A DERMATOLOGY FOUNDATION PUBLICATION
®
SPONSORED BY MEDICIS, THE DERMATOLOGY COMPANY
VOL. 26 NO. 1
SPRING 2007
DERMATOLOGY
FOCUS
™
Also In This Issue
DF
2006 Year in Review—
Strong Giving
DF Clinical Symposia:
Proceedings 2007–Part I
ADVANCES IN DERMATOLOGY
The Dermatology Foundation, the premiere notfor-profit organization funding the full spectrum of
dermatology’s research and teaching base, held its
annual 3-day cutting-edge symposia series addressing
the needs of the clinical community in March. This
program presented the most clinically relevant knowledge and guidance for making the newest advances—
and supportive research—accessible and usable.
A daily keynote talk preceded topic-focused, peerreviewed caliber presentations. This year’s topics were:
Inflammation; Diagnostic Challenges in Pediatric
Dermatology; UV Light: Protection and Uses; Special
Sites and Patients; Hot Topics; Future Paths and Proteins;
and Esthetics and Surgery—How To. The Proceedings
appear in the Spring (Part I) and Summer (Part II) issues.
Anita C. Gilliam, MD, PhD, and
Michael D. Tharp, MD—Program Co-Chairs
WERNER K. STIEFEL LECTURESHIP
Drug Reactions
Neil H. Shear, MD
Drug-induced rashes “are really drug-induced skin disease”
and thus require the dermatologist’s highly organized stepwise
approach to diagnosis to ensure accuracy. The challenge is
heightened because drug-induced cutaneous diseases are idiosyncratic—and thus unpredictable—and the nomenclature lacks
clarity and consensus. Shear explained his 4 Ds and Diagnostic
Triangle, then applied them to discussing both milder and severe
forms of exanthematous eruptions—probably the most common
drug reaction there is.
69 High-Impact
Research Awards Granted
Challenge for the Future:
$10 Million
The 4 Ds outline the assessment elements: Diagnosis of
adverse event, Differential diagnosis, Drug exposure (interval
between drug start and appearance of rash), Determine candidate
drug probabilities. The Diagnostic Triangle applies when diagnosis
is not clearly evident. Shear’s mnemonic for this triad is R.A.S.H.:
Remember—Appearance, Systemic aspects, Histology. His caveat:
never accept another’s description—always see the patient yourself.
Simple Exanthem. Shear compared two patients, one with
a simple gemifloxicin-induced exanthem, the other with carbamazapine-induced DHS (drug hypersensitivity syndrome). Because
the latter involves fever—indicating systemic illness—it is more
severe disease. Simple exanthems are less aggressive because they
occur via the MHC class II pathway, and the drug does not bind
to receptors that will perpetuate the immune response.
DHS. The three components, in addition to dramatic facial
swelling are: fever (a hallmark); rash (usually exanthematous,
occasionally urticarial plaques); and internal organ involvement
(most commonly the liver). The latter sometimes involves druginduced colitis, requiring cautious treatment. The pathogenic
pathway involves the formation of reactive metabolites that avidly
bind to larger proteins and act as haptens, with the predominant
T-cell response—CD4+ or CD8+—determining rash morphology.
Shear also discussed the possible role of viral reactivation, and
the interplay between genetic predisposition and a given drug in
a specific patient population.
Shear’s Diagnostic Triangle
▲
APPEARANCE
SYSTEMIC
Fever
Lymphadenopathy
Pharyngitis
Hepatitis
Arthritis
Exanthem
Urticarial
Bullous
Pustular
HISTOLOGY
Vasculitis
Interface dermatitis
CD8 predominance
Apoptosis
Blistering
Serum Sickness-Like Reaction (SSLR). SSLR involves
fever and arthritis, but unlike serum sickness it lacks immune
complexes and renal disease, and is caused by drugs, not by
serum. The drugs of highest risk are cefaclor and buprioprion.
Stevens-Johnson Syndrome (SJS)/Toxic Epidermolysis
Necrosis (TEN). Shear discussed the misconception in equating
erythema multiforme (EM) with SJS and TEN. Allopurinol has
become the drug most likely to cause SJS and TEN, displacing sulfonamide antimicrobials. Anticonvulsants remain important causes,
and ciprofloxacin presents a surprising risk. Biopsy is a must for suspected lesions. Shear noted the differential, then summarized treatment: the controversial nature of IVIG, the efficacy of cyclosporine
in early-stage SJS, and the need for an experienced ICU or Burn
Unit for TEN patients.
Testing. An overview of testing procedures and guidelines
emphasized patch testing.
Simple Exanthem—Histology
vacuolar alteration
lymphocyte infiltration
dyskeratotic and
necrotic keratinocytes
CTCL: Newer Treatments
(Photo courtesy of Werner Pichler, MD University of Basel)
Mostly in advanced stage disease; objective
response rate: 25%-50% in refractory cases
DHS: Drug to Disease
Non-Reactive
{
P450s
Oxidases
PG synthase
{
Acetylation
Glutathione
Epoxide hydrolases
Reactive/Toxic
Metabolites
Immune
Response
{
DRUG
cutaneous T-cell lymphoma (CTCL) and cutaneous B-cell lymphoma (CBCL). Current WHO-EORTC criteria classify CTCL as indolent (5-year survival >75%) or aggressive (5-year survival <25%).
Newer Treatments. These treatments—some on the market, others in clinical trials—are predominantly for patients with
recalcitrant advanced stage disease, with an overall response rate
(partial and complete remissions) in the 25%–50% range. They generally work by improving the immune system’s ability to fight the
malignant T-cell clone, or by retarding CTCL growth, or both.
Treatments on the horizon include histone deacetylase inhibitors,
cytokines, monoclonal antibodies, purine nucleoside analogs, tolllike receptor agonists, in situ vaccination, and the most effective
approach to stem cell transplant. Wood also noted Alain Rook’s
success with combined immunomodulatory therapies.
Molecular Pathogenesis. Because cDNA microarray technology provides “a genetic snapshot of all or most of the transcripts
expressed by a given cell at one point in time,” comparing normal
and malignant cells identifies genes over- or under-expressed in the
tumor. This led to identifying a bimodal dysregulation in mycosis
fungoides (MF)—blocked apoptotic pathways (lymphoaccumulative disorder) plus up-regulated cell cycling pathways (lymphoproliferative disorder). Benefits from this CTCL-related gene pool are
diagnostic and prognostic, with gene panels able to discriminate
between MF and dermatitis in 97% of cases, to detect Sézary syndrome in patients with only 5% leukemic cells in their blood, and to
identify patients with <6 months survival regardless of tumor burden.
Wood also discussed his recent research on apoptotic defects
in MF involving the T–cell-relevant Fas apoptotic pathway.
Cellular
CD4 ➨ rash
CD8 ➨ blisters
Cytokines
IL-8 ➨ pustules
MINI-SYMPOSIUM: INFLAMMATION
• HDAIs: vorinostat/SAHA (Zolinza™), depsipeptide
(Romidepsin)
• Cytokines: IFN-gamma, IL-12
• Antibodies: alemtuzumab (Campath-H1), zanolimumab
(HuMax-CD4®)
• Doxorubicin: pegylated form (Doxil®) >50% ORR
• Purine nucleoside analogs: fludarabine, forodesine
• Hematopoietic stem cell transplant: non-myeloablative
allogeneic
• TLR agonists: imiquimod, resiquimod, CpG
• In situ vaccination: Local XRT + intratumoral CpG
• COMBINATION THERAPY: multiple agents at reduced
doses enhance response rate (Rook et al)
ECP: 7PR, 2NR, ECP + IFN ± retinoid: 4CR, 4PR better, 1NR,
ECP, PUVA, TSEBT, XRT, IFNs, MTX, bexarotene, DAB-IL2, HDAIs
Update on CTCL
Gary S. Wood, MD
Classification. Essential immunologic information—and
sometimes even relevant molecular biology—now amplify the traditional clinical and histopathological information to approach
durable, reliable classifications. Lymphomas are divided into nonHodkgin’s lymphomas and Hodgkin’s disease. Non-Hodgkin’s lymphomas are divided immunologically into T cell/NK cell vs. B cell,
with each subcategory divided into precursor (the lymphoblastic
disorders centering in the thymus or bone marrow) and peripheral
disorders. Peripheral lymphomas typically arise in the lymph
nodes, with special extra-nodal cases that include the skin, ie,
2
Spring 2007
Role in our Future Practice
• cDNA and protein profiling to help establish
diagnosis, prognosis, and define tumor subtype
(eg, instead of MF, CTCL subtype A12).
• Therapy tailored to tumor subtype.
• Periodic tumor sampling to monitor for
evolution into a new subtype (moving target).
Alter therapy accordingly.
Dermatology Foundation
Update on Atopic Dermatitis
Jon M. Hanifin, MD
“More has happened in the past year than during the previous
15 years.” Hanifin highlighted some of these advances.
Focus on the Epidermis. This is “the epidermal era in
atopic dermatitis (AD).” Hanifin outlined the role of dysregulated
Fas/Fas-ligand binding in keratinocytes in inflammation and
spongiosis—a hallmark of AD that is perhaps its earliest lesion—and
in keratinocyte proliferation. Spongiosis also disrupts the epidermal barrier, adding to the known barrier defects in AD that provide
greater entry for, and reduced immunity to, toxins, microbes, and
allergens. Growing evidence supports the concept that “much of
the allergy seen in AD begins with defective barriers in the skin that
enable large protein antigens to enter and combine with amplifying dendritic cells to initiate Th2 immune responses.” TSLP (thymic
stromal lymphopoietin)—produced by keratinocytes in AD skin—
stimulates Th2 cells but can also initiate dermatitis independently
of T- or B-cell involvement. This shifting conceptualization of
eczema even raises the possibility that Th2 responses in AD may
be an epiphenomenon rather than pathogenic. The multi-system
impact of eczematization within the epidermis is emerging. A
possible cause of the defective epidermal barrier in AD includes
defective alleles of the filaggrin gene—an emerging genetic link
with ichthyosis vulgaris.
Itch. Important research involves the pruritogenic cytokine
IL-31. Current possible therapeutic options include the tricyclic
antidepressant mirtazapine, the -opioid antagonists, and the
-opioid antagonist butorphanol.
Infections. The deficient innate immune response in AD
lesions—including inadequate endogenous antimicrobials—plays
a critical role. For treating cutaneous staph infections, a 5-day
course of dicloxacillin for adults and children is sufficient. Add
rifampin or possibly oral tetracycline for frequent recurrences.
Allergy. “With this new perspective of allergy and AD, we
should view it as a skin disease with allergies, not as an allergic skin
disease.” Hanifin finds atopy an arcane, poorly defined, misused
term. He suggests describing AD as atopigenic dermatitis because
it predisposes to a lot of the allergic disease that we see.
Treatment of....
Itch
• Topicals—tar, pramoxine, menthol
• Steroids/CIs—for inflammatory itch
• Antihistamines—no proven effect
• Antidepressants—doxepin, amitriptylene
• Mirtazapine 15-30 mg/d
• -opioid antagonists—naloxone, naltrexone
• -opioid antagonist—butorphanol 1mg/d
Staph Infections
• Dicloxacillin, cephalexin—limited to 5 days—
is optimal for AD (eg, adults 500 mg tid;
children 125 mg tid).
• Frequent recurrences: Add rifampin; consider
oral tetracycline; topical mupirocin may reduce
colonization.
• MRSA: Trimethoprim/sulfa; clindamycin—
ADs may revert to sensitive colonies.
DF
DERMATOLOGY FOCUS
A PUBLICATION OF THE DERMATOLOGY FOUNDATION
Sponsored by
Medicis, The Dermatology Company
®
Editors-in-Chief
David J. Leffell, MD—Professor of Dermatology
Yale School of Medicine, New Haven, CT
Christina Herrick, MD, PhD—Asst Professor of Dermatology
Yale School of Medicine, New Haven, CT
Executive Director
Sandra Rahn Benz
Communications Manager
Christine Boris
Please address correspondence to:
David J. Leffell, MD & Christina Herrick, MD
Editors, Dermatology Focus
c/o The Dermatology Foundation
1560 Sherman Avenue, Evanston, Illinois 60201
Tel: 847-328-2256 Fax: 847-328-0509
e-mail: [email protected]
Published for the Dermatology Foundation by
Robert Goetz—Designer, Production
Sheila Sperber Haas, PhD—Managing Editor, Writer
This issue of Dermatology Focus is distributed without charge through
an educational grant from Medicis, The Dermatology Company®.
The opinions expressed in this publication do not necessarily reflect those
of the Dermatology Foundation or Medicis, The Dermatology Company®.
© Copyright 2007 by the Dermatology Foundation
Contact Dermatitis “Allergens of the Year”
James S. Taylor, MD
Seven years ago, the journal Dermatitis began naming an
allergen of the year. Reactions can present as acute or chronic
dermatitis, localized or disseminated.
Disperse Dye Allergy (2000): Disperse blue dyes 106 and
124 are present in 100% polyester and nylon fabrics, notably
acetate-lined fashion blue suits. Chronic dermatitis is more common. The reaction can be delayed, so do a delayed patch test
reading of at least 4 days, preferably 7. Disperse dye allergy can be
associated with fabric-finish allergy. Treatment equals avoidance.
Gold (2001): Reactions to this second most common metal
allergen may be delayed and persistent. Systemic contact dermatitis
can occur in gold-positive patients who received systemic gold. Goldcontaining coronary endovascular stents may induce gold sensitivity.
With jewelry the dermatitis is often not a direct contact reaction, so
wearing of all gold jewelry may have to be stopped for several months.
Bacitracin Allergy—Clinical Presentation
• First line topical remedy for cutaneous injuries and
dermatoses—often self-prescribed; Rx for eye and
ear infections; operative irrigation; post-operative
wound care; etc.
• Acute & chronic contact dermatitis—worsens with use
• Delayed wound healing or infection—leading to
costly medical evaluation
• Anaphylaxis (extremely rare)
• Use unidentified (OTC, Emergency Dept)
(Continued on page 6)
www.dermatologyfoundation.org
Spring 2007
3
2006 Year in Review: Strong Giving
Reflects Vital Role of Research
Commitment to research and the specialty’s future was the key message
when Bruce U. Wintroub, MD, Dermatology Foundation President, reported
2006 results for DF members at the recent Annual Meeting in Washington,
DC. Dr. Wintroub thanked the DF’s individual members and its corporate
and society partners for their generous contributions totaling $6.3 million.
Their continued support is evidence of the priority they place on dermatologic research and its enormous potential to improve patient care.
“Clearly, our supporters all recognize the importance of our mission to the specialty. We are in
the people business, and invest
in the future of patient care by
providing research funding that
will help talented investigators
develop into tomorrow’s leading
teachers and researchers,” Dr.
Wintroub explained. “All our
members and supporters understand that their investment in a
new generation of physicians and
scientists is vital to the development of new therapies and concepts about skin disease, and
a strengthened ability to train
others for the future.”
Research Awards Reach
$5 Million Mark
Due to the willingness of the
entire dermatologic community
and industry supporters to give,
$5 million was apportioned to
fund 69 promising individuals
and projects this year, along
with an allocation to the DF
research endowment fund. Dr.
Wintroub reported that this substantial support in 2006 enabled
the DF to fund a record number
of deserving research projects.
Almost two-thirds of these were
for career development awards.
This outstanding investment will
enable tomorrow’s top investigative dermatologists to conduct
life-improving research that
spans the full range of medical
and surgical dermatology.
Funding for the Future—
A Priority
“The Dermatology Foundation’s
large allocation to research was
made possible by the shared
vision and generosity of the
4
Spring 2007
Foundation’s many member
dermatologists, corporate partners, and society supporters,”
Dr. Wintroub pointed out.
From our Members...
Over half the DF’s funding this
past year, $3.4 million, came from
dermatologists and other individual
members who made a personal
commitment to the advancement
of the specialty. The lion’s share
of individual support came from
the top four membership tiers:
• Nine (9) Thomas B. Fitzpatrick
Legacy Fund members, giving
$100,000 or more accounted for
nearly 10% of individuals giving
to the DF.
• Fifty-nine (59) new Annenberg
Circle members committed
$25,000 to further medical and
surgical dermatology and brought
the total roster to 384. Twentynine (29) current members chose
to be Sustaining Members
and provided $5,000 beyond
their membership commitment.
• 1,026 members of the Leaders
Society continued their support
of the specialty with a contribution of $1,500.
From our Corporate Partners
& Specialty Societies...
Support from the DF’s 42 corporate
partners and 21 specialty societies
reached nearly $3 million. “The
synergy between physician and
corporate support continues.” Dr.
Wintroub summed it up: “All our
industry and society partners give
to the DF because they are committed to the specialty, and to the
expansion of its scientific base.”
The DF’s greatest industry
supporters are members of the
2006 Honorary Awardees
A highlight of each year’s DF Annual Meeting
is presentation of the prestigious honorary
awards. Pictured here with DF President,
Bruce U. Wintroub, MD, are this year’s awardees:
Edward A. Krull, MD, Lifetime Career Educator
Award (top); Nia K. Terezakis, MD, Clark W.
Finnerud Award (center); and Leonard J.
Swinyer, MD, Practitioner of the Year Award.
DF Corporate Honor Society
who gave $50,000 or more to
the DF (see page 17 ). The
Platinum Benefactors, our leading corporate partners, provided
$200,000 or more this year:
• Amgen Wyeth
• Galderma Laboratories, L.P.
• Medicis, The Dermatology
Company
• OrthoNeutrogena
• Stiefel Laboratories, Inc.
• Unilever
Dr. Wintroub recognized that
the focused support of two corporate partners resulted in the much
needed expansion of research
awards this year. Unilever
increased their giving to be the
first supporter of a new career
development award focusing on
the science of human appearance.
This new CDA recognizes the
Dermatology Foundation
specialty’s expanding focus on
human appearance and the
scarcity of relevant, high quality
research.
Corporate partner Stiefel
Laboratories, Inc. also pledged
additional funds to the DF to provide more career development
awards in medical dermatology.
The company’s significant support
of this program is made in honor
of the late Werner K. Stiefel and
his commitment to dermatology.
2007 and Beyond
The DF is grateful to its members
and its industry and society partners for their exceptional support
in 2006. However, the challenges
posed by limited federal funding
will continue next year and
beyond; and each generation of
teachers and researchers will
require the help that the specialty
provides through the DF to
progress. This year, consider
the profound impact you can
have on the future of your
specialty by increasing your
giving to the DF or becoming
a new member and joining
other dermatologists who have
pledged their annual support.
Contact the DF at
[email protected]
for more information.
$5 Million Invested
in Our Future Leaders
The DF’s $5 million research allocation will provide funding for
69 high-impact research projects this year to be carried out by today’s
most promising investigators in the early stages of their careers.
Funding recommendations were made by the DF’s Medical &
Scientific Committee based on scientific merit and the applicant’s
potential to be a leader—a serious role model—in dermatology.
The committee was chaired by Andrew Blauvelt, MD, a faculty member at the Oregon Health & Science University. Committee members
brought individual depth and collective breadth of research experience,
plus an understanding of the types of research and investigators
that will benefit our specialty now and in the future.
“Our committee carefully discussed and ranked each of this year’s
outstanding submissions. Proposed projects focused on the full range
of topics related to cutaneous biology and the pathogenesis of skin
diseases,” Dr. Blauvelt says.
Nine (9) fellowships and 19 grants were provided, with multi-year
awards ($55,000/year) representing the majority of the 69 funded
projects. These 41 career development
awards comprise the following categories:
• 15 Physician Scientist
19
Grants
• 12 Basic (Skin) Research
41
• 4 Dermatologic Surgery
Career
9
Development
• 7 Medical Dermatology
Fellowships
• 1 Psoriasis Research
• 1 Women’s Health Research
• 1 Science of Human Appearance
For a list of our 2007 award recipients and projects,
visit www.dermatologyfoundation.org.
The Thomas B. Fitzpatrick Legacy Fund—
The Power of Commitment
The Thomas B. Fitzpatrick Legacy Fund,
now with 9 members, offers individuals the
highest level of personal impact for meeting
the specialty’s needs. The Fund was established
by Eugene J. Van Scott, MD, to “address the continued growth
and evolution of dermatology by sponsoring talented career
scientists in the mold of Fitzpatrick himself.”
Members of the Thomas B. Fitzpatrick Legacy Fund pledge
$100,000 to be paid over a maximum of five years. To learn more,
contact the Dermatology Foundation by phone at 847-328-2256
or via e-mail at [email protected].
www.dermatologyfoundation.org
Rex A. Amonette, MD
Anonymous Donor
Susan V. Bershad, MD
James J. Leyden, MD
Robert L. Roschel, MD
Jonah Shacknai
Charles W. Stiefel
Eugene Van Scott, MD
Ruey J. Yu, PhD, OMD
Spring 2007
5
Thimerosol (2002): This common allergy is from either the
mercurial or thiosalicylate component. It is used as an antiseptic,
and a preservative in eye medications, some eye cosmetics, allergy shots, flu shots, etc. Current relevance is often difficult to detect.
Bacitracin (2003): This first-line topical remedy for cutaneous
injuries, commonly used in operative irrigations and post-op wound
care, can produce an acute or chronic allergic dermatitis that worsens
with use and may mimic delayed wound healing. Anaphylaxis has been
reported in connection with compromised skin, and intraoperative use.
Cocamidopropyl Betaine (2004): This nonionic surfactant—a significant and overlooked allergen—is in roughly 600 personal care and liquid detergent products. It is less irritating to the
mucous membrane than sodium lauryl sulfate but more likely to
produce contact allergy. Patch testing is essential for diagnosis.
Topical Corticosteroids (2005): Allergy is more common
in stasis, perineal, and chronic actinic dermatitis. Perinasal and
facial contact dermatitis from nasal sprays has been observed,
probably sensitized via the skin. Symptoms can include worsening
of rhinitis, sinusitis, and asthma. The primary steroid markers for
patch testing include tixocortol pivalate and budesonide. Crossreaction patterns are important.
p-Phenylenediamine (2006): This most effective permanent hair dye—and potent allergen—is also used for beard hair and as
a fixative for paint-on henna tattoos. The millions of users typically
ignore the pre-use patch test. Some severe acute reactions have
been misdiagnosed as severe infectious cellulitis. It can rarely present with immediate IgE-mediated reactions. History and timing are
critical to diagnosis. The Contact Allergen Replacement List (CARD)
from the American Contact Dermatitis Society (www.contactderm.org) includes alternative hair dye products.
Cross-Reaction (XR) Patterns of Topical
Corticosteroids—Selected Examples
• Group A: Hydrocortisone, methyl prednisolone,
tixocortol piv.—XR with group D2
• Group B: Acetonides: TAC, fluocinolone, amcinonide,
desonide, budesonide—XR with group D2
• Group C: Betamethasone base, dexamethasone
• Group D1: Betamethasone diproprionate,
B-17-valerate, clobetasol, fluticasone, mometasone
• Group D2: HC-17-butyrate, prednicarbate—
XR with group A
XR proof = positive reactions to corticosteroids to which patient was not exposed
Use systemic dexamethasone for patients allergic to steroids in groups A & B
(Isaksson M. Derm Ther 2004;17:314; Jacob S. JAAD 2006;54:723–7)
Textile Dye Avoidance*
• Strict avoidance of dye (avoidance of specific color
often not helpful)
• Avoid 100% acetate or 100% polyester liners
• Avoid nylon stockings (beige tones especially)
• Wear 100% natural-based fabrics (cotton, linen, silk, wool)
• Wear 100% silk long-sleeved undershirts and slip pants
• Wash all clothing x 3 before wearing
• Wear loose-fitting clothing
• Avoid tight synthetic spandex/lycra exercise clothing
• Levi Strauss 501 blue jeans (vat dyes) usually are safe
to wear
*From Melanie Pratt, MD
6
Spring 2007
Update on Rosacea
Diane M. Thiboutot, MD
The challenge of rosacea lies partly in the greatly varied phenotypes. Multifaceted treatment always includes sun protection
and proper skin care. Ask about eye symptoms, because many
rosacea patients are unaware that they can be part of this disease
(Artificial Tears are helpful).
For subtype 1 (erythematotelangiectactic), the most common
type, most of our medical therapies do not help significantly with
the redness, flushing, and telangiectasia and Thiboutot suggests
physical therapies. Subtypes 2 (papulopustular) and 3 (phymatous) are more responsive to available treatments. There are oral
and topical medical treatments for inflammatory lesions.
Oral Therapies. They also treat ocular rosacea, and include
tetracyclines, minocycline, and anti-inflammatory dose doxycycline
(40 mg). Thiboutot described the basis for low-dose doxycycline’s
anti-inflammatory action. She does not find oral metronidazole
effective. Beta-blockers are used to control flushing, but patient
response is erratic. Isotretinoin aids severe recalcitrant cases, but
remissions tend to be brief.
Topical Therapies. The two main topicals are metronidazole and azelaic acid. The newer gel forms deliver more drug
and with better penetration than the creams, with active drug
remaining in the skin. Thiboutot discussed a pivotal trial with azelaic acid gel and significantly improved inflammatory lesions, erythema, and global severity. Any local discomfort is usually mild and
transient. Thiboutot uses sodium sulfacetamide and sulfur products
for the patient subset with concomitant seborrheic dermatitis.
Physical Therapies. The use of lasers and other light
sources is an exciting new area. A number of small studies demonstrated significant improvement in erythema and telangiectacias,
but now large, well-controlled trials to assess efficacy are needed.
Thiboutot spoke briefly about effective rhinophyma treatments:
steel excision, CO2 laser, cauterizing scalpel, or a combination.
Rosacea: Therapeutic Options
Oral Therapies
Inflammatory lesions, ocular rosacea
• Tetracyclines
• Beta-blockers
• Minocycline, doxycycline
• Clonidine
• Metronidazole flushing
Extreme or recalcitrant cases
• Isotretinoin (variable duration of effect)
Pharmacologic Therapy: Topical Agents
Primary (Nally JB et al. J Drugs Dermatol. 2006;5:23-26)
• Metronidazole
• Azelaic acid
• Sodium sulfacetamide and sulfur
Secondary (not approved for treating rosacea)
• Clindamycin
• Erythromycin
• Benzoyl peroxide
• Other agents (eg, tretinoin, tacrolimus, pimecrolimus)
have been used on a case-by-case basis
Light Sources
• Monochromatic:
KTP—532 nm
PDL—585–595 nm
CO2—10,600 nm
• Polychromatic:
IPL—515–1200 nm
(telangiectasia, erythema)
(telangiectasia, erythema)
(phymas)
(telangiectasia, erythema)
Dermatology Foundation
Sensitive Skin
James J. Leyden, MD
After discussing the difficulties in diagnosing and characterizing sensitive skin, Leyden noted the two basic types of reactions—neurosensory (burning, stinging, tightness, perhaps
itching) and irritant (erythema, scaling, frank dermatitis).
Discussion focused on the face. Atopy is not a marker, but is
found at a much higher level among those clearly identified with
neurosensory or irritant reactions. High TEWL (transepidermal
water loss)—a measure of stratum corneum (SC), or barrier, function—seems to correlate with responses to patch testing and
other ways of testing irritants, suggesting that SC function may be
an important link.
The facial stinging reaction—a test applied to all products for
the face or scalp—emerged in 1977 from reactions to a new sunscreen. Vulnerable individuals are now identified by the use of
10% lactic acid in the nasolabial folds.
Leyden, much involved in testing facial tolerance (blinded,
controlled, objectively measured), finds “the topical retinoid is the
one molecule that clearly brings out this vulnerability,” illustrating
with data from a retinoid tolerance study comparing adapalene
and tazarotene gels.
Facial tolerance outliers all have rough (ie, dry) skin. Leyden
believes that “the primary problem is SC disruption and poor
barrier function,” which can be compounded by vascular lability and/or a form of atopic disease. He described the healthy
SC and the essential mix and ratio of lipids—ceramides, fatty
acids, and cholesterol—that produces a functional membrane.
“Much evidence identifies the primary problem in sensitive
skin as abnormal intracellular lipid composition, resulting in
decreased water content and poor desquamation.” Leyden
noted the various situations producing this phenotype, with its
dysfunctional thick, dessicated, and microfissured barrier.
These fissures allow chemical entry into the much more vulnerable epidermis, producing keratinocyte injury, cytokine
release, then hyperplasia and attempts at repair, and the host
response—which determines the degree of inflammation.
Leyden discussed the relationship between aquaporin transmembrane proteins—critical to water transport—and the
endogenous humectant glycerol, their dysfunction in sensitive
skin, and the implications for research. Patients with sensitive
skin require truly mild cleansers plus products that aid in
increasing the skin’s water content. The current approach adds
the correct ratio of intracellular lipids to help restore this tissue
to a more normal situation.
Sensitive Skin Inflammation
Stratum Corneum
• Microfissures allow chemical access
• Cytokine release
Epidermis
• Keratinocyte injury cytokine release
• Attempt to repair hyperplasia
Dermis
• Host response
MINI-SYMPOSIUM:
DIAGNOSTIC CHALLENGES IN
PEDIATRIC DERMATOLOGY
Scaly Rashes in Infants:
What Every Dermatologist Should Know
Sheila Fallon Friedlander, MD
Friedlander focused on both “horses” (common problems)
and “zebras” (rare entities buried among the millions of benign
scaly rashes we see in babies) that shouldn’t be missed. (Ichthyosis
was excluded due to time; atopic dermatitis [AD] was already covered.) These rashes are age and distribution dependent. Think
“horses” initially. But if the rash will not clear, think of “zebras” and
look at the whole picture—including signs of systemic disease.
Seborrheic Dermatitis—A Common “Horse.” The AD
rash—the most common “horse”—rarely occurs before 2 months of
age, itches intensely, and “does not stay within the diaper and intertriginous areas as do the other disorders of today’s talk.” Seborrheic
dermatitis (AKA cradle cap), the second most common disease,
presents very early but peaks at 3 months with thick, greasy, adherent, yellow scales on the scalp. The other preferred areas—often
with dull red coloration—are the diaper area, creases, and eyebrows. Lesions are sharply defined and not very itchy. For mild disease, recommend an oil (mineral, borage, tea tree, etc) to be massaged in, left overnight, then removed gently with a toothbrush after
shampooing (possibly with a product containing ketoconazole,
zinc, or selenium). For severe disease, try topical antifungals. With
no healing, speak with the mother and reexamine the skin. Likely
possibilities are scabies, tinea, psoriasis, or secondary infection.
Zebras. Look at the whole picture—if there is diarrhea, vomiting, failure to thrive, distinctive distribution of the rash, then consider more serious possibilities. Friedlander discussed metabolic
and nutritional abnormalities, illustrating with acrodermatitis enteropathica and the need to determine whether this zinc deficiency is
endogenous or a maternal breast milk deficit. Immunologic disease
involves a group of disorders involving complement deficiency or
dysfunction, including Omenn syndrome. Langerhans cell disease
(unifocal, multifocal, or disseminated) is a potentially devastating
clonal proliferative disorder that affects approximately 5 million
very young children, most often boys. Most survive, often with
long-term post-recovery involvement including osteolytic bone
Seb Derm—The Best Rx
• Sometimes reassurance is all that’s needed
• Oils—mineral, borage, tea tree—overnight
on scalp, remove with soft toothbrush
• Shampoos
– Baby, ketoconazole, zinc pyrithione, selenium sulfide
– Most people avoid tar and sal acid (irritation, absorption issues)
• Weak steroids—fluocinolone topical oil, hydrocortisone creams
• Antifungals—a few studies support efficacy and safety in infants
– Topical ketoconazole
– Applied to infants topically 2x/week x 4 wks
– No systemic levels, nl LFTs
– In vitro studies:
– Antifungal activity of ciclopirox olamine, zinc pyrithione
vs ketoconazole—MIC increased with time (3-30 mins);
ciclopirox & zinc synergistic; better than ketoconazole
(Continued on page11)
www.dermatologyfoundation.org
Spring 2007
7
1,026 Leaders Society Members
Invest in The Future
The Dermatology Foundation thanks the 2006 Leaders
Society members for making a commitment to support
high quality research in dermatology, and thus expanding the scientific base of the specialty. Their contributions will result in improved patient care and enable the
careers of tomorrow’s scientists and teachers. Please
join your colleagues by contributing $1,500 or more.
Contact the Dermatology Foundation at 847-328-2256
or via e-mail at [email protected]
for more information.
ALABAMA
Matthew K. Abele, MD
Robert W. Calcote, MD
Robert A. Clark, MD
James E. Elder, MD
Craig A. Elmets, MD
Sharon F. Gardepe, MD
Robert D. Griffith, MD
Christopher B. Harmon, MD
Elizabeth S. Jacobson, MD
James M. Krell, MD
Jason L. Lockridge, MD
Gary D. Monheit, MD
L. Terry Pynes, MD
Lon F. Raby, Jr., MD
Vera Y. Soong, MD
John K. Sowell, MD
George G. Tisdale, MD
Patricia Wilson, MD
Sandra L. Zahradka, MD
ALASKA
Robert F. Moreland, Jr., MD
Margretta A. O’Reilly, MD
ARIZONA
Mireille C. Algazi, MD
Evan G. Bauer, MD
Richard A. Cirelli, MD
Suzanne M. Connolly, MD
Mark V. Dahl, MD
Marc I. Epstein, DO
Lorna J. Fredrikson, MD
Rosemary J. Geary, MD
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Henry H. Roenigk, Jr., MD
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ARKANSAS
M. Francine Bruyneel, MD
Hayden Franks, MD
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Patrick M. Hatfield, MD
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CALIFORNIA
Fuad Abuabara, MD
Kim M. Albridge, MD
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8
Spring 2007
Todd S. Anhalt, MD
Timothy E. Baker, MD
Marina A. Ball, MD
Ronald J. Barr, MD
Louis Bauman, MD
Frederick Beddingfield, III, MD
Robert E. Beer, MD
Ralph T. Behling, MD
Timothy G. Berger, MD
Kimberly J. Butterwick, MD
Andrew S. Calciano, MD
Ivor Caro, MD
Philip Charney, MD
Marcus A. Conant, MD
Michael W. Condie, MD
Jody A. Cornelius, MD
Peggy S. Crawford, MD
E. Patrick Creehan, MD
Eileen Crowley, MD, PhD
Janice L. DaVolio, MD
Lawrence F. Eichenfield, MD
P. Haines Ely, MD
Beverly A. Epstein, MD
Erlinda S. Fang, MD
Ilona J. Frieden, MD
Sheila F. Friedlander, MD
Ruby Ghadially, MD
Amy E. Gilliam, MD
Hayes B. Gladstone, MD
Edward Glassberg, MD
Linda M. Globerman, MD
Richard G. Glogau, MD
Peter M. Goldman, MD
David C. Gorsulowsky, MD
Sergei A. Grando, MD, PhD, DSc
Joseph H. Greenberg, MD
Roy C. Grekin, MD
Pearl E. Grimes, MD
Christiaan P. Hallman, MD
David R. Harris, MD
Robert Hartman, MD
Catherine A. Hoffman, MD
Gail T. Jacoby, MD
Lenore S. Kakita, MD
Bryna Kane, MD
Donald M. Kay, MD
Amelia H. Kaymen, MD
Suzanne L. Kilmer, MD
Laura A. King, MD
Lincoln Krochmal, MD
Pui-Yan Kwok, MD, PhD
Alfred T. Lane, MD
Nikolajs A. Lapins, MD
Glenn N. Ledesma, MD
Delphine J. Lee, MD, PhD
Julie A. Letsinger, MD
Fu-Tong Liu, MD, PhD
Jamie L. MacDougall, MD
Seth L. Matarasso, MD
Theodora M. Mauro, MD
Brian P. Mekelburg, MD
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Robert L. Modlin, MD
Vic A. Narurkar, MD
Fern P. Nelson, MD
Isaac Neuhaus, MD
F. Richard Noodleman, MD
David H. Peng, MD, MPH
Daniel J. Piacquadio, MD
Jerome R. Potozkin, MD
Vera H. Price, MD
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Jack S. Resneck, Jr., MD
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Megin C. Scully, MD
Karen R. Simpson, MD
Stacy R. Smith, MD
Seth R. Stevens, MD
Abel Torres, MD
Denny L. Tuffanelli, MD
Jane S. Wada, MD
Gary Wagner, MD
Peter K. Webb, MD
John W. Weiss, MD
An Yen, MD
Christopher B. Zachary, MD
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COLORADO
John C. Ansel, MD
Cheryl A. Armstrong, MD
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J. Michael Maloney, MD
Brett K. Matheson, MD
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CONNECTICUT
Richard J. Antaya, MD
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DELAWARE
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DISTRICT OF COLUMBIA
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FLORIDA
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Robert A. Norman, DO
Keyvan Nouri, MD
Neal S. Penneys, MD, PhD, MBA
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Oliver M. Reed, MD
Marta I. Rendon, MD
Douglas N. Robins, MD
Susan S. Roper, MD
William J. Roth, MD, PhD
Lawrence A. Schachner, MD
Stanley V. Schwartz, MD
Joseph F. Seber, MD
Steven D. Shapiro, MD
Laura E. Skellchock, MD
Robert Snyder, MD
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Michael S. Spicer, MD
Gary L. Stevens, MD
Sharon Stokes, MD
John Strasswimmer, MD, PhD
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Maxine C. Tabas, MD
Panos Vasiloudes, MD, PhD
Jennifer L. Vesper, MD
Joel M. Wilentz, MD
GEORGIA
Jack L. Arbiser, MD, PhD
Julie A. Barber, MD
Garin D. Barth, MD
Linda M. Benedict, MD
Jordan H. Berne, MD
Harold J. Brody, MD
Dan K. Chalker, MD
Katarina G. Chiller, MD
Richard L. Detlefs, MD
John A. Fountain, MD
William E. Freeman, MD
Leslie C. Gray, MD
Edmond I. Griffin, MD
D. Scott Karempelis, MD
John D. Kayal, MD
Jay A. Levin, MD
David J. Levine, MD
Damon V. Mauldin, MD
Paula Nelson, MD
Diamondis Papadopoulos, MD
David B. Pharis, MD
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Daniel C. Rabb, MD
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James T. Sandwich, MD
George B. Skipworth, MD
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Nhu-Linh T. Tran, MD
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HAWAII
John D. Boyer, MD
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Stella S. Matsuda, MD
Sharon A. Minami, MD, PhD
Kevin J. Mott, MD
William K. Wong, MD
IDAHO
Ryan S. Owsley, MD
Carl R. Thornfeldt, MD
ILLINOIS
Iris K. Aronson, MD
Victoria H. Barbosa, MD
Bonnie Barsky, MD
Bruce Bennin, MD
Dermatology Foundation
Leaders Society Members
Kelle S. Berggren, MD
Mark A. Berk, MD
Wayne J. Blaszak, MD
Thomas R. Brander, MD
Darryl M. Bronson, MD
Jerome T. Budz, MD
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William A. Caro, MD
I-Ja Chan, PhD
Vassilios A. Dimitropoulos, MD
Irving H. Distelheim, MD
Lady Christine Cheng Dy, MD
Matthew P. Evans, MD
John H. Exner, MD
Lester J. Fahrner, MD
Michael Fretzin, MD
Jerome M. Garden, MD
Scott D. Glazer, MD
Jonathan N. Goldfarb, MD
James F. Gregory, MD
James B. Grossweiner, MD
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Shelley J. Halper, MD
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Joy D. Jester, MD
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Robert V. Kolbusz, MD
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Alan E. Lasser, MD
Anne E. Laumann, MBChB, MRCP
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Tehming Liang, MD, PhD
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Susan Liebovitz, MD
David A. Lorber, MD
Mary C. Massa, MD
Alexandria Meccia, MD
Julie A. Moore, MD
Warren W. Piette, MD
M. Joyce Rico, MD
June K. Robinson, MD
Marjorie M. Rosenbaum, MD
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Harry C. Stone II, MD
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KENTUCKY
Teresa J. Bentley, MD
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Jyoti B. Burruss, MD
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LOUISIANA
Rhonda R. Baldone, MD
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Brian P. Ford, MD
Josephine M. Futrell, MD, PhD
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Laurie H. Harrington, MD
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Deborah C. Hilton, MD
Deidre O. Hooper, MD
Janine O. Hopkins, MD
Christopher R. Hubbell, MD
John J. Jones, Jr., MD
Robert A. Koppel, MD
Daniel A. Marshall, Jr., MD
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Larry E. Millikan, MD
Thomas Nicotri, Jr., MD
Stella B. Noel, MD
Donald I. Posner, MD
H. Patrick Ragland, MD
Diane L. Rose, MD
Glenn G. Russo, MD
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Joseph P. Shrum, MD
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MARYLAND
Grant J. Anhalt, MD
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Robert S. Berger, MD
Elizabeth M. Burke, MD
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INDIANA
Diane S. Ford, MD
Anthony A. Gaspari, MD
Alexander A. Fondak, MD
Ronald Goldner, MD
Robert H. Huff, MD
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Ginat W. Mirowski, DMD, MD
Sam T. Hwang, MD, PhD
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Keeter D. Sechrist, MD
Grace F. Kao, MD
Barbara R. Sturm, MD
Dennis Kurgansky, MD
IOWA
Stanford I. Lamberg, MD
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Timothy G. Abrahamson, MD
Sean L. McCagh, MD
Richard T. Ameln, MD
Lynn J. McKinley-Grant, MD
Allen D. Harves, MD
Charlotte E. Modly, MD
J. William Holtze, MD
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Kathi Madison, MD
Diane Orlinsky, MD
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Angela R. Peterman, MD
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KANSAS
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Donald K. Tillman, Jr., DO
www.dermatologyfoundation.org
MASSACHUSETTS
Kenneth A. Arndt, MD
Howard P. Baden, MD
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Thomas G. Cropley, MD
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Marie-France Demierre, MD
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Donald J. Grande, MD
Terry P. Hadley, MD
Christine M. Hayes, MD
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Steven M. Kahn, MD
Michael S. Kaminer, MD
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Claire P. Mansur, MD
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MICHIGAN
Thomas F. Anderson, MD
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Amy B. Cardellio, DO
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Karen L. Chapel, MD
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Jenny Cotton, MD, PhD
Lawrence J. Desjarlais, MD
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George J. Murakawa, MD, PhD
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Dipa S. Patel, MD
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Robert J. Schoenfeld, MD
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Milton D. Soderberg, MD
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William F. Weston, MD
Yuelin Xu, MD
MINNESOTA
Lynn A. Benson Glesne, MD
Ngo T. Hien, MD
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Erika J. Rabeni, MD
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MISSISSIPPI
William Burrow, III, MD
Jeffrey C. Houin, Jr., MD
MISSOURI
Karen E. Edison, MD
Arthur Z. Eisen, MD
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MONTANA
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NEBRASKA
Geoffrey C. Basler, MD
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NEVADA
Curt P. Samlaska, MD
NEW HAMPSHIRE
Daniel W. Collison, MD
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NEW JERSEY
Beatrice B. Abrams, PhD
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NEW MEXICO
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NEW YORK
A. Bernard Ackerman, MD
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Julide T. Celebi, MD
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Arielle N.B. Kauvar, MD
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Lester Klein, MD
Kevin B. Kulick, MD
Shoshana M. Landow, MD
Wei-Li S. Lee, PhD
Donald L. Levin, MD
Stuart R. Levine, DO
Vicki J. Levine, MD
Lawrence M. Lieblich, MD
Julian M. Mackay-Wiggan, MD
Kenneth A. Mark, MD
Thomas O. McMeekin, MD
Jan E. Muhlbauer, MD
Rhoda S. Narins, MD
Richard B. Narins, MD
Kishwer S. Nehal, MD
Antoinette P. Notaro, MD
Allan R. Oseroff, MD, PhD
Grace H. Pak, MD
Alice P. Pentland, MD
Robert G. Phelps, MD
Stephanie H. Pincus, MD, MBA
Laurie J. Polis, MD
Philip G. Prioleau, MD
Hilary L. Reich, MD
Donald Rudikoff, MD
Jerome L. Shupack, MD
Lynn Silverstein, MD
Nicholas A. Soter, MD
Ruth K. Treiber, MD
Heidi A. Waldorf, MD
Jeffrey M. Weinberg, MD
Michael B. Whitlow, MD, PhD
Isabelle P. Wilson, MD
Regina M. Yavel, MD
Eugene G. Zappi, MD
NORTH CAROLINA
Marc R. Carruth, MD
Gerald E. Cooley, MD
Mary L. Courrege, MD
Luis A. Diaz, MD
Patrick McElgunn, MD
Ronald L. Godbold, MD
Russell P. Hall III, MD
Bhushan D. Hardas, MD, PhD
W. Dean Henrichs, MD
Spring 2007
9
Leaders Society Members
Catherine M. Hren, MD
Joseph L. Jorizzo, MD
Debra C. Liu, MD
Frederick A. Lupton, MD
Patrick McElgunn, MD
John C. Murray, MD
Adnan Nasir, MD, PhD
Elise Olsen, MD
James B. Patterson, MD
Elizabeth F. Rostan, MD
David S. Rubenstein, MD, PhD
Kerry M. Shafran, MD
Navjeet K. Sidhu-Malik, MD
Stuart Tafeen, MD
Jon C. Ter Poorten, MD
Val P. Vallat, MD
OHIO
Neera Agarwal-Antal, MD
John P. Anders, MD
Jonathan Bass, MD
Jaye E. Benjamin, MD
Wilma F. Bergfeld, MD
Brian P. Biernat, MD
Heidi B. Donnelly, MD
G. Scott Drew, DO
Z. Charles Fixler, MD
Hugh M. Gloster, Jr., MD
Scott C. Grevey, MD
Curtis W. Hawkins, MD
Paul G. Hazen, MD
Stephen E. Helms, MD
Michelle A. Jahnke, MD
Christine Jaworsky, MD
Neil J. Korman, MD, PhD
George H. Kuffner, MD
Jenifer R. Lloyd, DO
Robert E. Marsico, Jr., MD
Robert E. Marsico, Sr., MD
Anthony L. Mehle, MD
Beno Michel, MD
Susan T. Nedorost, MD
Nancy J. Pelc, MD
Rafael A. Perez-Figaredo, MD
Jerome R. Pomeranz, MD
Donald R. Schermer, MD
Guillermo R. Sicard, MD
Stephen C. Somach, MD
James S. Taylor, MD
Julian J. Trevino, MD
Allison T. Vidimos, MD
Jill S. Waibel, MD
Judith J. Walker, MD
Marlene D. Willen, MD
OKLAHOMA
Raymond L. Cornelison, Jr., MD
Mark A. Everett, MD ∞
Lawrence J. Gregg, MD
Mark D. Lehman, MD
Scott W. Meyers, MD
Richard D. Sontheimer, MD
OREGON
Michael J. Adler, MD
Andrew Blauvelt, MD
Jay N. Gade, MD, PhD
J. David Igelman, MD
Paul A. Klas, MD
Marla M. Klein, MD
Alfons Krol, MD
Ken K. Lee, MD
Edgar Maeyens, Jr., MD
Barbara E. Resnick, MD
Marla Ross, MD
Paul S. Russell, MD
Bert G. Tavelli, MD
Curtis T. Thompson, MD
Dwight R. Tribelhorn, MD
10
Spring 2007
PENNSYLVANIA
Edward Abell, MD
Donald J. Adler, DO
D. Brad Amos, MD, PhD
Ercem S. Atillasoy, MD
Arthur K. Balin, MD, PhD
John O. Barton, MD
Evelina A. Bernardino, MD
Elizabeth M. Billingsley, MD
Robert J. Bitterman
Dominic A. Brandy, MD
J.B. Braun, MD
Allison B. Kimmins, MD, MPH
Bruce A. Brod, MD
David G. Brodland, MD
Donald R. D’Annunzio, MD
Jau-Shyong Deng, MD
Rosalie Elenitsas, MD
Tanya Ermolovich, DO
Louis D. Falo, Jr., MD, PhD
Richard G. Fried, MD, PhD
Loren S. Funt, MD
Robin Gehris, MD
Larisa J. Geskin, MD
Stuart A. Glasser, MD
Orin M. Goldblum, MD
Scott L. Gottlieb, MD
Charles H. Greenbaum, MD
Thomas D. Griffin, MD
David A. Horvath, MD
Nancy S. House, MD
William D. James, MD
Bernett L. Johnson, MD
Jacqueline M. Junkins-Hopkins, MD
Kays H. Kaidbey, MD
Caroline S. Koblenzer, MD
E. Michael Kramer, MD
Douglas W. Kress, MD
Jason B. Lee, MD
Stephanie A. Mackey, MD
James G. Marks, Jr., MD
Victor J. Marks, MD
Renee J. Mathur, MD
Regis W. McHugh, MD
O. Fred Miller III, MD
Suzan Obagi, MD
Steven K. Orman, MD
Lawrence C. Parish, MD
Herbert M. Parnes, MD
Clifford S. Perlis, MD
Andrew K. Pollack, MD
Stephen M. Purcell, DO
Michael S. Rabkin, MD
Franziska Ringpfeil, MD
Rudolf R. Roth, MD
Paul J. Ruschak, MD
Michael Saruk, MD
Mark P. Seraly, MD
John T. Seykora, MD, PhD
Douglas L. Sheldon, MD
Alan R. Silverman, MD
Judith A. Small, MD
Elizabeth M. Spiers, MD
John G. Stoner, MD
Mary B. Toporcer, MD
David B. Vasily, MD
Marion M. Vujevich, MD
Victoria P. Werth, MD
Joseph A. Witkowski, MD
Jonathan T. Wolfe, MD
Jeffrey M. Wolff, MD
Richard D. Wortzel, MD, PhD
PUERTO RICO
Jorge L. Sanchez, MD
RHODE ISLAND
Michael A. Bharier, MD
M. Kathleen Carney-Godley, MD
Raymond G. Dufresne, Jr., MD
Ellen H. Frankel, MD
Jennifer Gray, MD
Nomate Kpea, DO
Thomas P. Long, MD
Charles J. McDonald, MD
Jennie J. Muglia, MD
David S. Pomerantz, MD
Leslie Robinson-Bostom, MD
Jon S. Solis, MD
Caroline S. Wilkel, MD
SOUTH CAROLINA
Robert D. Bibb, MD
Linwood G. Bradford, MD
Marguerite A. Germain, MD
Katherine R. Hamlet, MD
John M. Humeniuk, MD
Pierre Jaffe, MD
Carl A. Johnson, MD
Lawrence Klein, MD
John C. Maize, Sr., MD
Oswald L. Mikell, MD
Mark J. Quarterman, MD
Patricia P. Westmoreland, MD
SOUTH DAKOTA
Lycia A. Scott, MD
TENNESSEE
Michael W. Bell, MD
T. Wayne Day, MD
Darrel L. Ellis, MD
Charles S. Fulk, MD
Charles I. Huddleston, MD
Larry D. Hudson, MD
Robert L. Jackson, MD
Albert A. Kattine, MD
Lloyd E. King, Jr., MD, PhD
Dana L. Latour, MD
Michel A. McDonald, MD
Jami L. Miller, MD
Julie M. Pena, MD
Carla R. Retief, MD
Donald A. Sharp, MD
George P. Stricklin, MD, PhD
Michael D. Zanolli, MD
TEXAS
Daniel S. Achtman, MD
Mary Z. Adams, MD
Max F. Adler, MD
Kent S. Aftergut, MD
Ross A. Alexander, MD
Prapand Apisarnthanarax, MD
Daniel D. Bennett, MD
James R. Bond, Jr., MD
Angela G. Bowers, MD
Michael W. Braden, MD
Suzanne Bruce, MD
Vivian W. Bucay, MD
David F. Butler, MD
Turner M. Caldwell III, MD
M. Basem Chaker, MD
Robert L. Chappell, Jr., MD
Debra L. Chernosky, MD
Holly H. Clark, MD
Justin W. Clark, MD
Cynthia O. Clegg, MD
Linda J. Royall Coffey, MD
Jack B. Cohen, DO
Lucius P. Cook, MD
William F. Cothern, DO
Gary F. Cox, MD
Margaret A. Curry, MD
Ronald S. Davis, MD
Steven A. Davis, MD
Thomas L. Davis, MD
Elizabeth Dolan, MD
Susan E. Dozier, MD
Janet C. DuBois, MD
Anne Epstein, MD
Rebecca L. Euwer, MD
R. John Fox, Jr., MD
Toni Funicella, MD
Howard B. Gerber, MD
John J. Ghidoni, MD
Irma Gigli, MD
Philip W. Giles, MD
Leonard H. Goldberg, MD
Ronald E. Grimwood, MD
Aubrey C. Hartmann, MD
Adelaide A. Hebert, MD
James H. Herndon, Jr., MD
Peter D. Hino, MD
Richard H. Hope, MD
Stephen D. Houston, MD
F. Lester Howsden, MD
Susan M. Howsden, MD
Myra B. Hull, PhD
Mary E. Hurley, MD
Aaron K. Joseph, MD
Lawrence M. Joseph, MD
Candace S. Kasper, MD
Charles D. Kennard, MD
Mark D. Koone, MD
Leslie S. Ledbetter, MD
Lester F. Libow, MD
Jeffrey J. Meffert, MD
Denise W. Metry, MD
Kenneth H. Neldner, MD
Anh V. Nguyen, MD
Tri H. Nguyen, MD
Gregory A. Nikolaidis, MD
Janna Nunez-Gussman, MD
Robert L. Ochs, MD
Isaac Perez, MD
F. Charles Petr, Jr., MD
Susana C. Poliak, MD
William Posten, MD
Mark A. Price, MD
William M. Ramsdell, MD
Ronald J. Ressmann, MD
Robin A. Roberts, MD
Howard A. Rubin, MD
Hans M. Sander, MD
Lilly H. Schaffer, MD
Jerald L. Sklar, MD
Jennifer L. Smith, MD
Thomas J. Stephens, PhD
Allison J. Stocker, MD
Craig F. Teller, MD
Mark D. Thieberg, MD
Gregory W. Thompson, MD
Charles S. Thurston, MD
Bryan L. Townsend, MD
Jaime A. Tschen, MD
Premalatha Vindhya, MD
Mark S. Wallis, MD
T. Lynn Warthan, MD
Mark B. Weinstein, MD
Michael J. Wells, MD
David A. Whiting, MD
Daniel D. Witheiler, MD
John E. Wolf, Jr., MD
Jeffrey P. Young, MD
UTAH
John L. Bezzant, MD
John S. Blake, MD
Anneli R. Bowen, MD
R. Ralph Bradley, MD
Russell W. Eyre, MD
Warren G. Eyre, MD
Ivan D. Flint, MD
Scott R. Florell, MD
Douglas Grossman, MD, PhD
C. David Hansen, MD
Kraig K. Jenson, MD
Sancy A. Leachman, MD, PhD
Richard W. Parkinson, MD
Douglas L. Powell, MD
Wayne E. Smith, MD
Bradley K. Summers, MD
Payam Tristani-Firouzi, MD
VERMONT
Glenn D. Goldman, MD
Paul A. Krusinski, MD
Daniel P. McCauliffe, MD
Steven R. Partilo, MD
Kathryn Schwarzenberger, MD
VIRGINIA
Amir A. Bajoghli, MD
Allison K. Divers, MD
Lawrence J. Finkel, MD
Herbert S. Golomb, MD
Antoinette F. Hood, MD
Edward N. Kitces, MD
Hazle S. Konerding, MD
Gayle D. Masri-Fridling, MD
Neeraja C. Mattay, MD
Alan N. Moshell, MD
Charles F. Payne, Jr., MD
Michelle A. Rivera, MD
Steven M. Rotter, MD
Robert Silverman, MD
Katherine A. Treherne, MD
Hazel J. Vernon, MD
Carmen M. Williams, MD
WASHINGTON
Craig S. Birkby, MD
James L. Brazil, MD
Daniel B. Dietzman, MD
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Brandith Irwin, MD
Paul Nghiem, MD, PhD
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Joel K. Sears, MD
Janet M. Trowbridge, MD, PhD
Karen M. Vigeland, MD
WEST VIRGINIA
Alan M. Ruben, MD
WISCONSIN
William Aughenbaugh, MD
John S. Cantieri, MD
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Nyles R. Eskritt, MD
Sheila S. Galbraith, MD
Manish J. Gharia, MD
Ellen M. Gordon, MD
B. Jack Longley, MD
Eugene W. Monroe, MD
Thomas J. Russell, MD
Lawrence C. Scherrer, MD, PhD
Thorsteinn Skulason, MD
Michael J. Smullen, MD
Kathleen S. Stokes, MD
Bradley T. Straka, MD
Erik J. Stratman, MD
Gary S. Wood, MD
WYOMING
Scott D. Bennion, MD
Larry E. Seitz, MD
Sandra K. Surbrugg, MD
AUSTRIA
Erwin Tschachler, MD
CANADA
Alastair Carruthers, MD
Walter P. Unger, MD
JAPAN
Takashi Aoyagi, MD
Key
Leaders Society Founding
& Continuous Member
∞ Deceased (Memorial)
Dermatology Foundation
lesions and diabetes insipidus, and a secondary risk for tumors.
Many consider this a neoplastic disease, and a hematologic oncologist should be involved in treatment and monitoring.
Langerhans Cell Histiocytosis
Summary
• Tremendous variability in presentation
• Tremendous variability in outcome
• Age of onset and organ involvement at time of
diagnosis—prognostic indicator
• Therapy adjusted for severity of disease
Treatment
• Multisystem disease
– No consensus as to most effective & safe rx
• Best results
– Vinblastine, etoposide, prednisolone,
mercaptopurine, ± methotrexate
• Failure to respond to Rx at 6 weeks—poor prognosis
• Those >2yrs at Dx who did not have marrow, liver,
lung, spleen involvement—100% survival
• Other Rx: ATG, thalidomide, 2-chlorodeoxyadenosine,
cyclosporine, organ transplant
Atypical Spitz Tumor. Tsao discussed a 10-year-old girl
with a nevus—that had developed over her right posterior shoulder
during the previous year—identified as a large (3.2 mm) atypical
Spitz tumor. Tsao described these tumors, citing three patient
series showing them to be highly metastatic (positive SLNB in 25%,
44%, and 50%) but with a very low lethal potential (all were alive
at follow-up of 12–35 months).
PEM. A 4-year-old girl had a very dark and growing congenital mole—identified as a PEM—removed from the left side of her
head. Tsao traced the PEM’s molecular development and noted
overlap with tumors in the Carney complex. Data show that 46% of
PEM metastasize to the SLN (and additional positive nodes are
sometimes identified), but again, lethal potential is very low.
The Issues. Survival data for these two borderline tumors
and for pediatric melanomas are significantly better than for adult
melanoma. This all points to likely differences in melanocyte
biology and behavior between pediatric and adult melanocytic
tumors, critically affecting the SLNB discussion/decision. Does it
make sense to do SLNB if the consequences of a positive finding—
typically a complete node dissection (with high morbidity in a
young patient, especially in the head and neck area), and often
interferon treatment—will not alter a child’s survival?
Hemangiomas: Diagnosis and Treatments
Sheila Fallon Friedlander, MD
Melanomalies—Borderline Melanocytic Tumors
Hensin Tsao, MD, PhD
Of the borderline melanocytic tumors—which are clinically challenging entities—the two encountered in the pediatric population are
atypical Spitz tumors and the heavily melanized pigmented epithelioid
melanocytomas (PEM). Two parameters delineate the “borders”—one
ranging from metastatic to non-metastatic, the other ranging from
potentially lethal to non-lethal. For a borderline melanocytic tumor,
one must distinguish between its capacity to metastasize and its
ability to kill when discussing if: (1) it should be re-excised, and with
what margins? and (2) a sentinel lymph node biopsy (SLNB) should
be done, and should interferon treatment follow a positive result?
Common Mel-anomalies:
Sentinal Lymph Node Biopsy?
• DISCUSSION is critical, but not necessarily a firm recommendation
• Consider it more seriously in adult patients vs pediatric patients
• Weigh risk of completion lymph node neck dissection if SLNB
is positive
• What we know:
– Large trials have not shown SLNB to improve overall survival—
useful only for information
– If tumor detected in sentinel nodes, need to be prepared for
complete dissection—can be highly morbid
– Lymph nodes will be followed carefully with ongoing clinical
exams regardless of SLNB performance
– ≤40% of lymph nodes harbor tumor, but rarely lethal—
thus does not accurately predict outcome
– There is a small (probably <5%) but tangible chance that
tumor can prove fatal—eg, small subset of Spitzoid melanomas
that look identical to atypical Spitz
– NO trials have shown benefit for rare metastatic Spitz tumors—
no idea whether interferon will benefit.
• What will probably happen if positive:
– Refer to medical oncology
– Good chance that adolescent or older child will get interferon
– A “cure” will be touted as an interferon and oncology success
www.dermatologyfoundation.org
Current nomenclature for vascular lesions in children is based
on the distinction between malformations vs tumors, which
include hemangiomas. Hemangiomas of infancy have a programmed lifestyle: proliferation (up to 8–12 months), then involution, which initially is not clinically noticeable. Involution is typically 60% by age 6, 70% by age 7, 90% by age 9, etc. These hemangiomas are common, and many do not require treatment. Concern
is based on location (can it obstruct vision or breathing, will it be
subject to friction, is it midline), pattern (segmental is much more
risky than focal or small lesions), and patient age (urgency is
restricted to the rapid proliferation of infancy).
Gold Standard Approaches
• Watchful waiting
• Systemic prednisone 2-5 mg/kg/d—
Orapred 15 mg/5 cc tastes better;
give in a.m., 4-8 wks, taper asap
• Monitor: BP, growth
• Other issues:
– Infectious: Varicella, PCP, ?prophylaxis
– GI: ranitidine
• Topical class 1 steroids… eg, clobetasol
• Intralesional corticosteroids: beware of periorbital area!
• Laser
• Imiquimod cream 3x/wk; beware of ulcers
• Excision—if it’s pedunculated, in the right location
• For the difficult ones—
– interferon- 2a or 2b: 1-3 million units SC/m2 daily;
risks include spastic diplegia in ≤20%
– vincristine: 1 mg/m2 IV weekly; taper prn
Risks. A large plaque-like facial lesion is always cause for
worry and requires a careful exam, eye and cardiac exams
(including echo), and sooner or later a cranial MRA because of
long-term risk for vaso-occlusive phenomena. Beard area hemangiomas carry a risk of airway lesions. Midline lesions in the posterior lumbar–sacral area may be associated with spinal dysraphism
Spring 2007
11
problems. A large plaque-like lesion in the genital area involves
risk for pelvic and bladder anomalies.
Treatment. Provide calm reassurance when appropriate.
Treatment goals are: prevent function-threatening events, prevent
disfigurement, minimize psychosocial distress, avoid overly
aggressive procedures (and thus unnecessary scarring), prevent/
treat ulcerations. Small lesions need only watchful waiting. A large
facial lesion requires systemic prednisone (Orapred tastes better),
potentially for months with necessary precautions. Friedlander discussed both class I topical corticosteroids for small flat lesions,
concerns about intralesional corticosteroids around the eyes,
imiquimod (she is not a fan), excision (if pedunculated and
appropriately located), interferon (not preferred) and vincristine
(preferred) in severe cases.
Treating Ulcerated Hemangiomas. Friedlander advises
saline compresses, occlusive dressings and zinc oxide, and topical
antibiotics. For perineal lesions, she has excellent results with the
pulsed dye laser.
Friedlander concluded by summarizing the latest researchbased advances in understanding hemangiomas.
Immunomodulators in Children
Jon M. Hanifin, MD
This presentation addressed the more severely affected
pediatric patients with uncontrolled atopic disease, citing
relevant data.
IMR. Hanifin’s objectives are IMR—Induction, Maintenance,
and Rescue. The induction regimen—for both children and adults—
involves twice daily baths followed by triamcinolone 0.1% (or an
alternative of comparable potency) used on the face twice daily
for 3 days and on the trunk and extremities for 7 days. (This is far
more effective than prednisone, and avoids a rebound effect.)
With very unresponsive lichenified extremities, Hanifin switches to
betamethasone or a class I topical corticosteroid. Caveats: a low
potency steroid will not work; provide adequate quantities of
steroid but never give refills.
Maintaining control “is everything.” Some patients do well
with daily moisturizer and a twice-weekly mid-strength topical
steroid, including on the face. Topical calcineurin inhibitors
(TCIs) and UV light are the other important maintenance drugs.
Hanifin finds TCIs unequaled, safe for all areas needing treatment, and wonderful for eyelids. He reassures parents about the
black box warning by pointing to the phrase “evidence is lacking.” He repeated the well-known pro-TCI arguments for effective
maintenance. Hanifin typically uses a TCI for severe eczema in
babies as well, and finds that dermatologists are equipped to prescribe and monitor this appropriately. Rescue from inevitable
flares involves a timely, brief return to topical steroids. The sooner this occurs, the sooner the response.
Lichenified and Impervious. “Get in, hit it hard, and get
out.” Systemic therapy is appropriate, with “cyclosporin the
standout treatment for widespread, severe recalcitrant atopic
disease.” Begin at 5 mg/kg to avoid dragging out treatment time.
If no improvement in the first week, briefly increase to 7 mg/kg.
Gradually taper down to 3, possibly 2 mg/kg. If cyclosporin fails,
consider a transition to IFN- at 50 g/m2 (given subcutaneously
at bedtime to avoid headaches and flu-like symptoms). Hanifin
reported mixed results from trials of various biologicals, and
concern with both short- and long-term side effects.
He constantly confronts steroid phobia and TCI phobia—
fueled by pediatricians and naturopaths—which are major impediments to effective therapy of atopic dermatitis.
12
Spring 2007
Steroids for AD
What patients/parents need to know:
• The best—and often the only—anti-inflammatory
agent that works
• Toxic only with prolonged daily use (3-4 wk)
• Prolonged, twice weekly use is safe
• Brief, effective use is a safe goal
• Glucocorticosteroids—not androgenic steroids
• Potency must be proportional to severity
• Topicals always preferable to systemic
Personal philosophy of steroid use:
• Never use systemic steroids in pre-adolescents
• Twice daily baths followed by TAC 0.1% ung
– for 3 days (face, folds) to 7 days
– more effective than prednisone, and…
– avoids the rebound
• Adequate quantities but no refills
• For bad AD—low potency won’t work
Topical Calcineurin Inhibitors
Benefits and Reassurances
• Reduced disease—better infant growth
• Potential for less allergic respiratory disease
• Promotes lesser use of both TCS and TCI
• Rarely used extensively & continuously
• Blocking of NFAT far from complete
• Opportunistic infections vanishingly rare
The Practical Values
• As yet unequaled steroid-sparing therapy
• Great for eyelid inflammation—ocular irritation is rare
• Effective and apparently safe for face and intertriginous areas
• Necessary for severe AD, even in infants—and certainly
safer than cyclosporine!
Tough Acne in Adolescents
Diane M. Thiboutot, MD
Cases from Thiboutot’s practice were the springboard for discussing her approach. For mild and moderate acne—and sometimes
beyond—she begins with a topical retinoid, sometimes adding a benzoyl peroxide/clindamycin combination. If this fails, she adds an oral
antibiotic. With insufficient progress in a female patient, Thiboutot
prescribes an oral contraceptive and possibly low-dose spironalactone (25 mg once daily). The next step is isotretinoin. Maintenance
therapy for the difficult patient is often a topical retinoid.
She also offered the following guidance. (1) For sinus tracts that
remain after therapy with isotretinoin, intralesional injection during or
after isotretinoin may be beneficial. (2) With severe inflammatory
acne, avoid isotretinoin-induced flare by beginning with 0.5 mg/kg/day
along with prednisone (40–60 mg/day) that is tapered over the second
month of isotretinoin. (3) Culture lesions that resemble erosions
because a secondary infection is likely. (4) With facial edema, provide
high-dose steroids and taper over the first 2 months, continuing on
isotretinoin for 4 months. (5) Acne patients with sensitive skin do well
with modified regimens for the topical retinoids (tretinoin, adapalene,
tazarotene). One approach treats the skin just twice weekly. Another
involves short-contact regimens. Thiboutot also has these patients
wash with a gentle cleanser, then apply moisturizer over the retinoid
(Continued on page15)
Dermatology Foundation
“I have less itching
and flaking!”1
“Who says you can’t
have elegant hair using a
prescription shampoo?”
Efficacy and Elegance Together.
Please see full prescribing information on reverse side.
Safety Information:
LOPROX® Shampoo is indicated for the topical treatment of seborrheic dermatitis of the scalp in adults.
If no clinical improvement is shown after 4 weeks of treatment, the diagnosis should be reviewed.
LOPROX Shampoo is contraindicated in individuals who have shown hypersensitivity to any of its
components. The most common adverse reactions are pruritus, burning, erythema, seborrhea, and
rash. If a reaction suggesting sensitivity or irritation should occur, treatment should be discontinued and
appropriate therapy instituted. Avoid contact with eyes; if contact occurs, rinse thoroughly with water.
Seborrheic dermatitis may appear at puberty, however, no clinical studies have been done in patients
younger than 16 years. There is no relevant clinical experience in patients who have a history of
immunosuppression, who are immunocompromised, or who have diabetic neuropathy.
References:
1. LOPROX Shampoo [package insert]. Scottsdale, Ariz: Medicis Pharmaceutical Corporation; 2003.
© 2006 Medicis Pharmaceutical Corporation LPX 06-005 04/30/07 DF
at bedtime and alone in the morning. “Spending enough time educating patients on the proper use of topical retinoids increases the likelihood that they will stick with it and experience its impressive benefit.”
This includes teaching how much medication to use, because overuse
produces side effects. (6) Severe comedonal acne can be difficult to
treat because closed comedomes often remain after therapy. In such
cases, an epilating needle at a very low setting is effective.
Modified Regimens for
Acne Patients With Sensitive Skin
• Tretinoin, adapalene or tazarotene:
• Twice weekly
• Alternate day regimens
• Short contact:
– 30 sec daily for 3 days, increase at 30 sec
increments every 3 days up to 5 minutes.
– After 5 minutes, patients seem to tolerate
overnight quite well.
KEYNOTE ADDRESS
Not All Itches Arise in the Skin
Jeffrey D. Bernhard, MD
Neuropathic causes of localized itching—a source of itching
without a rash—can be diagnostically challenging due to the
absence of skin changes. (Excoriation, hyperpigmentation, and
eczematous changes, which can develop consequent to scratching and rubbing, may lead to the erroneous assumption that the
rash explains the itch rather than vice versa.) Bernhard traced the
neural pathway from skin to the spinal cord and up through the lateral spinothalamic tract to the cerebral cortex where itch is perceived. He presented illustrative conditions thought to arise from
impingement or compression of spinal or peripheral nerves.
Notalgia Paresthetica. This localized itching of the upper back,
often inferior to the scapula, is the primary symptom of this common
itch. Tingling, formication, burning, hyperalgesia, tenderness, and
numbness may also occur, separately or in any combination. A hallmark is the threadbare spot on clothing from continual scratching. The
physiopathology is thought to reflect the anatomy of the spinal nerves
innervating this area of the skin. The medial branch of the dorsal
ramus—unique in being extremely short, then making a right-hand turn
to reach the back—may be vulnerable to irritation as it travels through
the multifidus spinae muscle. X-ray-based studies point to impingement
Notalgia Paresthetica: Hyperpigmentation
from discs or vertebral abnormalities as another possible cause.
Brachoradial Pruritus. This intolerable itch—sometimes also
with tingling, prickling, or burning—typically affects the forearm over
the brachoradialis muscle but can cross the neck, involve the middle
back, the upper and lower extensor aspect of the arm, and be unilateral or bilateral. Skin-gouging for relief is not uncommon. Patients
often report that ice packs provide relief during the night (thus, asking a new patient about ice pack use is diagnostically useful). In a retrospective study of patient x-rays, Bernhard uniformly found cervical
spine disease correlated with itch location. He discussed putative
mechanisms involving impingement of axoplasmic flow in the nerve.
Miscellaneous. Some cases of scrotal itching may have a neurogenic origin. The itch in meralgia paresthetica involves the distribution of
the lateral femoral cutaneous nerve. In an x-ray study of patients with
anogenital itching, 80% showed degenerative changes in the lower spine.
Treatment. Off-label gabapentin may be helpful with neuropathic itches, especially in brachioradial pruritus.
MINI-SYMPOSIUM:
UV LIGHT: PROTECTION AND USES
Photoprotection and Sunscreens
Henry W. Lim, MD
The FDA Sunscreen Monograph. The FDA regulates UV filters as OTC medications, collating all relevant information in a periodically updated monograph. The latest version, dated 1999, includes
the 16 active agents approved at that point. Each agent has three
names: INCI (International Nomenclature of Cosmetic Ingredients),
USAN (U.S. Adopted Name), and trade name; eg, avobenzone
(USAN) is butyl methoxydibenzoyl methane (INCI) and Parsol 1789
(trade name). Organic agents are UV-absorbant chemicals. Inorganic
agents are the physical UV reflectors titanium dioxide and zinc oxide.
Because SPF testing (which addresses only UVB protection,
with no guideline for UVA protection) involves a much thicker
product application compared to typical use, compensate for this
dilution effect by using a higher SPF rating (45–60).
New Photoprotective Agents. The photostable shortspectrum UVA filter Mexoryl SX (ecamsule) was approved in July
2006, but only in the particular composition and SPF of the specific product submitted (Anthélios, SPF 15). Helioplex™ is the patented group of photostable and photostabilized UV filters combined
to provide a broad spectrum coverage. The FDA is currently considering 4 new UVB filters and 2 UVA/UVB filters. Other new filters
are available elsewhere in the world.
Sunscreen Agents: Highlights
• Octinoxate (ethylhexyl methoxy-cinnamate): the
most widely used UVB filter.
• Oxybenzone (benzophenone-3): the most common
cause of positive photopatch test response.
• Sulisobenzone (benzophenone-4): the most common
cause of positive patch test response among tested
UV filters.
• Avobenzone (butyl methoxydibenzoyl methane):
the only filter with long-spectrum UVA protection.
• Titanium dioxide: provides UVA & UVB coverage,
but low absorption peak impairs its efficiency.
(Continued on page18)
www.dermatologyfoundation.org
Spring 2007
15
384 Annenberg Circle Members Make
Strong Commitment to Research
Annenberg Circle members have
increased their support of dermatologic
research and the advancement of the
specialty by pledging $25,000. This substantial contribution to funding the knowledge base of the
specialty makes them all participants in shaping the
future of dermatology. To become an Annenberg Circle
member and share in maintaining a powerful specialty
for tomorrow, contact the Dermatology Foundation at
847-328-2256 or at [email protected].
SUSTAINING MEMBERS
Annual dues contribution of
$5,000 beyond $25,000 pledge
Thomas W. Andrews, MD
Robert B. Ash, MD
Eugene A. Bauer, MD
David R. Bickers, MD◆
Roger I. Ceilley, MD
Clay J. Cockerell, MD
William P. Davey, MD
Richard L. Edelson, MD
James O. Ertle, MD
Anita C. Gilliam, MD, PhD
Gloria F. Graham, MD
James H. Graham, MD
Harley A. Haynes, MD
Waine C. Johnson, MD
Robert E. Jordon, MD
Gerald G. Krueger, MD
Albert M. Lefkovits, MD
Gregory G. Messenger, MD
Warwick L. Morison, MD
Dennis E. Newton III, MD
Glenn A. Oclassen
Margaret E. Olsen, MD◆
Thomas G. Olsen, MD
Neil S. Sadick, MD
Daniel M. Stewart, DO
Leonard J. Swinyer, MD
Patricia S. Walker, MD, PhD
Bruce U. Wintroub, MD
Mitchell Wortzman, PhD
FROM THE SPECIALTY
David M. Adelson, MD
Susan K. Ailor, MD
D. Edgar Allen, MD
Tina S. Alster, MD◆
Douglas D. Altchek, MD
Jeffrey S. Altman, MD
David A. Amato, DO
Lawrence L. Anderson, MD
Diane R. Baker, MD
Phillip B. Bandel, MD
Joel R. Barkoff, MD
Matthew D. Barrows, MD
Rodney S.W. Basler, MD◆
Leslie Baumann, MD
Paul W. Becker, MD
Eric R. Berg, MD
Paul R. Bergstresser, MD
Alan R. Berlin, DO
Karl R. Beutner, MD, PhD
Jag Bhawan, MD
16
Spring 2007
Kenneth B. Bielinski, MD
Joseph B. Bikowski, MD
John Q. Binhlam, MD
Jay E. Birnbaum, PhD
David E. Biro, MD
Kay Bishop, MD
Marshall L. Blankenship, MD◆
Jean L. Bolognia, MD
Glen M. Bowen, MD
Ronald R. Brancaccio, MD
Martin Braun III, MD
Jonith Y. Breadon, MD
Robert A. Briggaman, MD
Robert T. Brodell, MD◆
Christine D. Brown, MD
Clarence W. Brown, Jr., MD
Forrest C. Brown, MD
Marc D. Brown, MD
Stuart M. Brown, MD
Karen E. Burke, MD, PhD
Lawrence L. Bushkell, MD
David A. Byrne, MD
Jeffrey P. Callen, MD
Valerie D. Callender, MD
Robert G. Carney, Jr., MD
Rebecca J. Caserio, MD
Gabriella Castillo, MD
Jennifer C. Cather, MD
S. Wright Caughman, MD
Johanna Chapel, MD
Marvin E. Chernosky, MD◆
Neldagae S. Chisa, MD
Lani E. Clark, MD
Richard A. Clark, MD
Mark G. Cleveland, MD, PhD
Lisa M. Cohen, MD
Steven R. Cohen, MD, MPH
Brett M. Coldiron, MD
Kevin D. Cooper, MD
Thomas W. Cooper, MD
Michael E. Cormier, MD
Lynn A. Cornelius, MD
Gregory J. Cox, MD, PC
Judith E. Crowell, MD
Ponciano D. Cruz, Jr., MD
C. Ralph Daniel III, MD
James Q. Del Rosso, DO
Vincent A. DeLeo, MD
Jerry E. Dickson, MD
William Dorner, Jr., MD
Jeffrey S. Dover, MD
Howard V. Dubin, MD
Dan A. Dunaway, MD
Karynne O. Duncan, MD
W. Christopher Duncan, MD
Madeleine Duvic, MD
Gary A. Dyer, MD
William H. Eaglstein, MD
Michael J. Ebertz, MD
Peter G. Ehrnstrom, MD
Boni E. Elewski, MD◆
Charles N. Ellis, MD
Melvin L. Elson, MD◆
Paul E. English, MD
John H. Epstein, MD◆
Ervin H. Epstein, Jr., MD
William L. Epstein, MD ∞
Wayne A. Fagan, MD
Janet A. Fairley, MD
Patricia Farris, MD
Patrick R. Feehan, MD
Steven R. Feldman, MD, PhD
Kathy A. Fields, MD
Marian C. Finan, MD
Robert M. Fine, MD
Frederick S. Fish III, MD
Richard E. Fitzpatrick, MD
Helen Flamenbaum, MD
David N. Flieger, MD
Michael J. Franzblau, MD
Irwin M. Freedberg, MD ∞
Alvin E. Friedman-Kien, MD
Phillip Frost, MD◆
J. Harvey Gardner, MD
Lisa A. Garner, MD
Jacquelyn B. Garrett, MD
Maria C. Garzon, MD
Bryon L. Gaul, MD
John K. Geisse, MD
Paul Getz, MD
Barbara A. Gilchrest, MD
Michael Girardi, MD
Robert F. Godwin, MD
Michael H. Gold, MD
David J. Goldberg, MD
Michael T. Goldfarb, MD
Harry M. Goldin, MD
Mitchel P. Goldman, MD
Lowell A. Goldsmith, MD
Ernesto Gonzalez, MD
Kenneth B. Gordon, MD
Lillian R. Graf, MD
Michael A. Greenberg, MD
Robert D. Greenberg, MD
Daniel S. Groisser, MD
Alexander S. Gross, MD
Karyn L. Grossman, MD
Victoria Gunn, MD
John C. Hall, MD
Ronald D. Hall, MD
George W. Hambrick, Jr., MD
John R. Hamill, Jr., MD
Jon M. Hanifin, MD
C. William Hanke, MD
John M. Haraldsen, MD
Thomas D. Harris, MD
N. Patrick Hennessey, MD
James J. Herrmann, MD
Warren R. Heymann, MD
Juliana Hicks, MD
Edmund R. Hobbs, MD
Julie A. Hodge, MD, MPH
Jean M. Holland, MD
Mark J. Holzberg, MD
Maria K. Hordinsky, MD
Michael S. Howard, MD
Nathan R. Howe, MD, PhD
Amy A. Huber, MD
Michael J. Huether, MD
Stuart I. Jacobs, MD
Coleman Jacobson, MD◆
Marie-Louise Johnson, MD, PhD
Richard A. Johnson, MD
Timothy M. Johnson, MD
William D. Ju, MD
John B. Kalis, MD
Ralph M. Kamell, MD
Robert Katz, MD
Valda N. Kaye, MD
Matthew R. Kelleher, MD
David N. Kingsley, MD
Arnold W. Klein, MD
Jeffrey A. Klein, MD
Jay C. Klemme, MD
Albert M. Kligman, MD, PhD◆
Thomas Kupper, MD
Marilyn S. Kwolek, MD
Walter G. Larsen, MD
Thomas J. Lawley, MD
Gerald S. Lazarus, MD
Phil LeBoit, MD
Stanton S. Lebouitz, MD
Mark Lebwohl, MD
Francis C. Lee, MD
Robert G. Lee, MD
David J. Leffell, MD
Barry Leshin, MD
Stuart R. Lessin, MD
Stephen B. Levitt, MD
Gary D. Lichten, MD
Patrick J. Lillis, MD
Henry W. Lim, MD
Marketa Limova, MD
Peter C. Lombardo, MD
Mary P. Lupo, MD
James D. Maberry, MD
Frederick D. Malkinson, MD, DMD
Michael G. Mancuso, MD
Eugene Mandrea, MD
Stephanie F. Marschall, MD
Mary C. Martini, MD
Barbara M. Mathes, MD
Robert T. Matheson, MD
Elizabeth I. McBurney, MD
Robert E. McCallister, MD
Camilla S. McCalmont, MD
Timothy H. McCalmont, MD
Robert A. McDonald, MD
Robert J. McNamara, MD
Jennifer M. McNiff, MD
Alan Menter, MD◆
Andrew L. Messenger, MD
Donald J. Miech, MD
Martin C. Mihm, Jr., MD
D. Scott Miller, MD
Stanley J. Miller, MD
John C. Moad, MD
Angela Yen Moore, MD
Eliot N. Mostow, MD, MPH
Ronald L. Moy, MD
Peter J. Muelleman, MD
M. Gayle Mullanax, MD
Howard Murad, MD◆
Diya F. Mutasim, MD
Douglas N. Naversen, MD
Lee T. Nesbitt, Jr., MD
Marcy Neuburg, MD
Jackie L. Nixon-Fulton, MD
David A. Norris, MD
Peter B. Odland, MD
Marianne N. O’Donoghue, MD
Seth J. Orlow, MD, PhD
Robert L. Orme, MD, PC
Richard E. Otoski, MD
Gerald G. Overly, MD◆
Lafayette G. Owen, MD
Amy S. Paller, MD
David M. Pariser, MD
John A. Parrish, MD
William T. Parsons, MD◆
Barry S. Paul, MD
Nicholas V. Perricone, MD
Marta J. Petersen, MD
Sheldon R. Pinnell, MD
Frank J. Pinto, MD
R. Todd Plott, MD
Rhonda Rand, MD
Ronald P. Rapini, MD
Desiree Ratner, MD
Marilyn C. Ray, MD
Barbara R. Reed, MD
Colleen M. Reisz, MD
Kathleen A. Remlinger, MD
Lisa J. Renfro, MD
Jack S. Resneck, MD
Arthur R. Rhodes, MD, MPH
Phoebe Rich, MD
Julee K. Richards, MD
Barry J. Richter, MD
Jennifer M. Ridge, MD
Mitchell A. Rinek, MD
Wendy E. Roberts, MD
Katie Rodan, MD
Roy S. Rogers III, MD
Alain H. Rook, MD
Jill R. Rosenthal, MD
Carl B. Rountree, MD
Louis Rubin, MD
Earl J. Rudner, MD
Richard N. Rudnicki, DO
Leslie F. Safer, MD
Harry W. Saperstein, MD
William S. Sawchuk, MD
Richard K. Scher, MD◆
Jimmy D. Schmidt, MD◆
John J. Schmidt, MD
Norma H. Schmitz, MD
Bryan C. Schultz, MD◆
Joseph J. Shaffer, MD
Alan R. Shalita, MD◆
Steven K. Shama, MD, MPH◆
Ava T. Shamban, MD
Albert Shapiro, MD◆
Robert S. Shapiro, MD
Christopher R. Shea, MD
Laurence A. Sibrack, MD
Daniel M. Siegel, MD
Marvin D. Siegel, MD
David N. Silvers, MD
Kristin W. Smallwood, MD
Stephen N. Snow, MD
Mary C. Spellman, MD
Richard L. Spielvogel, MD
David A. Spott, MD
John R. Stanley, MD
Thomas Stasko, MD
Marek A. Stawiski, MD
Cloyce L. Stetson, MD, MS
Roger H. Stewart, MD
Mitchell C. Stickler, MD
Donna L. Stockton, MD
Stephen P. Stone, MD
Paul A. Storrs, MD
John S. Strauss, MD
Hiram M. Sturm, MD
Richard L. Sturm, MD
Arthur J. Sumrall, MD
Neil A. Swanson, MD
Robert A. Swerlick, MD
Mark B. Taylor, MD
R. Stan Taylor, MD
Nia K. Terezakis, MD
Michael D. Tharp, MD
Maurice A. Thew, MD
Diane M. Thiboutot, MD
Julian M. Thomas, MD
Stephen T. Thomson, MD
Robert E. Tigelaar, MD
Marcia G. Tonnesen, MD
Helen M. Torok, MD
Ben M. Treen, MD◆
James L. Troy, MD
James E. Turner, MD, PhD
W. Harrison Turner III, MD
Stephen K. Tyring, MD, PhD
Jouni J. Uitto, MD, PhD◆
Sheryll L. Vanderhooft, MD
John J. Voorhees, MD
David Wacker, MD
Donald S. Waldorf, MD◆
Patrick Walsh, MD
Robert R. Walther, MD
Bill V. Way, DO
Wallace N. Weber, MD
Stephen B. Webster, MD
Susan H. Weinkle, MD
Jonathan S. Weiss, MD
Robert A. Weiss, MD
Howard G. Welgus, MD
Kathleen M. Welsh, MD
W. Phillip Werschler, MD
Patricia S. Wexler, MD
Barbara Dahl Wilson, MD
George B. Winton, MD
Allan S. Wirtzer, MD
David T. Woodley, MD
Kim B. Yancey, MD
Daniel B. Yarosh, PhD
Ruth A. Yates, MD
James A. Yeckley, MD
Herschel S. Zackheim, MD
Scott Zahner, MD
Nardo Zaias, MD
Robert H. Zax, MD
Douglas K. Zirker, MD
John J. Zone, MD
FROM THE PUBLIC
Douglas Canfield
Stephen W. Clark
David D. Fadness
Gavin S. Herbert◆
Ira Lawrence, MD
Thomas L. Mehl, Sr.
Werner K. Stiefel ∞
Wayne Traub
Thomas G. Wiggans
◆ Founder
∞ Deceased
Dermatology Foundation
Dermatology Foundation
Corporate Honor Society
Partners in Shaping Dermatology’s Future
The Dermatology Foundation gratefully acknowledges the following
corporate partners who generously support its mission to foster the
development of emerging leaders in the specialty and enhance patient care.
We are especially appreciative of the $1 million multi-year pledges
made by Galderma Laboratories, L.P. and Stiefel Laboratories, Inc.
Platinum Benefactor ($200,000 or more)
Gold Benefactor ($100,000 or more)
Abbott
Astellas Pharma US, Inc.
Allergan Dermatology
Dermik Laboratories, Inc.
Silver Benefactor ($50,000 or more)
Avon Products, Inc.
L’Oréal Recherche
Coria Laboratories
Mary Kay Inc.
Genentech, Inc.
Novartis Pharmaceuticals Corporation
Graceway Pharmaceuticals, LLC
www.dermatologyfoundation.org
Spring 2007
17
Vitamin D. There are 3 sources: exposure of the skin to the 300nm range of the UVB spectrum in sunlight; dietary intake (salt water fish,
cod liver oil, egg yolk); and vitamin supplement (as D3 or D2). Lim
noted a series of epidemiologic studies suggesting a role for vitamin D in
cancer protection and in other significant health issues, and specified
the groups vulnerable to vitamin D insufficiency. He indicated it is reasonable to revise the minimum supplement dose for adults to 800–1000
IU daily, noting that toxicity does not occur until above 10,000 IU daily.
Melanoma Specific Criteria
The New Light Boxes
Henry W. Lim, MD
Narrow Band-UVB (NB-UVB). This light source is used for
psoriasis, vitiligo, MF, PMLE desensitization, and many other conditions. Lim reviewed the reports from the U.K. and Europe, where it
has been used since the mid-1980s. Only basal cell carcinoma (BCC)
increased slightly, explainable by the presence of other risk factors.
UVA-1. This is the longest spectrum of UVA (340–400 nm), one of
the newer phototherapies with a lengthy list of indications, which
unfortunately is not yet widely available in the U.S. Results are especially good with sclerotic skin diseases (with morphea—localized scleroderma—the most studied) and urticaria pigmentosa. Lim summarized representative studies for a variety of indications, highlighting
the excellent results with morphea and noting it as his first-line treatment for this disease. In urticaria pigmentosa, UVA-1 dramatically
improves pruritus, and thus quality of life. UVA-1 induces collagenase
(MMP-1), its likely mechanism in treating sclerosing diseases, and also
induces apoptosis of T cells (in atopic dermatitis and CTCL) and mast
cells (in urticaria pigmentosa). Long-term side effects are unknown.
Targeted Phototherapy. Used primarily for psoriasis and
vitiligo, this involves the excimer laser, monochromatic excimer
light, and other devices. Lim uses it in psoriasis for residual resistant lesions after NB-UVB, for hyperkeratotic lesions on palms and
soles, and for scalp lesions.
Visible Light. Used in topical photodynamic therapy (PDT) for
actinic keratoses, the newest protocol involves application of 5-ALA
solution for 1–3 hours, then exposure to blue light. In Europe, it is also
used to treat non-melanoma skin cancer. There is a consensus that topical PDT is effective for Bowen’s disease, superficial BCC, nodular BCC
<2 mm, and for chemoprevention in immunosuppressed patients.
NB-UVB
Indications
• Psoriasis
• Vitiligo
UVA-1
• Morphea
• Atopic dermatitis
• Cutaneous T-cell lymphoma
• Polymorphous light eruption
• Atopic dermatitis
• Systemic sclerosis
• Scleroderma
• Urticaria pigmentosa
Application of Dermoscopy to Early Diagnosis,
Management, and Prevention of Melanoma
Albert M. Lefkovits, MD
Lefkovits summarized the significantly increasing melanoma
burden in the U.S., reflecting the interplay between the steep rise in
frequency (from 1/350 to 1/65 over the past 70 years), the continually growing U.S. population, and more and more people living
longer (mortality from melanoma increases with age). Melanoma
is a complex cancer with many predisposing factors—including
genetics and sun exposure—and can begin de novo or evolve from
a benign nevus. The prognosis for advanced disease is dismal, but
18
Spring 2007
Asymmetry of color and structure, a multicomponent global pattern (1,2,3),
irregular pigment network (), irregular dots and globules (), a focus of streaks
). Pink color, beware (+)!
(O), dotted vessels (O) and a blue-white structure (
(From: Robert Johr, MD; Iris Zalaudek, MD; Giuseppe Argenziano,
MD. Learn By Doing: A Dermoscopy Monograph)
early detection and treatment produce an almost 100% cure rate.
Thus, the earliest possible detection—at the stage of severely dysplastic nevus or early in situ—is crucial for saving many lives and
avoiding the debilitation of extensive surgery and chemotherapy.
Dermoscope is an umbrella term for a group of hand-held microscope-like instruments that magnify the lesion and provide a view of
structure beneath the stratum corneum. This enables a structural analysis of pigmented lesions along with a permanent visual record for
informative comparison. Dermoscopy proponents find that structural
analysis and classification of pigmented lesions enable identifying
potentially troublesome lesions in their earliest stages, and with a precision that avoids unnecessary biopsies. Lefkovits finds dermoscopy
significantly more effective than total body photographs for following
individual lesions over time in patients with dysplastic nevus syndrome, and it enables dermatologists in remote areas to communicate
effectively with colleagues in academic centers. Lefkovits described
different equipment and classification systems and provided a wealth
of slides demonstrating dermoscopy’s capabilities.
He also summarized dermoscopy’s current limitations, including the plethora of systems, the extensive array of features to master, and the variety of alternative classification schemata. Finally,
dermoscopy “is a very valuable diagnostic tool, but in the end
there is no substitute for clinical observation and evaluation by
well-trained dermatologists.” ■
2007 DF Clinical Symposia Faculty Disclosures (Part I)
Jeffrey D. Bernhard, MD: No financial relationships with commercial interest
Sheila Fallon Friedlander, MD: R,H/Connectics, Inc; R,C,A,H/Novartis; A,H/PharmaDerm
Jon M. Hanifin, MD: G,R,C/Astellas; G,R,C/Connectics, Inc; G,R,C/Corgentech;
G,R,C/Genentech; G,R,C/GlaxoSmithKline; G,R,C/Novartis; G,R,C/Stiefel, Inc; G,R,C/Taisho
Albert M. Lefkovits, MD: C/Synera
James J. Leyden, MD: C/Allergan; C/Anacor; C/Avon; C/CollaGenex; C/Connetics; C/Galderma;
C/Johnson & Johnson; C/Mary Kay; C/Medicis; C/Obaji; C/Skin Medica; C/Stiefel; C/Unilever
Henry W. Lim, MD: G,R/Johnson & Johnson; C,H/La Roche-Possay/L’Oreal; C,H/Orfagen;
C,H/OrthoNeutrogena
Neil H. Shear, MD: C/Cephalon; G,C/GlaxoSmithKline
James S. Taylor, MD: S/Amgen; C,H/Betco, Inc; S/GlaxoSmithKline; G/Guidant Inc; S/Johnson &
Johnson; S/Keithley Instruments; S/Medco Health Solutions; C,H/Medicis; S/Merck & Company;
A,H/Novartis, Inc; C,H/Shire PLC; S/Wyeth Labs
Diane M. Thiboutot, MD: G,C,A,H/Collagenex, Inc; G,C,A,H/Connectics, Inc;
G,C,A,H/Galderma, Inc; G,C,A,H/Intendis, Inc; G,C,A,H/Johnson & Johnson;
G,C,A,H/OrthoNeutrogena; C/Stiefel, Inc; G/Wyeth, Inc
Hensin Tsao, MD, PhD: No financial relationships with commercial interest
Gary S. Wood, MD: C/GenMab; C/Gloucester; C/Merck
Legend: G = Grants; R = Research Support; C = Consultant/Speakers Bureau;
A = Advisory Board Membership; S = Stockholder (not as part of mutual fund);
H = Honorarium Recipient; E = Editorial Board Involvement; 0 = Other Financial Support
2007 DF CLINICAL SYMPOSIA: PART II
To appear in the Summer “Dermatology Focus”
Special Sites and Patients; Hot Topics; Future Paths
and Proteins; Esthetics and Surgery—How To
Dermatology Foundation
CLINICAL SYMPOSIA 2007 FACULTY
Proceedings—Part I
Jeffrey D. Bernhard, MD
Professor of Medicine and Physiology
Division of Dermatology
University of Massachusetts
Sheila Fallon Friedlander, MD
Professor of Pediatrics and Medicine
Division of Dermatology
University of California, San Diego
Jon M. Hanifin, MD
Professor
Department of Dermatology
Oregon Health & Science University
Albert M. Lefkovits, MD
Associate Professor
Department of Dermatology
Mount Sinai Medical Center
James J. Leyden, MD
Professor
Department of Dermatology
University of Pennsylvania
Henry W. Lim, MD
Professor and Chairman
Department of Dermatology
Henry Ford Hospital
Neil H. Shear, MD
Professor and Chief of Dermatology
Department of Dermatology
University of Toronto
James S. Taylor, MD
Head, Section of Industrial Dermatology
Department of Dermatology
Cleveland Clinic Foundation
Diane M. Thiboutot, MD
Professor
Department of Dermatology
Penn State University
Hensin Tsao, MD, PhD
Director, Melanoma and Pigmented Lesion Center
Department of Dermatology
Massachusetts General Hospital
Gary S. Wood, MD
Professor and Chairman
Department of Dermatology
University of Wisconsin - Madison
PROGRAM CO-CHAIRS
Anita C. Gilliam, MD, PhD
Professor
Department of Dermatology
Case Western Reserve University
Michael D. Tharp, MD
Professor and Chairman
Department of Dermatology
Rush University Medical Center
www.dermatologyfoundation.org
Corporate Sponsors
2007 DF Clinical Symposia—
Advances in Dermatology
Diamond Sponsor ($100,000 or more)
Amgen Wyeth
Stiefel Laboratories, Inc.
Emerald Sponsors ($50,000 or more)
Abbott
Allergan Dermatology
Astellas Pharma US, Inc.
Galderma Laboratories, L.P.
Graceway Pharmaceuticals, LLC
Sapphire Sponsors ($25,000 or more)
Centocor, Inc.
Genentech, Inc.
Intendis, Inc.
Mary Kay Inc.
Medicis, The Dermatology Company®
Neutrogena
Obagi Medical Products
The Procter & Gamble Co.
Ranbaxy Laboratories, Inc.
Unilever
Program Sponsors ($10,000 or more)
Anacor Pharmaceuticals, Inc.
Barrier Therapeutics, Inc.
CollaGenex Pharmaceuticals
Connetics Corporation
Coria Laboratories
Dermik Laboratories, Inc.
Doak Dermatologics
Ferndale Laboratories, Inc.
Merck Oncology
Merz Pharmaceuticals
OrthoNeutrogena
SkinMedica, Inc.
Warner Chilcott
Supporting Sponsors ($5,000 or more)
Canfield Scientific, Inc.
Chester Valley Pharmaceuticals, Inc.
Dow Pharmaceutical Sciences, Inc.
GlaxoSmithKline Consumer Healthcare
INAMED, a division of Allergan
Lumenis
Spring 2007
19
$10 Million Goal—
Stepping Up to the Challenge of the Future
The need for early career funding is great, and continues to grow with increasing speed.
be developed and award amounts can be
Federal research money has leveled off and
increased to meet the needs of the specialty.
heightened the competitiveness for research
grants. Promising candidates for
With the support of the entire
Research Awards Goal
DF awards must be turned away
dermatologic community, this goal
The $10 Million Challenge
each year due to funding limitacan be achieved and will have a
tions. To ensure that talented junior
$10 Million/Yr. profound effect on our shared objecfaculty and investigators can
tive—improving the lives of patients
compete effectively for federal
seeking the best care in medical
funding, more needs to be done.
and surgical dermatology. Today’s
$5 Million/Yr.
new research knowledge will
To meet this need, the
become part of tomorrow’s patient
Dermatology Foundation has
care resources for the clinician.
set a new goal of investing
$10 million annually in talented
There is no better time to
faculty and investigators
join
or increase your support
Current
Future
embarking on academic and
of the DF. Your new commitment
research careers. The bar has been raised so
to dermatology will have a substantial impact on
new multi-year career development awards can
the future of patient care, and on your practice.
Contact the DF at 847-328-2256 or [email protected] for more information.
DF
Dermatology Focus
c/o Dermatology Foundation
1560 Sherman Avenue
Evanston, Illinois 60201-4808
Non-Profit
U.S. Postage
PAID
Permit No. 566
Utica, NY
ADDRESS SERVICE REQUESTED
A DERMATOLOGY FOUNDATION PUBLICATION
®
SPONSORED BY MEDICIS, THE DERMATOLOGY COMPANY
VOL. 26 NO. 1
SPRING 2007