passed in Key West, Fla., as well the U.S. Virgin Islands.
   • The Food and Drug Administration asked sunscreen manufacturers to perform additional studies on safety parameters, such as systemic absorption for 12 organic UV filters, to determine if they can continue to be listed as generally recognized as safe and effective. "The FDA is not currently discouraging sunscreen use and is not saying that these 12 organic UV filters that were studied are unsafe, so for now, both physical sunscreens and chemical sunscreens with those organic filters are considered acceptable," advises Dr. Tracey.
   • The measles outbreak in New York City, which was fueled by undervaccinated communities, ended in 2019 after becoming the city's largest measles outbreak in nearly 30 years. "[Questions about vaccination] probably doesn't come up in our clinic as much as a primary care provider's office but it is relevant to many dermatologic conditions and so I think it is our duty when approached with this issue to be advocates for what we know has scientific data to back it up," states Dr. Croley.
   • Dupilumab was FDA approved for adolescent atopic dermatitis, making it the third biologic with a pediatric dermatology indication.
   • Trifarotene cream and minocycline foam were approved for treatment of acne in patients 9 years and older.
   • Apremilast became the first FDA-approved medication for oral ulcers from Behçet disease.
   • Afamelanotide became the first FDA-approved medication for erythropoietic protoporphyria.
   • One lot of Johnson's Baby Powder was recalled because of possible asbestos contamination, but no asbestos was found when the bottles of interest were retested.
   • The Neutrogena Light Therapy Acne Mask was recalled because of rare reports of visual side effects from insufficient eye protection as well as risk for potentially irreversible eye injury in patients taking photosensitizing medications or with certain underlying eye conditions.

   Hosts: Elizabeth Mechcatie, Terry Rudd

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

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   Show notes by: Alicia Sonners, Melissa Sears, 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

This week, Nick Andrews talks with reporter Kari Oakes, whose feature for our January print issue highlighted the dermatologists working in Africa and here in the United States to promote inclusivity and provide care for people with albinism. The condition is much more common in parts of East Africa, where people with albinism are stigmatized and even hunted and maimed for body parts. The segment features David Colbert, MD, a Manhattan dermatologist whose foundation has partnered with the United Nations for an awareness-raising campaign. He also talks about the nuts and bolts of how even busy dermatologists can get involved in philanthropic and nonprofit work.

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Hair loss from central centrifugal cicatricial alopecia (CCCA) often is attributed to hairstyling practices used by black women, but the scarring process actually is similar to other scarring conditions. Dr. Vincent A. DeLeo talks with Dr. Crystal Aguh about the pathogenesis of CCCA and its systemic implications. "Before you can even start to ask what causes [CCCA], you have to believe that there is a biological basis of disease, and so when you put the onus on the patient and the blame on the patient, then in reality you're saying, 'Well if you didn't do this, this would not occur,' and we're really not seeing that in our patients," explains Dr. Aguh.

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Things you will learn in this episode:

• When CCCA was first described in the 1960s, it was initially called hot-comb alopecia. When hairstyling practices changed but CCCA persisted, it later became known as chemically induced alopecia. Later, it was associated with weaves and extensions.
• Research has shown there is a considerable overlap in gene expression patterns in CCCA and other scarring disorders such as uterine fibroids, hepatic fibrosis, and idiopathic pulmonary fibrosis. "This scarring process is very similar to other diseases of systemic scarring, and that really starts to shed light into the presentation of this disease," explains Dr. Aguh. In one study, black women with CCCA were 5-times more likely to have uterine fibroids than black women who did not have CCCA, which speaks to a systemic process.
• The gene implicated in uncombable hair syndrome, PADI3, has been found to be upregulated in patients with CCCA, suggesting that disorders of hair shaft formation may subsequently lead to the abnormal scarring seen in CCCA patients.
• The inheritance pattern of CCCA still is unknown but is an avenue for future research.
• The systemic implications of CCCA, such as the link to uterine fibroids, show that it is more than an aesthetic disease: "The skin and the hair are really kind of window into what's going on systemically, and [CCCA] is really important not just because the patient feels like they don't look the way they want to but because it can adversely affect their health," notes Dr. Aguh.
• Unlike other scarring alopecias, you cannot reliably use erythema or inflammation as a measure of activity in CCCA, as many patients have no clinical evidence of disease. As a result, topical treatment options such as intralesional steroid injections often are continued for years because it is difficult to tell if they are working.

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Hosts: Nick Andrews; Vincent A. DeLeo, MD (Keck School of Medicine of the University of Southern California, Los Angeles)

Guests: Crystal Aguh, MD (John Hopkins University, Baltimore)

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Show notes by: Alicia Sonners, Melissa Sears, 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

Leukemia cutis should be high on the differential in patients presenting with leukemia. Dr. Vincent DeLeo talks with Dr. Lindsay Strowd and Wasim Haidari about their research on the presentation of leukemia cutis and clinical implications. "For us as dermatologists, to recognize that you may not know that the patient has leukemia at the time that you're actually evaluating them I think points to the need to biopsy any spots that look unusual or a little bit different in nature," notes Dr. Strowd.

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We bring you the latest in dermatology news and research:

1. Oral lichen planus prevalence estimates go global
2. Dr. Daniel Siegel discusses the translational science behind natural ingredients

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Things you will learn in this episode:

• Leukemia cutis tends to present in patients with acute myeloid leukemia (AML) but also can present in other forms of the disease.
• Clinically, leukemia cutis is thought to present most commonly as solitary nodules, but recent research revealed that the primary presentation may include multiple papules or other unusual presentations such as mucosal and ulcerative lesions.
• Thorough and comprehensive full skin examinations are important in patients with leukemia: "Biopsy for leukemia cutis certainly is most times diagnostic for the disease, but I think paying attention to the entire skin surface of a patient with leukemia is also vitally important because [lesions] are not always going to present on the trunk or the arms or legs where they're easily identifiable. Some of our patients have lesions on the scalp, the mucosal surfaces like the oral mucosa, and in the genital region as well," says Dr. Strowd.
• Leukemia cutis can present at various stages during the course of leukemia, and time to diagnosis varies depending on subtype. For AML, study results indicated that the average interval between diagnosis of leukemia and leukemia cutis was about 5 months; however, many patients developed cutaneous findings at the onset of leukemia or with relapse.
• Leukemia cutis is considered a negative prognostic factor and may be associated with a shorter overall mortality in leukemia patients.
• It is important for dermatologists to have a good close working relationship with their oncology colleagues to facilitate prompt evaluation of leukemia patients who may present to their oncologist or another specialist with cutaneous findings.

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

Guests: Lindsay Strowd, MD, and Wasim Haidari, BS, BA (Wake Forest School of Medicine, Winston-Salem, North Carolina)

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Show notes by: Alicia Sonners, Melissa Sears, 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

Costs associated with dermatology residency applications average $10,000 per applicant. Dr. Daniel Mazori talks to Dr. Aamir Hussain about ways to reduce costs for applicants, particularly during the interview process when frequent long-distance travel may be required. "Right now we're in this lose-lose situation where applicants feel like they need to apply to every single program to maximize their chances and program directors are overwhelmed by hundreds of applications for one or two spots," advises Dr. Hussain.

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We bring you the latest in dermatology news and research:

1. Dupilumab-induced head and neck erythema described in atopic dermatitis patients It's a common side effect that's underreported in clinical practice and clinical trials.
2. Calif. woman poisoned by methylmercury-containing skin cream The patient has undergone extensive chelation therapy, but she remains unable to verbalize or care for herself.

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Things you will learn in this episode:

• Many dermatology applicants apply to residency programs they are not genuinely interested in to maximize their chances of matching in a very competitive specialty.
• Program directors who are overwhelmed by hundreds of applications for one or two may use arbitrary metrics to weed out candidates because there currently is no way to evaluate who has a genuine interest in the program.
• A cap on the number of applications permitted per applicant would reduce application fees and help students focus on programs that are the best fit for them. According to Dr. Hussain, 50-60 applications generally is a reasonable number: "After that point, there seem to be diminishing returns in the number of interviews you're getting for every application you send out in addition to that."
• Dermatology applicants often choose to write separate personal statements or contact their programs of choice directly. An option to flag applications for the programs a candidate is most interested in may be an effective way to formalize this process.
• Regional interview coordination among all the dermatology programs in certain cities or areas of the country would allow applicants to interview with multiple programs at the same time and save on travel costs, in addition to providing neutral ground for home applicants; however, that would require coordination and buy-in from every dermatology program in the region.
• Video conferencing could reduce travel costs during the interview process but would need to be standardized for every applicant, as candidates who participate in video interviews are consistently rated lower than those who have in-person interviews.

Hosts: Elizabeth Mechcatie, Terry Rudd

Guests: Daniel R. Mazori, MD (State University of New York, Brooklyn); Aamir Naveed Hussain, MD, MAPP (Northwell Health, Manhasset, N.Y.)

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Show notes by: Alicia Sonners, Melissa Sears, 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