Dermatology Update: Literature’s Takeaways for Clinical Practice

The Maui Derm NP + PA Summer 2022 program kicked off with an update on the state of the specialty. A review of current literature provided a platform for a panel discussion on the most influential articles and how their conclusions will change the practice of dermatology in 2022 and beyond.¹

Offering expert perspectives on the top stories and their impact for clinicians were presenters Ted Rosen, MD, professor of dermatology at Baylor College of Medicine and chief of dermatology at the Houston VA medical center in Houston, Texas, James Treat, MD, professor of clinical pediatrics and dermatology and education director, pediatric dermatology at Children's Hospital of Philadelphia, the HUB for Clinical Collaboration in Pennsylvania, and Matthew J. Zirwas, MD, an associate professor at Ohio University Heritage College of Medicine in Athens, Ohio.

Zirwas was responsible for developing the Contact Allergen Management Program (CAMP) for the American Contact Dermatitis Society (ACDS) and specializes in allergy patch testing, psoriasis, and eczema.

He began by examining the article, “The Influence of Sunlight Exposure and Sun Protecting Behaviors on Allergic Outcomes in Early Childhood,” a study in which infants associated with a family hx of atopy wore UV dosimeters for the first 3 months of life. This research determined that the total UV exposure was strongly associated with risk of developing atopic dermatitis.²

“This makes lots of pathophysiologic and epidemiologic sense,” he said. “We treat AD with UV light and UV exposure during childhood has dropped in concert with increasing rates of AD.”

Zirwas went on to discuss the rapid improvement of burning scrotum syndrome with indomethacin, noting that oral carvedilol has been the most effective treatment in his opinion.

When faced with a patient with red scrotum syndrome, he starts with 3.125 mg bid and titrates up to symptom control. Although he has observed some bradycardia, there has been no instance of hypotension or fatigue in his patients, he said.

“Indomethacin has also helped as short-term rescue when carvedilol not adequate,” Zirwas said, adding the max dose should be 50 mg tid, and tapered as quickly as possible.

Another piece of literature that grabbed his attention this past year was one that revealed that alcohol flushing during dupilumab (Dupixent; Sanofi and Regeneron Pharmaceuticals) could lead to an emerging adverse event.³

The study began after people were placed on dupilumab for 24 weeks, and found that 10 minutes after consuming alcohol, some patients would develop periorbital and perioral erythema. However, the case report referenced in the article noted the patient reported these symptoms “would spontaneously resolve” in 20 minutes, “regardless of continued alcohol intake,” wrote the authors. According to the patient, the reaction was not triggered every time she consumed alcohol but, “dark alcohols would make the flushing worse,” she told investigators. According to the article, the patient’s reactions were less severe or less frequent if she consumed alcohol on more consecutive days. the adverse effects did not happen while taking tacrolimus, leading the authors to conclude that it was related to IL-4 inhibition.

The next study that Zirwas examined was a case study of 7 patients with forearm contact dermatitis from frequent surface cleaning. It was revealed that it could be irritant or allergic contact dermatitis and recommendations included wiping surfaces down with water at work or after cleaning at home.⁴

A cohort study of long-term use of oral corticosteroids and related harms among adults came next, and Zirwas noted when he needs an anti-inflammatory, he turns to dexamethasone for atopic dermatitis, contact dermatitis, and itch, while if he needs immunosuppression, he uses a prednisone drug to treat conditions such as lichen planus, pemphigus or pemphigoid.⁵

Turning his attention to a clinical trial that looked at the effect of cynatine HNS on hair and nail parameters, he revealed that in a randomized, double blind, controlled study, when utilizing processed keratin from sheep’s wool, nails saw a large reduction in breakage and significant increase in nail hardness. Hair brightness also went up considerably.⁶

Other literature he examined dealt with the impact of lab work up and supplementation on alopecia patients; the enhancement of stratum corneum lipid structure to improve skin barrier function and protect against irritation in adults with dry, eczema-prone skin; and 1ll looking at localized systemic contact dermatitis, using the vulva as a clue to identify allergen ingestion.

The latter study looked at two patients with vulvar itching and dermatitis—1 clearly flared in relation to their ovulatory cycle. The patient patch-tested positive to formaldehyde and improved but did not clear with avoidance. Zirwas said it would be reasonable to empirically recommend a 1-month trial of strict aspartame avoidance in patients with “odd” dermatitis.⁷

Another study was on the efficacy and safety of HAT1 compared with Calcipotriol in the treatment of patients with mild-to-moderate chronic plaque psoriasis, and Zirwas presented the findings from the open-label randomized comparative pilot clinical study. He called the findings, “impressive.”

A mini review was done on the efficacy of azithromycin in treatment of acne vulgaris came next, with Zirwas commenting on many studies dealing with this.

“In my opinion, azithromycin has a better safety profile than doxycycline or minocycline,” he said. “There’s much less concern about resistance.He added that the 2 regiment that make the most sense to him are “500 mg po qd x 3 days per week” and “500 mg po qd x 4 days, then 500 mg po qd once a week.”

The literature review continued with a one noteworthy study on the pruritus-reducing effects of omega-3 fatty acids in hemodialysis patients, where the results saw over 50% reduction in itch.⁸

A more recent clinical trial was an assessment of hand hygiene strategies on skin barrier function during COVID-19, with the major takeaways being to use alcohol hand sanitizer instead of soap, and the idea that using cold water to wash hands was better.⁹

Zirwas finished his talk by looking at the effectiveness and safety of lotion, cream, gel and ointment emollients for childhood eczema gleamed from a randomized phase 4 superiority trial. While families strongly preferred lotions or gels, there were no marked differences in AD severity or steroid use between groups studied.

It is clear that there is a lot of interesting and innovative research being done in dermatology, he said. “[Based on that], you will never practice the same way again,” Zirwas noted.

Disclosures

Zirwas is a speaker for Genentech, Novartis, Sanofi, and Regeneron Pharmaceuticals. He is a consultant for Sanofi/Regeneron Pharmaceuticals, FitBit, L’Oreal, LEO Pharma, Pfizer, Eli Lilly and Company, Arcutis Biotherapeutics, Ortho Dermatologics, Sol-Gel, Bausch Health, and EPI Health. He is an investigator for Sanofi/Regeneron Pharmaceuticals, LEO Pharma, Janssen Pharmaceuticals, Incyte, Vyne Therapeutics, UCB, Pfizer, Eli Lilly and Company, Asana Biosciences, Avillion, AbbVie, Edesa Biotech, Galderma, Dermavant, Arcutis Biotherapeutics, EPI Health, and Concert Pharmaceuticals. He is part owner of AspeticMD.

References

1. Rosen T, Treat J, Zirwas M. Dermatology update 2022. Presented at Maui Derm NP + PA. Held June 23-25, 2022, Colorado Springs, Colorado, and virtual.
2. Rueter K, Jones AP, Siafarikas A et al. The influence of sunlight exposure and sun protecting behaviours on allergic outcomes in early childhood. Int J Environ Res Public Health. 2021 May 19;18(10):5429. doi: 10.3390/ijerph18105429. PMID: 34069576; PMCID: PMC8161152.
3. Igelman SJ, Na C, Simpson EL. Alcohol-induced facial flushing in a patient with atopic dermatitis treated with dupilumab. JAAD Case Rep. 2020 Jan 25;6(2):139-140. doi: 10.1016/j.jdcr.2019.12.002. PMID: 32021896; PMCID: PMC6994276.
4. Hamann CR, Duprat G, Dagrosa AT, Mann JA. "Desktop dermatitis": a case series of 7 patients with forearm contact dermatitis from frequent surface cleaning. Dermatitis. 2021 Nov-Dec 01;32(6):e104-e107. doi: 10.1097/DER.0000000000000766. PMID: 34115668.
5. Yasir M, Goyal A, Sonthalia S. Corticosteroid adverse effects. [Updated 2021 Jul 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531462/
6. Beer C, Wood S, Veghte RH. A clinical trial to investigate the effect of cynatine HNS on hair and nail parameters. ScientificWorldJournal. 2014;2014:641723. doi: 10.1155/2014/641723. Epub 2014 Oct 16. PMID: 25386609; PMCID: PMC4214097.
7. Admani S, Maghfour J, Jacob SE. Localized systemic contact dermatitis: The vulva as a clue to identify allergen ingestion. Int J Womens Dermatol. 2021 Mar 3;7(5Part B):843-844. doi: 10.1016/j.ijwd.2021.02.009. PMID: 35028397; PMCID: PMC8714567.
8. Forouhari A, Moghtaderi M, Raeisi S et al. Pruritus-reducing effects of omega-3 fatty acids in hemodialysis patients: A cross-over randomized clinical trial. Hemodial Int. 2022 Feb 3. doi: 10.1111/hdi.13007. Epub ahead of print. PMID: 35112475.
9. Montero-Vilchez T, Martinez-Lopez A, Cuenca-Barrales C et al. Assessment of hand hygiene strategies on skin barrier function during COVID-19 pandemic: A randomized clinical trial. Contact Dermatitis. 2022 Apr;86(4):276-285. doi: 10.1111/cod.14034. Epub 2022 Jan 13. PMID: 34954837.
10. Ridd MJ, Santer M, MacNeill SJ et al. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial. Lancet Child Adolesc Health. 2022 May 23:S2352-4642(22)00146-8. doi: 10.1016/S2352-4642(22)00146-8. Epub ahead of print. PMID: 35617974.