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2022 Fall Clinical Dermatology Conference Summary Day 1

A highly detailed look at the presentations and discussions from Day 1 of 2022 Fall Clinical.

Were you unable to make Fall Clinical this year? Or maybe you missed a session you really wanted to see? Don't worry, we have you covered. Here is a thorough look at Day 1 of 2022 Fall Clinical.

Working Together to Diagnose and Manage Patients with Generalized Pustular Psoriasis

VIDEO Highlight: Working Together to Diagnose and Manage Patients with Generalized Pustular Psoriasis - YouTube

Generalized pustular psoriasis (GPP) is a hot topic in the world of inflammatory skin diseases with the recent U.S. Food and Drug Administration (FDA) approval of spesolimab, an IL-36 receptor antagonist, for the treatment of acute GPP. In this session, Alice B. Gottlieb, M.D., Ph.D. and Boni E. Elewski, M.D. gave a thorough review of the diagnosis and management of GPP. Widespread sterile pustules are the hallmark of acute GPP, which can also occur with systemic symptoms such as fever, malaise, and joint pain. It is important to remember that GPP is diagnosed based on clinical and histologic findings, but certain blood tests should be done for management of complications. The pathogenesis of GPP differs from plaque psoriasis in that it is driven by the IL-36 pathway and can be associated with mutations in the IL-36RN gene.

Drs. Gottlieb and Elewski highlighted how GPP can significantly impact patient’s quality of life and there is often a delay in diagnosis due to unfamiliarity with the disease. Treatment options for GPP include topical medications routinely used for plaque psoriasis, as well as various oral and biologic medications. Cyclosporine is rapidly effective (in particular doses) and can be used as a bridge to long-term treatment. Biologic medications including TNF-alpha inhibitors, IL-17 inhibitors, and IL-23 inhibitors have been approved for GPP in Japan, but these approvals are based on small studies without proven efficacy in acute GPP flares. They concluded by introducing two new IL-36 receptor antagonists, spesolimab and imsidolimab. Spesolimab was recently approved by the FDA for treatment of acute GPP flares and demonstrated rapid clearance of pustules within 1 week in clinical trials, with 54.3% of spesolimab-treated patients achieving a GPPGA pustulation score of 0 at week 1, compared to 5.6% of those receiving placebo. Importantly, spesolimab has shown efficacy in patients that do not have an IL-36RN mutation. Phase 3 trials of imsidolimab are ongoing.  

Atopic Dermatitis – Getting the Inside Track on JAKs

VIDEO Highlight: Atopic Dermatitis Management—Getting the Inside Track on JAKs - YouTube

One of the biggest stories in dermatology this year has been the approval of three janus kinase (JAK) inhibitors for atopic dermatitis (AD), leaving clinicians wondering how these medications should fit into their practice. In this session, James Q. Del Rosso, DO and Lisa Swanson, M.D. discussed how to choose when to use these medications, for which patients, and how to minimize adverse events. Ruxolitinib 1.5% cream is a topical JAK inhibitor approved for short term treatment of moderate to severe AD in patients 12 and older. They shared that the ideal scenario for using ruxolitinib cream includes those with < 20% body surface area involvement, use in sensitive areas, and those who are steroid-averse or have failed other topicals.

Moving on from topical JAK inhibitors, Drs. Del Rosso and Swanson provided an excellent overview of abrocitinib and upadacitinib, the two JAK inhibitors approved for oral treatment of AD. Upadacitinib is also approved for psoriatic arthritis (PsA) and rheumatoid arthritis (RA), it is approved for use in adolescents for AD, and dosing starts at 15 mg/day. Abrocitinib is approved for patients 18 years and older, cannot be used with anti-platelet medications other than low-dose aspirin in the first 3 months, and females should be advised that it may impair fertility. Both medications should be avoided during pregnancy, breast feeding, and severe hepatic or renal impairment or in those with severe infections, history of venous thromboembolism, or malignancy.

Dr. Del Rosso and Dr. Swanson concluded this session with a few points on the practical use of these medications. Screening tests prior to use should include routine CBC, CMP, and lipid panel as well as viral hepatitis screening, tuberculosis screening, and possibly HIV screening if high risk. Follow up monitoring should include CBC and LFTs at months 1 and 3, then every 3 months and a lipid panel at 3 months. Despite the black-box warning on these medications, JAK inhibitors offer patients the ability for a rapid and high rate of clearance. Clinicians that attended this session left armed with the knowledge needed to have open discussions with patients about the risks and benefits and the confidence to monitor their use in practice.

Seminar-In-Depth: Topical Therapies for Acne Management: Evolving Skin One Patient at a Time

VIDEO Highlight: Topical Therapies for Acne Management: Evolving Skin One Patient at a Time - YouTube

Acne vulgaris is one of the most commonly encountered diseases in clinical practice for dermatologists. In this Seminar in Depth, James Q. Del Rosso, DO and Hilary Baldwin, M.D. reviewed topical therapies for acne, including how to select which topicals for which patient. The discussion began with a review of the four components of acne pathogenesis and the life cycle of individual acne lesions. Drs. Del Rosso and Baldwin reminded listeners that combination therapies are more effective, but also must not be so complicated that compliance is inhibited.  Microencapsulated benzoyl peroxide 3% / tretinoin 0.1% cream, a fixed dose combination product, targets multiple components of acne pathogenesis and was shown to reduce inflammatory and non-inflammatory acne lesions by 66.1% and 61.6% respectively in clinical trials. Local tolerability was excellent, with itching, burning, and stinging rated as less than mild throughout the entire study.

Clascoterone 1% cream, the first topical androgen receptor inhibitor approved for use in both men and women, gives clinicians the opportunity to inhibit sebum product and target the hormonal component of acne with a once-daily topical cream. Tazarotene 0.045% lotion has shown comparable efficacy to tazarotene 0.1% cream with more favorable tolerability. Post-hoc analyses have shown that tazarotene 0.045% lotion has efficacy in all skin types and leads to less oily skin after 12 weeks. Tazarotene 0.045% lotion has also shown impressive efficacy in treating truncal acne, with almost 90% of subjects achieving an IGA score of clear or almost clear at week 12. Drs. Del Rosso and Baldwin concluded this session by introducing an exciting new fixed-dose combination product currently in clinical trials: clindamycin 1.2% + benzoyl peroxide 3.1% + adapalene 0.15% gel (IDP-126). In a phase 2 study, IDP-126 gel showed superior efficacy in reducing inflammatory and non-inflammatory lesions than other fixed-dose combination products (CLIN/BPO, BPO/ADAP, CLIN/ADAP), and provides great promise for improving compliance. With these newly-approved and in-development molecules, it is an exciting time for clinicians and acne patients alike!

(Thursday AM POTD) Deucravacitinib Long-term Efficacy and Safety in Plaque Psoriasis: 2-Year Results From the Phase 3 POETYK PSO Program

Deucravacitinib, a novel TYK-2 inhibitor, is an oral tablet recently FDA approved for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. This poster presents the long-term efficacy and safety data from a two-year open-label extension study of deucravacitinib 6 mg once daily. In this study of 1221 patients, efficacy was maintained with 75.7% of patients achieving PASI 75 and 56.4% achieving clear or almost clear skin at week 48, compared to 65.1% and 50.9%, respectively, at study baseline. Adverse event rates were similar in the long term extension study as compared to the controlled period, and no new safety signals were identified.

Seminar-In-Depth: What You Need to Know About Personal Care Products

VIDEO Highlight: What You Need to Know About Personal Care Products - YouTube

Patients frequently ask dermatologists for recommendations regarding personal care products, and the rapidly-expanding personal care industry can leave clinicians wondering how to keep track of it all. In this session,   Dee Anna Glaser, M.D. and  Joshua Zeichner, M.D. discussed pertinent updates from the personal care industry. Focusing on hair care, Dr. Glaser began the session with a study demonstrating the importance of zinc pyrithione (ZPT) particle size and how it relates to anti-dandruff activity. Additionally, the use of non-anti-dandruff conditioners following zinc pyrithione shampoos has been shown to reduce the level of ZPT left on the scalp. Patients should be counseled to not use conditioner after ZPT shampoos or use a conditioner containing active anti-dandruff ingredients. Dr. Glaser concluded her portion of the talk with a look at the differences in pubic hair and leg hair as it pertains to shaving and provided tips on best shaving practices for reducing nicks, cuts, and ingrown hairs.

Dr. Zeichner continued the discussion with a look at fabric detergents. Laundry detergent can contain a variety of substances that induce allergic or irritant contact dermatitis, such as fragrances and dyes, and dermatologists should recommend that patients with sensitive skin use detergents free of these additives. There are two leading free detergents on the market, which vary significantly in their pH. Studies have shown minimal difference in mildness of clothes washed with both detergents, but there can be increased irritation when skin is exposed directly to the higher pH detergent during hand laundering. To close out this session, Dr. Zeichner briefly touched on one of the hottest topics in personal care products lately—anti-perspirants. Leading medical societies continue to refute any link between aluminum and negative health outcomes such as breast cancer or Alzheimer’s disease. In studies, over-the-counter clinical strength anti-perspirants containing 20% aluminum zirconium were shown to reduce sweat levels more than prescription aluminum chloride. Patients should be counseled to apply anti-perspirants at night in order to achieve the highest efficacy.

Seminar-In-Depth: Practicing Good Antibiotic Stewardship When Treating Acne

VIDEO Highlight: Practicing Good Antibiotic Stewardship When Treating Acne - YouTube

Antibiotic stewardship is critical to the fight against global antibiotic resistance. In this informative session,   Christopher G. Bunick, M.D., Ph.D. and Emmy Graber, M.D., MBA discuss the important role dermatologists can play in preventing the spread of antibacterial resistance. Oral antibiotics are often used in moderate-to-severe acne vulgaris for their ability to target cutibacterium acnes colonization and reduce inflammation, with the tetracycline class of antibiotics being most commonly prescribed. The use of older medications, including doxycycline and minocycline, can be limited by bacterial resistance and undesirable side effects such as photosensitivity, GI upset, and vestibular adverse effects. Drs. Bunick and Graber used real-world examples to introduce sarecycline, a new tetracycline antibiotic that is FDA approved for the treatment of acne vulgaris. Sarecycline has a narrow spectrum of activity against gram positive organisms to reduce the risk of resistance and minimize GI disturbance. It can be taken with or without food, does not cross the blood-brain barrier to reduce vestibular side effects, and has a very low incidence of photosensitivity. 

Compliance with a complex topical regimen can be a barrier to effective treatment in young adolescents with acne. Drs. Bunick and Graber highlighted IDP-126, a novel triple-combination of clindamycin 1.2%, benzoyl peroxide 3.1%, and adapalene 0.15% currently under investigation for moderate-to-severe acne. Efficacy with IDP-126 appears to be higher when compared to other combination products currently available. This session concluded with a few important take-home points: tetracycline antibiotics do not reduce the effectiveness of oral contraceptive pills (OCPs), and the efficacy of OCPs for acne appears to equal that of oral antibiotics after 6 months of use. Clinicians should consider using OCPs in women in order to reduce long term antibiotic treatment.

Seminar-In-Depth: What’s New in Skin Cleansers

VIDEO Highlight: What's New in Skin Cleansers - YouTube

Cleansers are a critical part of a healthy skin regimen but can also serve to disrupt the skin barrier and cause irritation if not chosen properly. In this session,  Hilary Baldwin, M.D. and Joshua Zeichner, M.D. discuss the latest innovations in skin cleansers and how to recommend the best cleansers for your patients. Dr. Baldwin kicked off the session with a review of the history and mechanism of action of skin cleansers. Most skin cleansers contain surfactants, amphiphilic molecules which break down and emulsify oil and dirt and allow them to be detached from the skin and rinsed off. These surfactant molecules can remain in the skin after rinsing, leading to disruption of the stratum corneum and increased inflammation. Dr. Baldwin emphasized the importance of cleansers having a pH close to that of physiologic skin. Consequences of an elevated pH include a decreased permeability barrier, increased inflammation, and a more physiologic microbiome. Dr. Baldwin concluded her portion of the talk with some tips on choosing the right cleanser for different patient skin types and ages.

Dr. Zeichner continued the surfactant discussion by introducing hydrophobically modified polymers (HMPs), which have been developed to modify surfactant architecture and behavior. Once surfactants form micelles around impurities, HMPs bind micelles into polymers allowing more stability and less surfactant to remain in the stratum corneum after rinsing. In clinical studies, HMP cleanser led to a 43% reduction in irritation, as measured by IL-1a levels, compared to placebo cleanser and was rated as very well-tolerated by patients. Additionally, use of HMP cleanser in those with atopic dermatitis, acne, and rosacea led to a statistically significant reduction in levels of burning, stinging, and itching at two and four weeks.

Thursday PM POTD: Secukinumab in Moderate to Severe Hidradenitis Suppurativa: Primary Endpoint Analysis From the SUNSHINE and SUNRISE Phase 3 Trials

Secukinumab is a fully human, monoclonal antibody which selectively inhibits interleukin-17A. This poster presents efficacy data for two double-blind, phase 3 randomized controlled trials of secukinumab 300 mg every 2 (SEC2W) or four weeks (SECQ4W) in patients with moderate-to-severe hidradenitis suppurativa. In both trials the SECQ2W dosing regimen achieved the primary endpoint at week 16, with 42.3-45.0% of patients in the SECQ2W group achieving hidradenitis suppurativa clinical response (HiSCR) compared to 31.2-33.7% of patients in the placebo group. The SECQ4W dosing regimen met the primary endpoint in one study only, with 46.1% of patients in the SECQ4W achieving HiSCR compared to 31.2% of those in the placebo group. Secukinumab was well tolerated with no new safety signals.

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