Dr. Leyden - Modern medicine

Transcription

Dermatology Times®
Clinical Analysis for Today’s Skincare Specialists
In This Issue December 2015 VOL. 36, NO. 12
CLINICAL 12
Neruotransmitters may fuel
inflammatory flares
December 2015
Recommending stress reduction techniques
a reasonable therapy
COSMETIC 34
New option for pigmented lesions
Details of the new approved indication for PicoWay
Volume 36 No. 12
ONCOLOGY 42
ASDS responds to surgeon general’s
skin cancer prevention call to action
December 2015 | VOL. 36, NO. 12 |
SKIN GIVES CLUES TO
INTERNAL DISEASE
Experts discuss keys to recognizing
symptoms and treatment tips
A
Resources and programs you can implement now
to prevent skin cancer in your community.
BUSINESS 46
Three marketing tactics for lasers
Keep business coming in without breaking the
bank
CLINICAL
Keys to managing
adverse drug
reactions
B
Ilya Petrou, M.D. | Senior Staff Correspondent
DermatologyTimes.com
In the United States, approximately 1.5
million hospitalizations every year are due
to adverse drug reactions, and an estimated
100,000 people die from them. Cutaneous
drug reactions account for a large proportion of all adverse drug reactions and present
a unique set of diagnostic challenges. This
data underscores the need for clinicians
to carefully weigh which drugs they prescribe for their patients, according to Neil
H. Shear, M.D., F.R.C.P.C., F.A.C.P., professor
and chief of dermatology, University of Toronto, and director of the Drug Safety Clinic
at Sunnybrook Health Sciences Centre, Toronto, Canada.
Although many approved medications have excellent safety profiles, adverse drug reactions can be caused by
most any drug. These can range from a
fixed eruption to systemic manifestations,
which can be very severe. These reactions may mimic a large variety of skin diseases, including viral exanthems, collagen
vascular disease, neoplasia, bacterial
infection, psoriasis, and autoimmune
DRUG REACTIONS see page 13
C
A Erythematous poikilodermatous eruption seen in dermatomyositis, a condition with possible systemic involvement and an
approximately 10-20% association with an internal malignancy.
B Sarcoidosis presenting as subcutaneous nodules in the
arm. This condition can also involve lymph nodes, lungs, and
numerous other organ systems. C Picture of a hand displaying
Sweet Syndrome, an eruption in the skin that can be a sign of an
internal disease, including infections, inflammatory bowel disease,
and malignancy. Photos courtesy of Dr. Courtney Schadt
Louise Gagnon | Senior Staff Correspondent
Dermatologists have an opportunity
to play a pivotal role in the accurate identification and diagnosis of systemic diseases, according to Courtney Reynolds
Schadt, M.D., F.A.A.D., assistant professor of dermatology at the University of
Louisville in Louisville, Ky.
“The skin can be the presenting symptom of an internal disease,” Dr. Schadt
says. “There is a very broad differential
for rashes and skin lesions. Knowing the
appropriate differential diagnosis and
doing a biopsy guides the diagnosis and
management of patients.”
Cond it ion s t hat a re pr i m a r i l y
s y stem ic c a n have der matolog ic
m a n i fe s t at ion s , w it h s y mptom s
such as erythema and pruritus, Dr.
Schadt points out. Chronic cutaneous
SKIN CLUES see page 22
| THE TAKEAWAY | JAMES LEYDEN, M.D., discusses intralesional corticosteroids for sinus tracts and keratinous cysts. SEE PAGE 8
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DECEMBER 2015 ⁄ DERMATOLOGYTIMES.COM
EDITORIAL ADVISORY BOARD
Insight & Opinion From Our Advisory Board Leaders
Ronald G. Wheeland, M.D.,
is a private practitioner
in Tucson, Arizona
Mentoring and education
An exploration of the role of mentoring in the medical community,
medical education, and learning in general.
R
ecently, my six-year-old grandson stumbled and fell and cut his
chin, requiring “stitches.” It was pretty traumatic since he never
had “stitches” before and he was worried. Once it was all over
and proved to be a painless adventure, he called me to tell me
all about it and proudly said: “And, Grandpa, it didn’t even hurt!
How did he learn to do that?” I thought for a short moment and then replied
that his doctor probably started learning early in school all about “stitches”
and kept reading and learning from his teachers and mentors until he could
sew up a cut like his without it hurting. He was happy with this answer which
made me glad since I was sure his normal high level of curiosity would have
led him to ask me a much tougher question, that being: “What is a mentor?”
No matter, this interaction with my grandson starting me thinking about the whole
process of medical education, learning in
general, and the role of “formal medical education” (medical school and residency) and
“informal medical education” (under which
I’ll include reading, medical meetings and
mentoring). Since most of us have a pretty
clear understanding about the “formal medical educational” learning processes that
occur in medical school and residency, I
won’t discuss those here. What I would like
to focus on is the “informal medical educational” process, especially in regard to mentoring and how it is both dependent upon
and highly interactive with formal medical
education.
So what is mentoring? I believe mentoring is a collegial, supportive, one-onone interaction, usually between two people, where information, skills or advice is
shared. This should not suggest that mentoring requires a “superior or senior” to
“inferior or junior” relationship to work. In
fact, I have seen very effective mentoring
done between two individuals of the same
age and level of educational achievement. I believe that virtually anyone with
the proper desire, a humanistic sharing
Virtually anyone
with the proper
desire, a humanistic
sharing philosophy of
life, a little bit of time,
and a certain degree
of patience, can be an
effective mentor.
philosophy of life, a little bit of time, and a
certain degree of patience, can be an effective mentor. However, in order to be
most effective, mentoring does generally
require a level of formal education, experience, or understanding that can be used
as a starting point and then finessed,
honed, or strengthened into something
better by the mentor.
I’ve been incredibly fortunate to have
some fantastic mentors throughout my professional career. Early on, I got to know Mer-
lin K. DuVal, M.D., the dean of my medical
school, very well from having served as a class
officer. The patience, understanding, and support he demonstrated during a rather turbulent
time in the young medical school’s development served as a role model for me throughout my career. Effective mentors, like my dean,
seem to be able to provide this kind of guidance almost without trying. I never sat down
with him and asked him to be my mentor, he
just was! Later, in my junior academic career, I
was mentored by Walter H.C. Burgdorf, M.D.,
(who recently passed away) in how to be an
effective medical writer. The countless revisions he recommended in my first manuscript
not only taught me about patience (on his part)
but also about how to be more effective in the
communication of ideas and the use of newer
technologies.
Formal education and mentoring share a
number of similarities, including a willingness
to share information with others; provide new
ideas or insights to better deal with some unsolved or difficult problem; and a desire to
be supportive and helpful. There are no limits
to where education or mentoring can prove
beneficial. Over the years, I have served as
a mentor for dozens of medical students,
young physicians and residents. The greatest reward is hearing from some of them that
they felt that I played a role in their success.
There simply is no greater reward than that!
So, I urge those of you reading this to volunteer your time, energy and knowledge right
now and serve as a mentor to a colleague,
medical student or junior partner. I promise
you it will be worth it!
The day after I started writing this editorial
my grandson called indeed to ask what a mentor was. After I provided him with a brief summary of what I’ve written above, he replied:
“Well, I’ve got to go now and mentor my sister (who is three years old)!” At least he got my
message and I hope others will as well. DT
3
4
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BRIEF SUMMARY OF FULL PRESCRIBING INFORMATION
Neuromuscular Blocking Agents
This Brief Summary does not include all the information needed to use ONEXTON
Gel safely and effectively. See full prescribing information for ONEXTON Gel.
Clindamycin has been shown to have neuromuscular blocking properties that may
enhance the action of other neuromuscular blocking agents. ONEXTON Gel should be
used with caution in patients receiving such agents.
ONEXTON™ (clindamycin phosphate and benzoyl peroxide) Gel, 1.2%/3.75%, for
topical use
Initial U.S. Approval: 2000
CONTRAINDICATIONS
Hypersensitivity
ONEXTON Gel is contraindicated in those individuals who have shown hypersensitivity
to clindamycin, benzoyl peroxide, any components of the formulation, or lincomycin.
Anaphylaxis, as well as allergic reactions leading to hospitalization, has been reported
in postmarketing use with ONEXTON Gel [see Adverse Reactions]
WARNINGS AND PRECAUTIONS
Colitis/Enteritis
Systemic absorption of clindamycin has been demonstrated following topical use of
clindamycin. Diarrhea, bloody diarrhea, and colitis (including pseudomembranous
colitis) have been reported with the use of topical and systemic clindamycin. If
significant diarrhea occurs, ONEXTON Gel should be discontinued.
Severe colitis has occurred following oral and parenteral administration of
clindamycin with an onset of up to several weeks following cessation of therapy.
Antiperistaltic agents such as opiates and diphenoxylate with atropine may prolong
and/or worsen severe colitis. Severe colitis may result in death.
Studies indicate toxin(s) produced by Clostridia is one primary cause of antibiotic-associated
colitis. The colitis is usually characterized by severe persistent diarrhea and severe abdominal
cramps and may be associated with the passage of blood and mucus. Stool cultures for
Clostridium difficile and stool assay for C. difficile toxin may be helpful diagnostically.
Ultraviolet Light and Environmental Exposure
Minimize sun exposure (including use of tanning beds or sun lamps) following drug
application [see Nonclinical Toxicology].
ADVERSE REACTIONS
The following adverse reaction is described in more detail in the Warnings and
Precautions section of the label:
Colitis [see Warnings and Precautions].
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction
rates observed in clinical trials of a drug cannot be directly compared to rates observed in
the clinical trials of another drug and may not reflect the rates observed in clinical practice.
These adverse reactions occurred in less than 0.5% of subjects treated with ONEXTON
Gel: burning sensation (0.4%); contact dermatitis (0.4%); pruritus (0.4%); and rash (0.4%).
During the clinical trial, subjects were assessed for local cutaneous signs and
symptoms of erythema, scaling, itching, burning and stinging. Most local skin reactions
either were the same as baseline or increased and peaked around week 4 and were
near or improved from baseline levels by week 12. The percentage of subjects that had
symptoms present before treatment (at baseline), during treatment, and the percent
with symptoms present at week 12 are shown in Table 1.
Table 1: Local Skin Reactions - Percent of Subjects with Symptoms Present.
Results from the Phase 3 Trial of ONEXTON Gel 1.2%/3.75% (N = 243)
Before Treatment
(Baseline)
Maximum During
Treatment
End of Treatment
(Week 12)
Mild Mod.* Severe
Mild Mod.* Severe
Mild Mod.* Severe
Erythema
20
6
0
28
5
<1
15
2
0
Scaling
10
1
0
19
3
0
10
<1
0
Itching
14
3
<1
15
3
0
7
2
0
Burning
5
<1
<1
7
1
<1
3
<1
0
Stinging
5
<1
0
7
0
<1
3
0
<1
*Mod. = Moderate
Postmarketing Experience
Because postmarketing adverse reactions are reported voluntarily from a population
of uncertain size, it is not always possible to reliably estimate their frequency or
establish a causal relationship to drug exposure.
Anaphylaxis, as well as allergic reactions leading to hospitalizations, has been reported
in postmarketing use of products containing clindamycin phosphate/benzoyl peroxide.
DRUG INTERACTIONS
Erythromycin
Avoid using ONEXTON Gel in combination with topical or oral erythromycincontaining products due to its clindamycin component. In vitro studies have shown
antagonism between erythromycin and clindamycin. The clinical significance of this in
vitro antagonism is not known.
Concomitant Topical Medications
Concomitant topical acne therapy should be used with caution since a possible
cumulative irritancy effect may occur, especially with the use of peeling, desquamating,
or abrasive agents. If irritancy or dermatitis occurs, reduce frequency of application
or temporarily interrupt treatment and resume once the irritation subsides. Treatment
should be discontinued if the irritation persists.
USE IN SPECIFIC POPULATIONS
Pregnancy
Pregnancy Category C.
There are no adequate and well-controlled studies in pregnant women treated with
ONEXTON Gel. ONEXTON Gel should be used during pregnancy only if the potential
benefit justifies the potential risk to the fetus.
Animal reproductive/developmental toxicity studies have not been conducted with
ONEXTON Gel or benzoyl peroxide. Developmental toxicity studies of clindamycin
performed in rats and mice using oral doses of up to 600 mg/kg/day (240 and 120
times amount of clindamycin in the highest recommended adult human dose based
on mg/m2, respectively) or subcutaneous doses of up to 200 mg/kg/day (80 and 40
times the amount of clindamycin in the highest recommended adult human dose
based on mg/m2, respectively) revealed no evidence of teratogenicity.
Nursing Mothers
It is not known whether clindamycin is excreted in human milk after topical application
of ONEXTON Gel. However, orally and parenterally administered clindamycin has been
reported to appear in breast milk. Because of the potential for serious adverse reactions
in nursing infants, a decision should be made whether to use ONEXTON Gel while
nursing, taking into account the importance of the drug to the mother.
Pediatric Use
Safety and effectiveness of ONEXTON Gel in pediatric patients under the age of 12
have not been evaluated.
Geriatric Use
Clinical trials of ONEXTON Gel did not include sufficient numbers of subjects aged 65
and older to determine whether they respond differently from younger subjects.
NONCLINICAL TOXICOLOGY
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity, mutagenicity and impairment of fertility testing of ONEXTON Gel have
not been performed.
Benzoyl peroxide has been shown to be a tumor promoter and progression agent in
a number of animal studies. Benzoyl peroxide in acetone at doses of 5 and 10 mg
administered topically twice per week for 20 weeks induced skin tumors in transgenic
Tg.AC mice. The clinical significance of this is unknown.
Carcinogenicity studies have been conducted with a gel formulation containing
1% clindamycin and 5% benzoyl peroxide. In a 2-year dermal carcinogenicity study in
mice, treatment with the gel formulation at doses of 900, 2700, and 15000 mg/kg/day
(1.8, 5.4, and 30 times amount of clindamycin and 2.4, 7.2, and 40 times amount of
benzoyl peroxide in the highest recommended adult human dose of 2.5 g ONEXTON Gel
based on mg/m2, respectively) did not cause any increase in tumors. However, topical
treatment with a different gel formulation containing 1% clindamycin and 5% benzoyl
peroxide at doses of 100, 500, and 2000 mg/kg/day caused a dose-dependent increase in
the incidence of keratoacanthoma at the treated skin site of male rats in a 2-year dermal
carcinogenicity study in rats. In an oral (gavage) carcinogenicity study in rats, treatment
with the gel formulation at doses of 300, 900 and 3000 mg/kg/day (1.2, 3.6, and 12
times amount of clindamycin and 1.6, 4.8, and 16 times amount of benzoyl peroxide
in the highest recommended adult human dose of 2.5 g ONEXTON Gel based on mg/
m2, respectively) for up to 97 weeks did not cause any increase in tumors. In a 52-week
dermal photocarcinogenicity study in hairless mice, (40 weeks of treatment followed by
12 weeks of observation), the median time to onset of skin tumor formation decreased
and the number of tumors per mouse increased relative to controls following chronic
concurrent topical administration of the higher concentration benzoyl peroxide formulation
(5000 and 10000 mg/kg/day, 5 days/week) and exposure to ultraviolet radiation.
Clindamycin phosphate was not genotoxic in the human lymphocyte chromosome
aberration assay. Benzoyl peroxide has been found to cause DNA strand breaks in a variety
of mammalian cell types, to be mutagenic in S. typhimurium tests by some but not all
investigators, and to cause sister chromatid exchanges in Chinese hamster ovary cells.
Fertility studies have not been performed with ONEXTON Gel or benzoyl peroxide,
but fertility and mating ability have been studied with clindamycin. Fertility studies in
rats treated orally with up to 300 mg/kg/day of clindamycin (approximately 120 times
the amount of clindamycin in the highest recommended adult human dose of 2.5 g
ONEXTON Gel, based on mg/m2) revealed no effects on fertility or mating ability.
PATIENT COUNSELING INFORMATION
See FDA-approved patient labeling (Patient Information).
Distributed by:
Valeant Pharmaceuticals North America LLC, Bridgewater, NJ 08807
Manufactured by:
Contract Pharmaceuticals Limited Mississauga, Ontario, Canada L5N 6L6
U.S. Patents 5,733,886 and 8,288,434
Issued 11/2014
9389300
DM/ONX/14/0031(1)
INTER
Resource Center s
For more information on specialized
areas of dermatology, related articles
and business resources, go to:
modernmedicine.com/ResourceCenters
WHAT’S YOUR DIAGNOSIS
Current and emerging
treatments for acne
Image appears with permission from VisualDx and Logical Images Inc.
Stewardship of acne
bit.ly/acnestewardship
TEST YOURSELF AT
bit.ly/painfulgreennail
A 55-YEAR-OLD WOMAN who normally
prided herself on her beautifully manicured
hands accidentally pulled one of her nails
away from the nail bed while doing the dishes,
which she did regularly, after her husband
cooked dinner. A few weeks later, her nail
was painful and had turned green.
HERE IS HOW YOUR COLLEAGUES VOTED LAST MONTH
A 26-year-old woman presented with round scaly plaques
scattered across her back, and with a few on her extremities but not her face or scalp. She complained that the lesions
itched. The patient said she had been enjoying relaxing bubble baths in addition to a daily shower since having her bathroom remodeled a month earlier.
90% 5.4% 2.7% 1.6%
CHOOSE ONE:
bit.ly/emergingtx
Rosacea research and treatment
SUBUNGUAL HEMATOMA
ONYCHOMYCOSIS
PSEUDOMONAS NAIL INFECTION
NAIL CANDIDIASIS
Congenital
melanocyctic
nevus
The more complex the regimen, the less
compliant the patient. Complicated regimens
affect primary and secondary adherence.
➍ CONSIDER COST
It’s not hard to guess that patients won’t
comply if they can’t afford the treatment.
High medication costs make this issue
particularly thorny.
➎ EXPLAIN, FRAME SIDE EFFECTS
Side effects terrify people and cause them to
stop using their medicine. But we can frame
benign side effects as an advantage.
Follow-up at one week is essential—a
return visit, an email or phone call —
during which the patient reports how the
medication is working.
—Read the full article: bit.ly/overcomenoncompliance
Do your peers
share your traits?
JUST FOR FUN
ISTJ
ISFJ
INFJ
INTJ
ISTP
ISFP
INFP
INTP
In one word,
what drew you
to dermatology?
ESTP
ESFP
ENFP
ENTP
Tell us here:
ESTJ
ESFJ
ENFJ
ENTJ
bit.ly/dermpersonality
bit.ly/submentalcontouringrejuv
Café-au-lait
macule
➌ KEEP IT SIMPLE
PEARLS FOR OVERCOMING
PATIENT NONCOMPLIANCE
Are you
organized,
logical and
detailed? Quiet,
compassionate
and creative?
Select the
personality type
that best fits you.
Blue
nevus
bit.ly/nov2015diagnosis
➋ FOLLOW-UP EARLY
Achieving Total Facial Rejuvenation with
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and Emerging Strategies (sponsored)
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TOTAL RESPONSES: 112
➊ BUILD TRUST
Winning patient trust is key. Patients
don’t trust drugs. They don’t trust drug
companies. They don’t trust insurers.
Patients trust their doctors. A trusted
doctor is the foundation for getting
patients to use their medicine
bit.ly/rosacearesearch
CTIVE
bit.ly/whyderm
7
8
THE
TAKEAWAY
®
Part three
How to recognize sinus
tracts, keratinous cysts
Dermatology Times editorial advisor, Dr. Elaine Siegfried continues her discussion with
Jim Leyden, M.D., emeritus professor of dermatology at the University of Pennsylvania
about the art and science of isotretinoin therapy. In part three, the two discuss
distinguishing sinus tracts or keratinous cysts from nodular areas of inflammation and
techniques for treating via intralesional injection.
ELAINE SIEGFRIED, M.D.
DR. SIEGFRIED: A patient I saw recently had
horrendous crescentic bilateral scars on
her cheeks where she had been treated
with intralesional corticosteroids after she
had this granulation tissue response. She
had cystic acne in other places. All the time
she was on 100 mg of isotretinoin a day. I
debrided the wounds and the biopsy came
back as epidermoid cyst. She had sinus
tracts that had developed.
In the very early days of isotretinoin,
intralesional corticosteroids were a much
more frequently used treatment, and I think
that the particular complication of this
sinus tract happened more back in those
days. What are your thoughts?
A Dr. Leyden: You can overdo intralesional steroids, but the first
question is identifying the patient
who has sinus tracts. This can be
tricky. I have had patients referred to me who have failed
isotretinoin, and what they
have are sinus tract lesions that usually do not
respond very well. Sinus
tracts tend to be linear as
opposed to circular, nodular lesions; they often have
an angulation to them.
Once you learn how to recognize
them, then it is very easy to spot
them. They tend to be in individuals who have other sinus tract disease or who have family members
with sinus tract disease, like what
we call hidradenitis or pilonidal
sinus or occasionally sinus tract
disease on the scalp.
With acne you get a lot of disruption of sebaceous follicle epithelia.
These patients have a tendency for
Listen to the discussion.
bit.ly/isotretinoinpart3
epithelial repair response — to have
epithelial buds migrate through
the dermis and produce these linear serpentine epithelial tracts —
which can become recurrently inflamed. Just like hidradenitis does
not respond to isotretinoin, those
types of lesions do not respond to
isotretinoin treatment either.
I think intralesional steroids are
very useful for sinus tracts, but if
they are persistent and you just
can’t get the inflammation to
subside, then they have to be surgically removed.
I think that
intralesional
steroids are
very useful for
sinus tracts,
but if they are
persistent and you
just can’t get the
inflammation to
subside, then they
have to be surgically
removed.
James Leyden, M.D.
University of Pennsylvania
DR. SIEGFRIED: How does that differ from
the eruptive keratin cysts that happen with
isotretinoin?
A Dr. Leyden: You can have keratinous cysts as part of the attempt to
heal disrupted follicular epithelium
that occurs in acne. Occasionally with
the higher doses of 1 mg/kg, you can
get eruptive keratinous cysts. A keratinous cyst is another imperfect healing.
You can recognize them in a
couple of ways. First of all, these areas
are constantly recurring areas of inflammation in the exact same spot.
If you suspect it clinically or you hear
that history, feel around the obvious
area of inflammation under the surface. You can feel the rest of the lesion
as something you can define and get
your fingers around. They can occur
eruptively with the 1 mg/kg dose.
DR. SIEGFRIED: That reminds me of John
Strauss’ teaching: He palpated everyone’s
acne. He couldn’t really judge cystic acne
alone without palpating it. It was an incredible, valuable clinical tool. You can learn a
lot by feeling it as well as looking at it.
A Dr. Leyden: I could not agree more.
Hoffmann-La Roche had a new
formulation of isotretinoin that got
approved by the FDA and then they
decided not to market it because the
FDA wanted a phase IV study that
would have taken three generations of
dermatologists to be involved in. They
were concerned about, for one thing,
whether or not ideation of suicide
could be induced by the drug.
But I looked at the baseline photoTAKEAWAY see page 60
10
IRREGULAR
®
BORDER
Peter Lio, M.D.
is assistant professor of clinical
dermatology and pediatrics at
Northwestern University and has
a private practice in Wicker Park,
Chicago.
Unconventional treatments for warts and molluscum
“Is it not a strange fate that we should suffer so much
fear and doubt for so small a thing? So small a thing!”
— J.R.R. Tolkien, The Fellowship of the Ring
B
oromir, Captain of the White Tower, was referring to
the one Ring of course, but his words could perhaps
equally apply to warts and molluscum. Indeed, despite
the fact that these small viral growths are benign and self-limited, they are responsible for some 21% of all dermatology referrals1 and a disproportionately large amount of angst and worry.
Disconcerting perhaps, there is an incredible menagerie of strange
and unconventional treatments posited for treating warts and molluscum; everything from antacids to duct tape has been tried, and entire
books on the topic exist.2
While the general approach to treatment seems to focus on stimulating the innate immune response via destructive measures or irritation3,
the fact that, in trials, even the best therapies rarely show greater than
60% clearance means there will be sizeable demand for unconventional
approaches. We will explore several alternatives for treating warts and
molluscum, but I would stress that these are best used as complementary/adjunctive therapies rather than as stand-alones.
WARTS
Zinc, as an oral supplement, may play a role in enhancing immunity, particularly against viral infections4. In a study of 31 patients with warts, administration of oral zinc (as zinc sulfate) resulted in complete resolution in
half the patients5. A more rigorous randomized placebo-controlled trial
of 32 patients with multiple, recalcitrant warts found that by two months
78% of the zinc group was cleared versus only 13% of the placebo control, a statistically significant difference6. In each of these studies, the
zinc sulfate was dosed at 10mg/kg/d up to a maximum of 600 mg/d, and
nausea was noted to be a significant side effect.
Interestingly, although zinc is listed favorably in the venerable and
quite conventional Cochrane database, one of the authors of the review
has expressed skepticism about zinc for warts despite the data7. Perhaps most clinically relevant, zinc was shown to be a helpful adjuvant
therapy in the treatment of vulvar warts. In a study of 228 patients, relapse was significantly lower in those who received concomitant oral zinc
sulfate versus those who received conventional therapy alone8. The idea
that there may be zinc deficiency in some patients with refractory warts
is compelling, and this has been found in some series9. Further work may
help ascertain patients for whom zinc can be more helpful.
Some evidence indicates that propolis, a resinous mixture used by
bees to seal their hives, has immunomodulatory functions10, and it has
been shown to have a positive effect in the treatment of aphthous stomatitis, mouth ulceration, and the prevention of otitis media11. A fairly large
study demonstrated an effect on warts as well. In this study, 135 patients
were randomized to receive propolis daily for three months versus a placebo control group. At the end of three months, 73% of patients in the
propolis group were cured, compared to only 8% in the placebo group, an
impressive finding, indeed12. While thought-provoking, more studies are
needed. The fact that propolis is safe and inexpensive is encouraging, but
it should be avoided in those with bee allergy.
MOLLUSCUM
These tiny dome-shaped papules show a predilection for children with
atopic dermatitis, suggesting that impaired skin barrier can enhance their
spread13. Maddeningly, they often induce an associated dermatitis that
makes for a chicken-or-egg situation, with increasing misery for the patient. Finally, a staphylococcal superinfection can develop, forcing anyone
to question just how “benign” and “self-limited” this condition really is.
While warts seem to have a more distinguished cannon of conventional therapy, the literature for molluscum is relatively sparse. I adamantly
agree with Dr. Katz that imiquimod is not effective for molluscum, and, in
fact, can cause significant harm14. Several years ago we reported a case
of cytokine dermatitis and febrile seizure resulting in hospitalization from
imiquimod applied to molluscum15.
Cantharidin (an extract of the blister beetle) remains my favorite therapy, although it has never been FDA-approved and can be difficult to obtain, driving the need for other options.
Lemon myrtle (Backousia citriodora) is an essential oil that is used in
foods and perfumes. It has been shown to have antimicrobial properties
which may be relevant to its action on molluscum16. In a study of 31 children, 56% of those treated with a once daily application of lemon myrtle had a 90% reduction in molluscum, compared to none in the control
group17. The treatment appeared safe and was well-tolerated, suggesting
that this could be a promising approach.
Tea tree oil (Melaleuca alternifolia) has antimicrobial properties and also
can be irritating, both of which could theoretically be of help in molluscum.
A provocative study examined tea tree oil for molluscum, but complicated
things slightly by adding iodine without clear purpose for one of the groups,
though this was a proprietary product in the study. Fifty-three children with
molluscum were treated twice daily with tea tree oil bound to iodine compared to tea tree oil alone or iodine alone. At four weeks they evaluated for
90% clearance of molluscum and found that 56% met this mark in the tea
tree oil plus iodine group, while only 17% in the pure tea tree oil group and
6% in the iodine group met this goal18. The authors reported no adverse effects, although there are multiple reports of contact allergy to topically applied tea tree oil, and this must be considered19.
CONCLUSION
Warts and molluscum have probably been with humans since the very
beginning, and will likely continue to plague us. Like the common cold,
we are somewhat powerless to stop them completely, but there are perhaps some useful tools in our alternative armamentarium yet. DT
References online: bit.ly/wartsandmolluscum
12
CLINICAL
®
DERMATOLOGY
Neurotransmitters may
fuel inflammatory flares
LOUISE GAGNON | STAFF CORRESPONDENT
Immune-mediating neuropeptides
may provide an avenue for addressing
inflammatory skin diseases including
psoriasis, according to Richard D. Granstein, M.D. He is the George W. Hambrick, Jr., Professor, and chairman of
the department of dermatology at Weil Cornell Medical College.
“Most patients and
physicians believe that
stress influences many
inflammatory skin disDr. Granstein
eases. It is said that
psoriasis, rosacea and acne all get worse
with stress. This is a clinical impression;
I believe it’s almost certainly true.”
Several studies support this impression anecdotally, he adds, but
controlled studies are rare: “Where
do you find a control group that’s not
under stress?”
One report showed that, after a
large earthquake in Japan, the likeli-
QUICK READ
The connection between emotional
stress and skin disease is clear
enough, an expert says, that it makes
sense to recommend stress relief for
patients who say their inflammatory
skin disease flares under duress.
hood of atopic dermatitis (AD) flares
rose in proportion to the severity of
local damage.1 Dr. Granstein says
that potential confounding variables
include the fact that “perhaps people in the earthquake zone did not
apply their ointments or creams because they had other things to worry
about.”
Other studies show that combining pharmacological treatment with
stress reduction interventions clears
psoriasis faster than medical interventions alone, he says. Regarding
AD, NC/Nga mice raised in a normal environment develop an itchy,
eczema-like rash. Those raised in a
cleaner, specific pathogen-free set-
Quotable
Neal Shear, M.D.
Toronto, Canada
See story page 19
FLARES see page 20
DTExtra
Drug reactions, especially the severe ones,
can sometimes take
four to six weeks
before patients
present with any
systemic symptoms.”
Adverse drug reactions
ting do not, unless exposed to psychological stress. 2
Dr. Granstein says, “These are soft
data. Nonetheless it all supports the
idea that certain inflammatory skin
diseases worsen w it h stress. The
question is, how?”
Several laboratory studies elucidate mechanisms by which nerves
may inf luence inf lammator y skin
disease, Dr. Granstein says. The observation in humans and certain animal models that denervating (either
surgically or phamacologically) psoriatic skin resolves the psoriasis has
been known since the 1970s, he says,
however people don’t talk about it
much. Although psoriasis certainly
involves the immune system, he says
the ner ves contribute something.
Further support for this idea comes
from clinical reports suggesting that
botulinum toxin can clear psoriasis, 3
he says.
There might be an association between excess
weight loss post-bariatric surgery and symptomatic improvement in cases of severe psoriasis. An analysis of patients with severe disease
revealed that excess weight loss was associated with greater improvements in psoriasis and
higher excess weight loss at one year was
associated with a trend in psoriatic arthritis
improvement. The improvements were most
pronounced among patients with more severe
disease at the time of surgery and among
those who were diagnosed at older ages.
SOURCE: BIT.LY/BARIATRICSURGERYPSORIASIS
CLINICAL DERMATOLOGY
DRUG REACTIONS:
Multiple medications can lead to life-threatening complications from page 1
blistering diseases, Dr. Shear points out.
A better understanding of which medications can cause these adverse drug
reactions and how to best find the potential offenders is key to managing patients.
MULTIPLE MEDICATIONS
“Many patients are on multiple medications
for their disease or condition, which can
make it much more difficult to determine
which drug could be the potential offender
in a patient with a suspected adverse drug
reaction,” Dr. Shear says.
“When approaching a patient with cutaneous symptoms that appear to be in line
with an adverse drug reaction, it is important that the clinician carefully weigh the
potential differential diagnoses that fit the
clinical picture and not quickly assume
that the cutaneous symptoms seen are a
direct result of a drug or drugs that the patient is on,” he adds.
“Automatically assuming that a drug
is the cause of cutaneous symptoms
seen in patients is a mistake,” Dr. Shear
says. “Unwary clinicians can fall into this
trap, which is almost impossible not to be
drawn into, as many cutaneous manifestations can look very much like adverse
drug reactions.”
On the flip side, Dr. Shear explains that
it is also important to consider that cutaneous symptoms seen in a patient, such as a
skin exanthema or other cutaneous eruptions, could be a reaction to a drug taken
by the patient.
S.T.O.P.
In an attempt to help clinicians better manage patients with a suspected cutaneous
drug eruption, Dr. Shear developed the acronym STOP, which can be used to more
quickly and systematically identify a potential drug offender:
Suspect systemic syndromes
Therapeutic tally
Other causes of the disease
Probabilities
When approaching a patient with a skin
exanthema or other cutaneous eruption,
Dr. Shear explains that it is of paramount
importance to first be clear about what one
is seeing and establish a working diagnosis.
A very detailed drug history can be extremely helpful in incriminating or ruling
out avariety of potential offending drugs.
Clearly, patients on multiple drugs can
complicate the weeding-out process of
potential offenders.
“Drug reactions, especially the severe
ones, can sometimes take four to six weeks
before patients present with any systemic
symptoms,” Dr. Shear says, adding that a
clinician “thinking that the potential drug
eruption was caused by the last medication patients took could be incorrect, as it
may be due to a drug they took weeks before they came in to see you. These things
13
CLINICAL DERMATOLOGY
DRUG REACTIONS:
Approval is not the same as safety from page 13
have a tipping point; sometimes it can
take several weeks for drug reactions to
show themselves clinically.”
Dr. Shear emphasizes that clinicians
should first try to discontinue certain
medications that the patient may not
need or, if possible, replace them with other
longer-standing agents
that could have a more
favorable safety profile.
“Of ten you go
through the list of drugs
Dr. Shear
patients are on and find
that a lot of those drugs are not needed,”
he says. “The first thing you want to do
is treat the patient, and then you want to
stop the drug that you think could have
caused the drug eruption.”
Physicians also have to consider the
probability a drug may have in causing
a drug eruption. According to Dr. Shear,
the timing of a cutaneous manifestation
is critical because a specific adverse reaction can occur with a very specific timing
after exposure to certain drugs, which impacts the probability of potential drug offenders that the patient may be on.
Some drugs and drug groups are more
frequently associated with adverse drug
reactions than others, Dr. Shear explains.
These include the “antis” such as antibiotic, antigout, anticonvulsant, and antiinflammatory medications.
Drug reactions may be exanthematous or urticarial and can sometimes
be very severe, such as hypersensitivity syndrome, Stevens-Johnson syndrome, and toxic epidermal necrolysis.
Although the more severe conditions are
rare, these can be lethal, underscoring
the urgency to find or rule out a potential drug offender.
DIAGNOSTIC COMPONENTS
“Shear’s Diagnostic Triangle” is another
acronym tool designed to help clinicians
consider the different diagnostic components simultaneously rather than as
a list. Dermatologists can remember the
word RASH for Remember, Appearance,
Systemic, Histology.
The rash seen in a patient could be
exanthematous, urticarial, bullous, or
pustular, Dr. Shear explains. Systemic
symptoms could include fever, lymphadenopathy, pharyngitis, hepatitis,
or arthritis. In the histology, clinicians
QUICK READ
APPROVAL DOES NOT EQUAL FULL SAFETY
The drugs that physicians prescribe
are generally believed to be safe,
having typically undergone thorough
FDA scrutiny. Nevertheless, adverse
drug reactions do occur and knowing
which drugs are common offenders
and how to best identify potential
offenders is crucial in optimally
treating and managing patients
with adverse drug reactions.
could look for vasculitis, interface dermatitis, CD8 predominance, apoptosis,
or blistering.
“All three parameters are important,”
Dr. Shear says. “In an ideal scenario, you
would find aspects of all three components in the patient. Fever is perhaps
one of the most telltale features indicating that a drug is likely at fault. Fever
usually changes everything, particularly
“It is important that physicians recognize
the strengths, limitations, and sources of
error when assessing drug safety, whether
dealing with longer standing drugs or
newer agents that come to market,” says
Joel M. Gelfand, M.D., M.S.C.E., associate professor of dermatology and epidemiology, medical director of the Clinical
Studies Unit, and senior scholar at the
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania,
Philadelphia, Penn.
In the FDA drug approval process,
drugs are studied in relatively small
numbers of people for short periods of
time. As a result, Dr. Gelfand explains,
one can only be certain of safety from
common side effects, which may occur
in approximately 1% of the patient population and can occur after short-term
Shear’s Diagnostic Triangle
Dr. Shear created this acronym tool to help clinicians consider the
different diagnostic components simultaneously rather than as a list.
APPEARANCE
R.A.S.H.
SYSTEMIC (FEVER)
HISTOLOGY
REMEMBER: APPEARANCE, SYSTEMIC, HISTOLOGY
when associated with other systemic features,” he explains.
According to Dr. Shear, toxicity assays or genetic testing can be used to find
some potential drug offenders including
allopurinol and carbamazepine. Other
diagnostic evaluations include patch
testing. “Finding the offending drug
using these diagnostic paths is crucial,
particularly in the more severe drug reactions. If a patient has a very severe reaction, even a 5% likelihood that it could
have been due to ibuprofen or another
medication would not make you want to
use that drug again, unless you can prove
it wasn’t at fault,” Dr. Shear says.
exposure to the drug. Clinical trials
are generally unable to properly determine the risk of serious but less common
events, such as cardiovascular events,
risk of cancer, or risk of new morbidities.
“Many of these are things that are
not picked up in the initial studies used
to prove efficacy, but instead often become evident in the post-marketing
setting. It is not possible to completely
rule out any side effect in any drug that
has gone through the FDA, which highlights the need for ongoing risk assessment throughout the life cycle of a drug,”
Dr. Gelfand says.
Clinicians need to understand that,
19
20
CLINICAL
®
DERMATOLOGY
FLARES:
Neuropeptides and stress from page 12
PATHOGENESIS CLUES
More recently, he says, “Our laboratory
has demonstrated that two neuropeptides—pituitary adenylate cyclase-activating peptide (PACAP) and vasoactive intestinal polypeptide (VIP)4—
influence Langerhans cells to present
antigen preferentially for generation of
Th17 cells and interleukin (IL)-17 production,” both of which are involved
in the pathogenesis of psoriasis.
“If stress causes release of PACAP
and VIP from nerves in the skin,” he
surmises, “this may cause the outcome of local immune responses to
be skewed towards IL-17, which one
might imagine could make psoriasis
worse.” Because lymph nodes are innervated, he adds, “Perhaps antigen
presentation occurring within the
lymph nodes could also be affected.”
thelial cells. Also, he says, “norepinephrine, which is the principal neurotransmitter of the sympathetic nervous system, has the same effect as
CGRP on endothelial cells. So certainly one would imagine that under
periods of stress, as the sympathetic
nervous system is activated as part of
the fight-or-f light reaction, norepinephrine will be released and could
influence endothelial cells” to skew
antigen presentation toward IL-17.
POTENTIAL CONTRIBUTORS
Regarding other potential contributors, he says, “we’ve shown, for example, that although adenosine triphosphate (ATP) is important in the
energy chain, it also is an extracellular messenger. And, in fact, it’s a sympathetic co-transmitter —it comes
“If one could imagine a way to
block the effect of some of these
neurotransmitters only in the skin
and not in the rest of the body —
perhaps with a cream, which would
have negligible systemic absorption —
this might be useful.”
Richard D. Granstein, M.D.
New York City, New York
Furthermore, an unpublished in
vitro study co-authored by Dr. Granstein suggests that the neuropeptide
calcitonin gene-regulating peptide
(CGRP) can also inf luence the outcome of antigen presentation—not
directly, but through the effects of
endothelial cells. 5 The dermatologist says that, “If we treat endothelial cells with CGRP, then wash out
the CGRP, when in the presence of
Langerhans cells and responding T
cells, those endothelial cells are also
able to influence the outcome of antigen presentation towards IL-17.”
This is important, Dr. Granstein
says, because blood vessels in the
skin are innervated (by nerves that
contain CGRP) and lined with endo-
out with norepinephrine when sympathetic nerves are activated.”6 ATP
can induce endothelial cells to release chemokines that may attract
certain inflammatory cells and IL-6,
he notes.
“In this scenario, under stress, the
sympathetic nervous system is activated; ATP is released and binds to
receptors on endothelial cells. This
causes release of chemokines that
allow for the accumulation of inflammatory cells,” Dr. Granstein says.
Also of interest, a recent paper reported that sensory nerves involved
with pain sensation were needed for
the development of psoriasiform inflammation in a mouse model of skin
inflammation caused by a topically
applied immune stimulator.7 In this
report, the nerves appeared to induce release of the cytokine IL-23
from dendritic cells in the dermis;
IL-23 is important in inducing IL-17
production by other cells, Dr. Granstein says, and it was reported to induce IL-17 release by a class of lymphocytes known as gamma-delta T
cells. Whether stress would activate
this pathway is unknown, he adds.
Some of the above pathways might
provide drug targets, Dr. Granstein
says, adding that “if one could imagine a way to block the effect of some of
these neurotransmitters only in the
skin and not in the rest of the body —
perhaps with a cream, which would
have negligible systemic absorption
— this might be useful.”
For clinicians treating inflammatory skin conditions such as psoriasis or AD in patients who believe that
stress is contributing to the disease,
he adds that “it’s reasonable to recommend as part of the therapeutic
armamentarium interventions to relieve stress.” Examples include relaxation techniques, support groups and
perhaps, where appropriate, counseling or psychotherapy.
“It’s reasonable for another reason — although stress may cause
disease, disease causes stress. Psoriasis and AD are uncomfortable and
often itchy.”
Ultimately, he says, “You don’t
need to postulate any of these mechanisms. If a patient says, ‘when I have
trouble at work, my psoriasis flares,’
that’s all you need to know.” DT
Disclosures: Dr. Granstein has been a consultant
(fee) for Galderma, a consultant (no compensation) for Kolltan and an advisory board member
(no compensation) for Velius.
See full article and references at:
bit.ly/inflammatoryflares
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22
CLINICAL
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DERMATOLOGY
SKIN CLUES:
Spotting systemic illnesses from page 1
graft-vs.-host disease (GVHD), for
example, is a condition that can be
treated with systemic therapies like
extracorporeal photopheresis or psoralen ultraviolet A (PUVA) therapy. One
study demonstrated that topical tacrolimus ointment can be effective for
the itching and erythema in patients
with steroid-refractory disease.1
CARDIAC SARCOIDOSIS
The presence of cutaneous sarcoidosis can indicate internal involvement,
which, in some patients, can be life
threatening. Nearly any organ in the
body can be affected, including the
lungs, eyes, GI tract, and the heart. Up
to one third of patients with sarcoidosis have skin findings, which may be
the only symptom of the disease. About
20% of patients with sarcoidosis have
cardiac involvement, and the condition can be fatal, Dr. Schadt notes. Cardiac sarcoidosis is, in fact, one of the
most common causes of sudden death
in African-American men.
“It is important for us as dermatologists to be aware of the potential cardiac complications in patients with cutaneous sarcoidosis,”
Dr. Schadt says, noting that cardiac
sarcoidosis can present as complete
heart block. She advises that patients
w ith cardiac sarcoidosis undergo
cardiac eva luat ions t hat include
an electrocardiogram and echocardiogram.2
In a recent study, 32% of patients
without known sarcoidosis presenting with unexplained Mobitz type II or
third degree AV block were diagnosed
with cardiac sarcoidosis.3
Treatments for sarcoidosis include
steroids, doxycycline, hydroxychloroquine, thalidamide, and the biologic
agent adalimumab, Dr. Schadt notes.
CUTANEOUS LYMPHOMA
Being current with the classification
of cutaneous lymphomas is key to arriving at correct diagnoses, says Soon
Bahrami, M.D., assistant professor of
medicine at the University of Louisville
in Louisville, Ky. The World Health Organization/European Organization for
Research and Treatment of Cancer has
put forth a classification of cutaneous
lymphomas based on clinical, histo-
QUICK READ
When systemic illnesses present
with cutaneous manifestations,
dermatologists have an opportunity
to play a pivotal role in fast, accurate
identification and diagnosis.
logical, immunohistochemical, and molecular aspects.4
Anatomic location
of a lesion can be a
clue when narrowing
down cutaneous lymDr. Bahrami
phomas like follicular
lymphoma, the most common cutaneous B-cell lymphoma, Dr. Bahrami explains.
While marginal zone lymphomas
appear below the head and neck, and
diffuse large B-cell lymphoma is usually present on the leg, lesions of follicular lymphoma almost always appear on the head and neck, Dr. Bahrami says.
Immunohistochemistry results are
variable depending on the type of lymphoproliferative disorder, but certain
key results are instrumental to diagnosing certain entities as is the case of
blastic plasmacytoid dendritic cell neoplasm and CD123 positive cells, Dr.
Bahrami says.
“What a dermatopathologist is excited about [are] CD123 [cells] that
are diffusely positive,” Dr. Bahrami
explains. “That is the clincher.”
As this disease often presents as aleukemic leukemia cutis initially only involving the skin, dermatologists are well-positioned to assist in the early detection of
the condition, Dr. Bahrami adds.
“There are ver y few conditions
where we use can use the term always,
but blastic plasmacytoid dendritic cell
neoplasm always presents in the skin,”
Dr. Bahrami says. “[Dermatologists]
are the ones on the front line of this
diagnosis. About 50% of patients will
only have skin involvement and nothing leukemic. It is the so-called aleukemic leukemia cutis is what this refers
to. In time, they will go on to develop
it. Men are more commonly affected,
about two-thirds of patients, and they
are more commonly older patients,
usually 60 and above.”
Nodular, disseminated, and bruise-
like lesions can present in blastic plasmacytoid dendritic cell neoplasm, but
there are a host of clinical presentations. Central nervous system involvement occurs in about 10% of patients,
with pulmonary involvement also
being described, Dr. Bahrami says.
Biopsy is crucial to the correct diagnosis of blastic plasmacytoid dendritic cell neoplasm, according to Dr.
Bahrami. “It can be a tricky one, so you
want to work with a dermatopathologist who keeps abreast of lymphoid neoplasms,” she says. “They need to be
able to use their immunohistochemistry to get to the right diagnosis.”
Once the right diagnosis is made,
flow cytometry is necessary to see if
the blood is involved. Bone marrow
aspirate and CT scans should also be
conducted, according to Dr. Bahrami.
“Once you have determined how advanced the disease is, there is a whole
host of chemotherapies and therapeutic regimens that you can try,” she says.
“There is nothing really great to treat
this lesion.”
Dr. Bahrami recommends t hat
patients be monitored every three
months to assess if their blood is leukemic, adding that the neoplasm is extremely aggressive, with “median survival [at] about 12 to 14 months” and a
0% survival rate at five years.
Patients who present with one single
cutaneous lesion and no initial blood
involvement have been reported to
have better survival rates than those
who present with more disseminated
lesions, suggesting that there may be
a cutaneous sanctuary. Dr. Bahrami
says, “with a small number of cases, it
is hard to say.”
GENETIC SYNDROMES
The skin serves as a window for some
genetic syndromes, and dermatology
can have a significant impact on the
outcomes via early recognition, according to Dr. Bahrami.
Birt-Hogg-Dubé syndrome is an autosomal dominant condition that affects the skin with benign skin tumors
that develop on the face and other sites.
Pulmonary disease and other comorbidities can develop. Patients who have
Birt-Hogg-Dubé syndrome need to be
EFFACLAR DUO
DUAL ACTION ACNE TREATMENT
1
An antibiotic-free benzoyl peroxide acne treatment
Clinically tested to be as effective as a leading benzoyl
2
peroxide/antibiotic prescription
Baseline
Week 2
Week 12
· 5.5% Micronized Benzoyl Peroxide acne medication
· Micro-exfoliating LHA (derivative of Salicylic Acid) for precise exfoliation
High tolerance
Oil-free/Non-comedogenic
Fragrance-free
Paraben-free
Dermatologist tested
Tested on sensitive skin
Significant reduction of acne lesions
INFLAMMATORY LESION COUNTS2
NON-INFLAMMATORY LESION COUNTS2
0%
-25%
-31.9%
-50%
-46.9%
-55.2%
-59.7%
-75%
-65.7%
-65.8%
-63.3%
-68.4%
-100%
% CHANGE FROM THE BASELINE
% CHANGE FROM THE BASELINE
0%
-25%
-50%
-31.1%
-44.7%
-37.4%
-57.5%
-63.1%
-57.9%
-63.8%
-75%
-65.2%
-100%
Baseline
*Week 2
*Week 4
*Week 8
■ Leading acne Rx + topical retinoid [0.025%]
■ EFFACLAR DUO + topical retinoid [0.025%]
*Week 12
Baseline
*Week 2
*Week 4
*Week 8
*Week 12
*P ≤ 0.001
(1) Dual action acne treatment stems from Benzoyl peroxide.
(2) Protocol: A 12 week dermatologist controlled, multi-center study: double blind clinical trial to evaluate safety and efficacy of two acne creams in subjects with mild to moderate acne vulgaris. 61 patients, ages 18–50, multiethnic skin, all skin types. 2 cell study: Cell 1, 27 patients, [EFFACLAR DUO]+ 0.025% Topical Retinoid vs. Cell 2, 34 patients, [a leading topical Benzoyl peroxide prescription] + 0.025% Topical Retinoid. Results measured at
mean % change from baseline at 12 weeks of use. Application of topical retinoid applied once a day in PM and application of Effaclar DUO or a leading topical prescription Benzoyl peroxide twice a day. Inclusion criteria: ≥ 15
inflammatory lesions and ≥ 20 non-inflammatory lesions.
24
CLINICAL
®
DERMATOLOGY
SKIN CLUES:
Genetic syndromes, chemical toxicity, and HIV/AIDS from page 22
recognized early because they can develop spontaneous pneumothorax, Dr.
Bahrami stresses.
To make the diagnosis, one major or
two minor diagnostic criteria should
be met, Dr. Bahrami says. The major
criteria: At least five fibrofolliculomas/
trichodiscomas with pathologic confirmation of one; or germline mutation
in FLCN. The minor criteria: Multiple
lung cysts with or without spontaneous
pneumothorax; renal cancer; or a firstdegree relative with Birt-Hogg-Dubé
syndrome. If colon cancer develops in
Birt-Hogg-Dubé syndrome patients, it
is more likely sporadic and not genetically linked to the syndrome.
In Muir-Torre syndrome, another hereditary cutaneous cancer syndrome,
colon cancer is the most common visceral malignancy.
Like Birt-Hogg-Dubé syndrome, MuirTorre syndrome is autosomal dominant.
Muir-Torre syndrome occurs as a result
of a defect in mismatch repair proteins.
The most common protein defect in the
skin lesions is related to a loss of MSH2,
explains Dr. Bahrami, noting that the patients develop cutaneous sebaceous tumors that can serve as a clue to early recognition. Immunohistochemical testing
can assess for loss of protein expression
and allows dermatopathologists to triage
these patients.
SEPTIC VASULOPATHY
Bacterial septic vasculopathy can occur in
patients who are not immunosuppressed
and studies indicate that cutaneous manifestations can be an early sign, explains
Cindy England Owen M.D., M.S., assistant professor of dermatology and director of the ACB Dermatology Clinic at the
University of Louisville, Ky.
She highlights as an example a pediatric case of septic vasculopathy where
rapid diagnosis of community-acquired
MRSA bacteremia was made using
punch biopsies for frozen section, tissue culture, and hematoxylin and eosin
stain. Investigations showed no immune
dysfunction in the child. She adds that
the focus of the original infection was
not identified.
She notes one study that looked at
cutaneous lesions in 32 patients diagnosed with bacterial septic vasculopathy found that cutaneous manifestations
were an early event in more than 90% of
patients. The mortality rate in this study
was 28%, which points to the importance
of early recognition of cutaneous signs
for prompt diagnosis and treatment. A
minority of the patients were immunosuppressed.
“The majority of patients were healthy,
so a high index of suspicion should be
maintained even in previously healthy
patients presenting with signs of septic
vasculopathy,” Dr. Owen says.5
Whereas before community-acquired MRSA (CA-MRSA) and hospitalacquired MRSA (HA-MRSA) were considered to be two distinct entities, there
is now overlap in the two conditions, Dr.
Owen says. pattern and timing of hair loss, suggested anagen effluvium, a rare form
of hair loss in patients not undergoing
chemotherapy.
“Thallium was the culprit,” Dr. Owen
says, describing how further questioning revealed that the patient worked with
thallium in a laboratory as part of his
graduate chemistry program. Extremely
elevated serum and urine thallium levels confirmed the diagnosis.
Thallium toxicity is extremely rare
and often the result of intentional poisoning. In this patient, following confirmation of the diagnosis, treatment
with Prussian blue and hemodialysis
resulted in a complete recovery, Dr.
Owen says.
“The majority of patients were healthy,
so a high index of suspicion should be
maintained even in previously
healthy patients presenting with
signs of septic vasculopathy.”
Cindy England Owen M.D., M.S.
Louisville, KY.
“We are starting to see CA-MRSA in
the hospital and HA-MRSA in the community,” she notes, adding that the most
common CA-MRSA strain is USA 300.
In terms of choosing appropriate therapies for CA-MRSA, clinicians should
obtain culture with antibiotic sensitivity testing. Because clindamycin resistance is a concern, the double-disk diffusion method or D-zone test should be
performed to assess for inducible clindamycin resistance prior to using clindamycin as monotherapy. She adds that
chloroquines can also develop rapid resistance to CA-MRSA and should not be
used.
CHEMICAL TOXICITIES
Dr. Owen notes the case of a young patient with neuropathy and rapid onset of
significant hair loss and explains how obtaining a detailed history of the patient’s
occupation and a simple bedside hair pull
test was instrumental in establishing the
differential diagnosis.
The bedside trichogram (using a dermatoscope) revealed anagen hairs on
hair pull test, which, together with his
HIV AND AIDS
Nicholas Compton, M.D., assistant professor in the division of dermatology at
the University of Washington in Seattle,
Wash., says that inflammatory conditions often represent a cutaneous manifestation of the immune dysregulation
seen in patients with HIV, especially in
those with advanced disease, and that
both common and uncommon inflammatory skin conditions develop in patients with HIV.
Seborrheic dermatitis is the most
common inflammatory skin condition
seen in patients with HIV and can be
seen at all stages of HIV, Dr. Compton
says. It can be treated with topical steroids and ketoconazole or tar shampoo.
“The reason for the high prevalence
is not entirely understood. It is thought
to be because of the high burden of Malessezia on the skin,” he says.
In patients with HIV on antiretroviral
therapy and uncontrolled psoriasis, it is
preferable to choose a treatment that is
not immunosuppressive, such as acitretin, Dr. Compton says.
26
CLINICAL
®
DERMATOLOGY
SKIN CLUES:
Genetic syndromes, chemical toxicity, and HIV/AIDS from page 24
Dr. Compton notes that the progression of psoriasis appears to be correlated
with advanced HIV disease. “It is a little
bit odd that you get a worsening of your
psoriasis, a Th1 mediated disease, in
more advanced (HIV) disease because
of the Th2 predominant cytokine profile
in advanced HIV,” he says, adding that
patients with HIV may present with several morphologies of psoriasis overtime
or concomitantly.
Psoralens plus ultraviolet A (PUVA)
may not be a suitable therapy for patients with HIV who develop psoriasis because these patients can be photosensitive as a result of HIV disease
itself or because of the HIV therapies that
they are taking, Dr. Compton explains.
Narrow band UVB (NB-UVB) appears to
be safe, however.
Dermatologic conditions like onychomychosis and seborrheic dermatitis are also very common in HIV
patients. Non-specific rash can result w it h HI V infect ion and, if a
patient’s HIV status is unknown, that
patient should be tested, says Adam D.
Lipworth, M.D., an instructor at Harvard Medical School and Director, Program for Infectious Diseases of the Skin,
and Director, Process Improvement, Department of Dermatology, Boston, Mass.
Umbilicated papules with a white core
suggest molluscum, a condition that signifies low CD4 count. “Giant facial mol-
luscum in HIV signals advanced immunosuppression or can be a manifestation
of the immune reconstitution inflammatory syndrome (IRIS),” Dr. Lipworth says.
Herpes simplex with acyclovir resistance, most commonly seen among HIV
patients, can often be effectively treated
with high dose valcyclovir or acyclovir,
though refractory cases require thymidine-kinase independent medications,
Dr. Lipworth notes.
Carrie Kovarik M.D., associate professor of dermatology, dermatopathology, and infectious disease at the University of Pennsylvania in Philadelphia,
Penn., discussed skin malignancies related to HIV.
Kaposi’s sarcoma, which can have
cutaneous manifestations, is the malignancy that has the highest relative risk of
development in patients with AIDS. Leiomyosarcoma is one malignancy related to
Epstein-Barr virus that is linked to AIDS,
particularly in children.
The beneficial effect of antiretroviral
therapy may be less pronounced when
human papilloma virus (HPV)-related
disease has progressed with HIV immunosuppression, because HPV-specific
immunity has been irreversibly damaged and/or HPV-related changes have
persisted for long periods of time, says
Dr. Kovarik.
What may appear as routine warts
in locations such as the areas around
the fingernails may actually be digital
squamous cell carcinoma, linked to
high-risk HPV types, Dr. Kovarik notes.
“If you have transplant patients or
pat ients w it h HI V/A IDs, monitor
them and treat them aggressively,” she
says.
Oral lesions can present in patients with
HIV and HPV, in particular, so clinicians
should look for this condition, mainly in the
men having sex with men population, Dr.
Kovarik says.
Extensive flat warts can be present,
particularly in adults who have HIV and
HPV, and they can be adequately treated
with glycolic acid, Dr. Kovarik.
Recent research and a recent classification puts forth that children with HIV
who present with Kaposi’s sarcoma have
better outcomes if they have limited skin
or lymph node involvement.6
“The staging system is different from
adults,” Dr. Kovarik says. “Those who
had fewer skin lesions without visceral
involvement did better.” DT
Disclosures: Dr. Schadt, Dr. Bahrami, Dr. Owen, Dr.
Lipworth, Dr. Kovarik, and Dr. Compton all report no
relevant disclosures.
See references at:
bit.ly/skinclues
DRUG REACTIONS:
When new drugs should not be first-line therapies from page 19
when a drug is approved, the benefits are
generally well proven but the safety is not
as well understood. When a brand new
drug is approved, Dr. Gelfand explains,
it takes time to completely understand if
there are rare but serious side effects that
could sideline the drug.
One classic example would be efalizumab (Raptiva, Genentech, Merck Serono),
which showed PML (progressive multifocal leukoencephalopathy) side effects
years after the drug came to market, ultimately resulting in the drug’s discontinuation.
FINDING THE BALANCE
There is always a tension between bringing the new drugs to market that patients
need and fully understanding their safety
profile. According to Dr. Gelfand, 51%
of approved drugs have serious adverse
effects that are not detected before approval and 7.5% of drugs have a black box
warning added after approval. Roughly
3% of drugs are withdrawn from the
market because of safety issues that
weren’t discovered during the development process.
Dr. Gelfand comments that, for a
brand new drug that just received approval, physicians should be aware that
the full safety profile is not available yet
and they should counsel their patients
accordingly. Physicians may also want
to consider not using a newer drug as a
first-line therapy if it does not offer patients any major advantages to more established drugs.
“O n one h a nd, a
brand new drug may
have issues t hat we
don’t know about, but
on the other, we need to
move away from older
drugs because they are
Dr. Gelfand
being surpassed by better drugs in terms of efficacy and improved safety profiles. Moving forward,
physicians can be cautiously optimistic
when prescribing medications for their
patients,” Dr. Gelfand says. DT
Disclosures: Dr. Shear reports no relevant financial interests. Dr. Gelfand has been an investigator and/or consultant for Amgen, Abbvie, Jansen, Merck (DSMB), Pfizer, Lilly, Celgene, Coherus
(DSMB), and Novartis.
32
COSMETIC DERMATOLOGY
Researchers reveal
unexplored skin
virus population
LISETTE HILTON | STAFF CORRESPONDENT
More than 90% of skin-based viruses represent “dark matter,”
meaning they have viral genetic features but no taxonomic
classification, according to a new study by University of Pennsylvania scientists, published October 2015 in the open-access
journal mBio.
“Skin viral communities and their relationships with their
hosts remain poorly understood despite their potential to modulate states of cutaneous health and disease,” according to the
study’s abstract.
Researchers from Penn’s Perelman School of Medicine
collected samples from 16 subjects at eight body sites during a onemonth period. In their survey of the skin’s virus population, or
virome, they found human papilloma virus to be the most
abundant skin-cell infecting virus. Most of the DNA they detected from virus-like particles did not match documented viral
genomes. The study’s findings clearly link the skin virome to the
skin microbiome, according to a Penn press release. Most of the viral DNA detected seemed to belong to phage
viruses, which infect and often live for long periods within bacteria. The researchers found that the microenvironment and natural skin occlusion were strongly associated with skin virome
community composition.
“Although the results suggest that most of our normal skinresident viruses are in fact resident in our skin bacteria, such
viruses can still affect our health via their influence on the microbiome. The Penn researchers found evidence in the phage DNA
of genes that could make host bacteria more resistant to antibiotics, for example, or more likely to cause a harmful infection,”
according to the release.
Skin virome varies depending on where it is on the body. Senior author Elizabeth A. Grice, Ph.D., an assistant professor of Dermatology at Penn Medicine, and colleagues analyzed subjects’
palms, foreheads, armpits, navels and elsewhere, but found virome was most diverse in the crook of the arm.
The research sets a foundation for future investigations of the
normal, healthy skin virome and how it changes with disease.
Scientists who want to pursue such studies can freely use a set of
virome analysis tools, developed by the Penn researchers, which
are available in the paper’s supplemental information.
“There has been a real need for a better understanding of these
viruses, given their potential effects on our skin cells, as well as
on our resident bacteria,” Dr. Grice, says. “Until now, relatively
little work has been done in this area, in part because of the technical challenges involved.” DT
Reference: Hannigan GD, Meisel JS, Tyldsley AS, Zheng Q, Hodkinson BP, SanMiguel
AJ, Minot S, Bushman FD, Grice EA. The Human Skin Double-Stranded DNA Virome:
Topographical and Temporal Diversity, Genetic Enrichment, and Dynamic Associations with the Host Microbiome. MBio. 2015 Oct 20;6(5). http://www.ncbi.nlm.nih.gov/
pubmed/26489866
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34
COSMETIC
®
DERMATOLOGY
ANTI-AGING STRATEGIES
38 CAN
BACKFIRE?
How to avoid hyper-aging your patients
Patient before
and after treatment
with PicoWay laser.
Photos: Syneron Candela
New option for pigmented lesions
A laser that made news in tattoo removal and shows promise in the treatment
of acne is now cleared for a new indication:
the treatment of pigmented lesions.
A picosecond is a one trillionth of a
second pulse duration, and the PicoWay
offers the shortest picosecond pulse and
highest peak power on the market, according to Syneron Medical’s CEO Amit
Meridor. PicoWay is a dual wavelength
device, with 532nm and 1064nm wavelengths. The FDA has approved the
PicoWay laser for the treatment of
pigmented lesions.
NEW INDICATION
Der m atolog i s t V ic
Narurkar, M.D., principal investigator for the
pivotal FDA clinical trial
for PicoWay for benign
pigmented lesions, said Dr. Narurkar
he uses the PicoWay for the treatment of
multicolored tattoos, the indication
Quotable
QUICK READ
New indication for pigmented
lesions approved for PicoWay laser
for the first FDA clearance in 2014, as
well as benign epidermal and dermal
pigmented lesions, such as lentigos,
nevus of Ota, nevus of Ito, ephelides and
dyschromia on the face, neck, chest
and hands.
“Epidermal pigmented lesions such
as lentigos typically clear in one to
two treatments [with the PicoWay],”
Dr. Narurkar says. “There is no need
for topical anesthesia. The clinical
appearance immediately after treatment
is a flaky white color; followed by some
crusting, which can last several days; followed by clearance of the lesion.”
In the clinical trial, the results of
which were presented as a poster abstract at the American Society for Laser
Medicine and Surgery (ASLMS) 2015
annual meeting, patient satisfaction
was high and pain scales were less
than one in the majority of patients.
Treatment side effects were few and
minor, including post-treatment crusting and purpura, which, if it occurs,
can last several days, according to Dr.
Narurkar.
In genera l, use of picosecond
devices on pigmented lesions has
had mixed results, according to Sacramento, Calif.-based dermatologist
Suzanne Kilmer, M.D.
“In ma ny cases,
the alexandrite
picosecond laser has
more rapidly cleared a
pigmented lesion than a
Q-switched alexandrite
laser. We have seen this
Dr. Kilmer
in several nevus of Ota,
mel a s m a , t r au m at ic a nd d r u ginduced (minocycline, silver, hydroquininone) hyperpigmentation and
congenital nevi. However, café-au-lait
macules, lentigos and freckling are more
unpredictable in t heir responses
[to picosecond lasers],” Dr. Kilmer says.
PICOWAY see page 37
DTExtra
Younger people can
look older when they
get that plastic-y look
that older people who
are ‘trying too hard’
get.”
Avoid hyper-aging your patients
A broad range of aesthetic procedures—from surgery
to lasers, light-based therapies and injectables—can
result in blindness or vision loss, according to Wendy W.
Lee, M.D. Dr. Lee recently presented at the Global Aesthetics Conference, in Miami Beach, Fla., about different
causes of visual impairment and ways to avoid potential
ocular complications from aesthetic procesures.
Dr. Lee advocates careful measurement, protective eye
wear for everyone in the room, and a conservative
approach to injectables.
See story page 38
READ THE FULL ARTICLE AT BIT.LY/AVOIDINGBLINDNESS
Brian S. Biesman, M.D.
Nashville, Tenn.
TOPICORT® (desoximetasone) Topical Spray, 0.25%
Rx Only
Table 1. Number (%) of Subjects with Adverse Reactions Occurring in ≥ 1%
Topicort® Topical Spray,
0.25% b.i.d. (N = 149)
Vehicle spray b.i.d.
(N = 135)
Number of Subjects with
Adverse Reactions
13 (8.7%)
18 (13.3%)
4 CONTRAINDICATIONS
None
Application site dryness
4 (2.7%)
7 (5.2%)
Application site irritation
4 (2.7%)
5 (3.7%)
5 WARNINGS AND PRECAUTIONS
5.1 Effect on Endocrine System
Topicort® Topical Spray is a topical corticosteroid that has been shown to suppress the
hypothalamic-pituitary-adrenal (HPA) axis.
Application site pruritus
3 (2.0%)
5 (3.7%)
BRIEF SUMMARY
1 INDICATIONS AND USAGE
Topicort® Topical Spray is a corticosteroid indicated for the treatment of plaque psoriasis in
patients 18 years of age or older.
Systemic absorption of topical corticosteroids can produce reversible HPA axis suppression with
the potential for glucocorticosteroid insufficiency. This may occur during treatment or upon
withdrawal of the topical corticosteroid.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Teratogenic Effects: Pregnancy Category C
There are no adequate and well-controlled studies in pregnant women. Topicort® Topical Spray should
be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
In a study including 21 evaluable subjects 18 years of age or older with moderate to severe
plaque psoriasis, adrenal suppression was identified in 1 out of 12 subjects having involvement
of 10-15% of body surface area (BSA) and 2 out of 9 subjects having involvement of >15%
of BSA after treatment with Topicort® Topical Spray twice a day for 28 days. [see Clinical
Pharmacology (12.2)]
Corticosteroids have been shown to be teratogenic in laboratory animals when administered
systemically at relatively low dosage levels.
Because of the potential for systemic absorption, use of topical corticosteroids may require that
patients be periodically evaluated for HPA axis suppression. Factors that predispose a patient
using a topical corticosteroid to HPA axis suppression include the use of high potency steroids,
larger treatment surface areas, prolonged use, use of occlusive dressings, altered skin barrier,
liver failure and young age.
8.3 Nursing Mothers
Systemically administered corticosteroids appear in human milk and could suppress growth, interfere
with endogenous corticosteroid production, or cause other untoward effects. It is not known whether
topical administration of corticosteroids could result in sufficient systemic absorption to produce
detectable quantities in breast milk. Because many drugs are excreted in human milk, caution should
be exercised when Topicort® Topical Spray is administered to a nursing woman.
An ACTH stimulation test may be helpful in evaluating patients for HPA axis suppression.
If HPA axis suppression is documented, an attempt should be made to gradually withdraw
the drug, to reduce the frequency of application, or to substitute a less potent steroid.
Manifestations of adrenal insufficiency may require supplemental systemic corticosteroids.
Recovery of HPA axis function is generally prompt and complete upon discontinuation of topical
corticosteroids.
Cushing’s syndrome, hyperglycemia, and unmasking of latent diabetes mellitus can also result
from systemic absorption of topical corticosteroids.
Use of more than one corticosteroid-containing product at the same time may increase the total
systemic corticosteroid exposure.
Pediatric patients may be more susceptible to systemic toxicity from use of topical
corticosteroids. [see Use in Specific Populations (8.4)]
5.2 Local Adverse Reactions with Topical Corticosteroids
Local adverse reactions may be more likely to occur with occlusive use, prolonged use or use
of higher potency corticosteroids. Reactions may include atrophy, striae, telangiectasias,
burning, itching, irritation, dryness, folliculitis, acneiform eruptions, hypopigmentation, perioral
dermatitis, allergic contact dermatitis, secondary infection, and miliaria. Some local adverse
reactions may be irreversible.
5.3 Allergic Contact Dermatitis with Topical Corticosteroids
Allergic contact dermatitis to any component of topical corticosteroids is usually diagnosed by a
failure to heal rather than a clinical exacerbation. Clinical diagnosis of allergic contact dermatitis
can be confirmed by patch testing.
5.4 Concomitant Skin Infections
Concomitant skin infections should be treated with an appropriate antimicrobial agent.
If the infection persists, Topicort® Topical Spray should be discontinued until the infection has
been adequately treated.
5.5 Flammable Contents
Topicort® Topical Spray is flammable; keep away from heat or flame.
ADVERSE REACTIONS
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates
observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials
of another drug and may not reflect the rates observed in practice.
In randomized, multicenter, prospective vehicle-controlled clinical trials, subjects with moderate
to severe plaque psoriasis of the body applied Topicort® Topical Spray or vehicle spray twice daily
for 4 weeks. A total of 149 subjects applied Topicort® Topical Spray.
Adverse reactions that occurred in ≥ 1% of subjects treated with Topicort® Topical Spray were
application site dryness (2.7%), application site irritation (2.7%) and application site pruritus
(2.0%).
Another less common adverse reaction (<1% but >0.1%) was folliculitis.
Desoximetasone has been shown to be teratogenic and embryotoxic in mice, rats, and rabbits when
given by subcutaneous or dermal routes of administration at doses 3 to 30 times the human dose of
Topicort® Topical Spray based on a body surface area comparison.
If used during lactation, Topicort® Topical Spray should not be applied on the chest to avoid accidental
ingestion by the infant.
8.4 Pediatric Use
Safety and effectiveness of Topicort® Topical Spray in patients younger than 18 years of age have not
been studied; therefore use in pediatric patients is not recommended. Because of a higher ratio of skin
surface area to body mass, pediatric patients are at a greater risk than adults of HPA axis suppression
and Cushing’s syndrome when they are treated with topical corticosteroids. They are therefore at
greater risk of adrenal insufficiency during and/or after withdrawal of treatment. Adverse effects
including striae have been reported with inappropriate use of topical corticosteroids in infants and
children. [see Warnings and Precautions (5.1)]
HPA axis suppression, Cushing’s syndrome, linear growth retardation, delayed weight gain,
and intracranial hypertension have been reported in children receiving topical corticosteroids.
Manifestations of adrenal suppression in children include low plasma cortisol levels and absence of
response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles,
headaches, and bilateral papilledema. [see Warnings and Precautions (5.1)]
8.5 Geriatric Use
Clinical studies of Topicort® Topical Spray did not include sufficient numbers of subjects aged 65 years
and over to determine whether they respond differently from younger subjects. Other reported clinical
experience has not identified differences in responses between the elderly and younger patients. In
general, dose selection for an elderly patient should be cautious, usually starting at the low end of the
dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of
concomitant disease or other drug therapy.
10 OVERDOSAGE
Topicort® Topical Spray can be absorbed in sufficient amounts to produce systemic effects. [see
Warnings and Precautions (5.1)]
17 PATIENT COUNSELING INFORMATION
See FDA-approved patient labeling (Patient Information and Instructions for Use)
Inform patients of the following:
I Use this medication as directed by the physician.
I Topicort® Topical Spray is for external use only. Avoid use on the face, axilla or groin.
I Do not use this medication for any disorder other than that for which it was prescribed.
I Do not bandage or otherwise cover or wrap the treated skin so as to be occlusive.
I Report any signs of local or systemic adverse reactions to the physician.
I Do not use other corticosteroid-containing products with Topicort® Topical Spray without first
consulting with the physician.
I Discontinue therapy when control is achieved. If no improvement is seen within 4 weeks, contact
the physician.
I This medication is flammable; avoid heat, flame, or smoking when applying this product.
I Discard this product 30 days after dispensed by pharmacist.
Mfd. by: Taro Pharmaceuticals Inc., Brampton, Ontario, Canada L6T 1C1
Dist. by: TaroPharma® a division of Taro Pharmaceuticals U.S.A., Inc., Hawthorne, NY 10532
Revised: April 2013
AD100-0030
PICOWAY:
The claims and the debate from page 34
PICOWAY BEST PRACTICES
The PicoWay device works best for
benign epidermal pigmented lesions
and multicolored tattoos, according
to Dr. Narurkar.
“The main advantage of the PicoWay over ot her picosecond lasers is it delivers t he shortest picosecond pulse, allowing for more
photo-acoustic than photothermal
effects, thereby, making treatments
considerably less painful and also
with less risk of postinf lammatory
hypo- or hyperpigmentation,” Dr.
Narurkar says. “Unlike the 755nnm
waveleng t h, t he 1064n m laser is
much safer for darker sk in tones,
when treating dermal pigmented
lesions such as tattoos and nevus of
Ota and Ito. It also penetrates deeper
than 755nm.”
That claim, however, is up for debate. Roy G. Geronemus, M.D., director of Laser & Skin Surgery of New
York and clinical professor of dermatology at New York University Medical Center, New York City, says he disagrees that the 1064nm wavelength
picosecond laser is much safer than
the 755nm picosecond laser for the
treatment of benign pigmented lesions.
“We have successfully treated pigmented lesions, as well as tattoos,
at the 755nm wavelength with minimal
risk of side effects,”
Dr. Geronemus says.
“T he focus lens attachment to t hat
particular laser [the
Dr. Geronemus
755nm waveleng t h]
allows for the treatment of various
pigmented lesions, acne scars and
facial rejuvenation without noticeable downtime.”
The PicoWay’s other wavelength
of 532n m, is sa fe i n da rker sk i n
tones, according to Dr. Narurkar.
That’s because the photo-acoustic effect predominates the photothermal
effect. The fluences, however, should
be reduced by about 20%, he says.
When it comes to treating pigmented
lesions with picosecond devices, wavelength still seems to determine absorption, according to Dr. Kilmer.
“Our hope was that the picosecond
technology would be colorblind with
respect to treating tattoos. Unfortunately, this did not turn out to be the
case. Red light still better treats green
ink and vice versa. So, it’s important
to have more wavelengths, which all
the companies are working on,” Dr.
Kilmer says. DT
Disclosures: Dr. Narurkar is a clinical investigator for
Syneron Candela. Dr. Geronemus is an investigator
for Cynosure and performed the clinical trials on the
PicoSure. Dr. Kilmer is a researcher for Cynosure and
consultant for Syneron Candela and Cutera.
PICOSECOND DEVICES AT A GLANCE
LASER
MANUFACTURER WAVELENGTH
PULSE DURATION
INDICATIONS
NOTES
PicoSure
Cynosure
Combination
755nm/
532nm
550ps to 750 ps
PicoSure 755 is FDA cleared to treat tattoos and pigmented lesions in skin types I through VI. PicoSure 755
with Focus is cleared to treat pigmented lesions in skin
types I through VI, as well as wrinkles and acne scars in
types I through IV. PicoSure 532 is cleared to treat tattoos
in skin types I through III.1
PicoSure’s Focus Lens Array magnifies the
device’s pulse 20 times, to microscopically concentrate energy on small areas
of tissue. In a study2 looking at use of the
755nm alexandrite picosecond pulse duration laser with diffractive lens array for
the treatment of facial acne scarring, researchers found the technology improved
acne scars at three months.
Enlighten Cutera
Dual wavelength
of 1064nm/
532 nm
Dual pulse duration 750ps/2 ns
Enlighten is FDA cleared for tattoo removal. The 1064 nm
wavelength of the enlighten laser system is indicated for tattoo removal for dark-colored tattoo inks and for multicolored
tattoos containing dark-colored tattoo inks on patients with
all skin types (Fitzpatrick I through VI). The 532 nm wavelength of the enlighten laser system is indicated for tattoo removal for lighter colored tattoo inks, including red and yellow
inks, on patients with skin types I-III, according to the FDA.3
The 532 nm wavelength of the enlighten laser system is indicated for the treatment of benign pigmented lesions on patients with Fitzpatrick skin types I through III. The 1064 nm
wavelength of the enlighten laser system is indicated for the
treatment of benign pigmented lesions on patients with all
skin types, according to the FDA.
For more: http://www.cutera.com/Product-Landing-Pages/enlighten.aspx
PicoWay
Dual
wavelengths
1064 nm/ 532
nm
450ps (Nd:YAG
frequency)
/375ps (double
Nd:YAG)
frequency)
/375ps (double
Nd:YAG)
For more: http://syneron-candela.com/int/
PicoWay is FDA cleared for the treatment of tattoos and beproduct/picoway
nign cutaneous pigmented lesions. The 532nm is cleared
for removal of tattoos for Fitzpatrick skin types I through III,
to treat red, yellow and orange inks. The 1064nm is cleared
for removal of tattoos for all skin types to treat black, brown,
green, blue and purple. The PicoWay is cleared to treat benign
pigmented lesions for skin types I through IV.
For more: http://www.cynosure.com/product/picosure/
Syneron
Candela
1. http://www.ncbi.nlm.nih.gov/pubmed/?term=Kazlouskaya+V+brauer+j
2. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, Bae YS, Bernstein LJ, Anolik R, Heller PA, Geronemus RG. Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring.
JAMA Dermatol. 2015 Mar;151(3):278-84.
3. http://www.accessdata.fda.gov/cdrh_docs/pdf14/K140727.pdf
37
38
COSMETIC
®
DERMATOLOGY
Can anti-aging strategies backfire?
KAREN DONLEY-HAYES | STAFF CORRESPONDENT
In the age-old quest to defeat the ravages of time, societies have devised ingenious tactics to try and turn back the
clock — or at least to mitigate its effects
on appearance. Today, consumers can
choose from measures as conservative
as avoiding the sun and quitting smoking to more aggressive measures, including injections, laser treatments, and cosmetic surgery.
Sometimes in their efforts to defy the
appearance of aging, however, people
undergo procedures that actually make
them look older, or give them a stiff,
artificial, “worked on” look. It can be a
vicious cycle: the more someone dislikes the results of a procedure, the more
procedures he or she may undergo to
“correct” the “mistakes,” and the cumulative effect may truly backfire.
Avoiding a misstep onto that slippery
slope is a matter of experience, an educated approach, and often a healthy
dose of conservatism, says Brian S. Biesman, M.D., clinical assistant professor
at Vanderbilt University Medical Center
and director of the Nashville Center for
Laser and Facial Surgery.
“Certainly we’re seeing younger and
younger patients coming in to see if
they’re candidates for procedures,” Dr.
Biesman says. “There’s something to be
said for not doing things too early,” and
he says he does his best to avoid doing
surgery before it’s absolutely necessary.
Sometimes that means reining in the
patient.
“I had a patient recently, late 30s, and
her friends told her she should have surgery before she needed it so it would look
better over time.” Dr. Biesman says physicians need to make a distinction between an enhancement procedure in
younger patients and more restorative
procedures in older people. He believes
in a healthy respect for people’s anatomy.
“I think younger people can look
older when they get that plastic-y look
that older people who are ‘trying too
hard’ get. Folks who have too much filler
or lasers get that pasty or artificial look.
That, in a sense, is how younger people
look older by looking too artificial at too
young an age.”
D oi n g a n y t h i n g for ae s t he t ic
reasons in minors is ill-advised, in
Dr. Biesman’s opinion. There are
psychological as well as physiological issues involved, he points out. “I
had a mother bring her 15-year-old
daughter in for cosmetic eyelid surgery, and I told them absolutely not.
Her mother had had a lot of aesthetic
procedures done and had that sort of
artificial look.” He cites another example: A 14-year-old who had undergone a blepharoplasty procedure with
another practitioner and she didn’t
like the appearance of the upper eyelid scars.
TIPS FOR A LONG-TERM APPROACH
Dr. Beasman says, “It is important not to go
into autopilot mode where the same treat-
ment or treatments are automatically performed in the same way over many years.
Keep the big picture in mind; try to make
each visit like it’s the very first visit. It can be
hard to look at someone you know so well
objectively every time you see them, but
doing so allows you to keep people looking really good for a really long time.” DT
Read the full article:
bit.ly/hyper-aging
39
IN ATOPIC DERMATITIS,
UNDERLYING CHRONIC INFLAMMATION IS A
SOURCE OF LESIONS AND ITCH, THE PRIMARY
SIGNS AND SYMPTOMS OF THE DISEASE1-3
Th2 cytokines IL-4 and IL-13 are key drivers involved with the underlying
inflammatory process.1,2
Chronic skin inflammation can be orchestrated by a mixture of activated
immune and epidermal cells and can lead to pruritic lesion development.4-10
Xerosis, infection, and/or allergens
all contribute to pruritus, which can11:
& Initiate a harmful itch-scratch cycle
& Enhance disease progression
& Damage the skin barrier
& Exacerbate atopic dermatitis
Moreover, recent evidence has
shown that nonlesional skin is
not normal skin due to persistent
subclinical inflammation throughout
the body.1-3,13
DISCOVER THE
INFLAMMATION
BENEATH.
Bieber T. N Engl J Med. 2008;358(14):1483-1494.12
UNCOVER MORE AT
medscape.com/isite/ad
Sanofi and Regeneron are committed to investigating new therapies
that address unmet medical needs in inflammation and immunology.
Content developed by Sanofi and Regeneron Pharmaceuticals, Inc.
All rights reserved. 10/2015
© 2015 Sanofi and Regeneron Pharmaceuticals, Inc.
US.DUP.15.10.012
ILF-0645
42
CUTANEOUS
®
ONCOLOGY
GOALS FOR COMBATING
44 FIVE
SKIN CANCER
Details of ASDS call to action
ASDS responds to Surgeon General’s
skin cancer prevention call to action
Then Acting and now Deputy Surgeon
General Boris Lushniak, M.D., M.P.H.,
a dermatologist, established skin cancer prevention as a national priority in
2014, setting five goals for combatting
skin cancer in America.
The American Societ y for Der matologic Surgery (ASDS)
announced in August
2015 that it not only
supports the governDr. Maher
ment’s five goals to
combat skin cancer, but also has specific initiatives that will help reach
those goals.
“I think it’s up to us to be on top of
the skin cancer epidemic. Right now,
one in five Americans will have a skin
cancer in their lifetime. It’s projected
that in another 20 years, it’s going to be
one in three Americans,” says Ian A.
Maher, M.D., assistant professor and
associate director of Mohs surgery
and cutaneous oncology, department
of dermatology, St. Louis University, St.
Louis, Mo.
“I think it’s incumbent that we as
dermatologists respond to this call to
action in our efforts to educate the public about skin cancer prevention and
help drive our policies to contribute to
the skin health of our nation,” he says.
The government’s call to action sets
goals for increasing sun protection and
QUICK READ
The ASDS, AAD, and other
dermatology societies offer a wide
variety of resources and programs
that dermatologists can implement
and get involved in to prevent skin
cancer in their communities.
educating the public about the dangers
of UV exposure, as well as for promoting legislation aligned with skin cancer
prevention, reducing indoor tanning
and fueling skin cancer prevention research, monitoring and evaluation.
Dr. Maher, chair of the ASDS public service committee, says dermatologists are good at spreading the word
about the need for sun protection to
their patients day in and day out, but
the ASDS takes that a step further, encouraging dermatologists to take their
messages to the community and local
lawmakers.
“We’ve worked hard to centralize
everything on the [ASDS] website, so
materials are easy to find. Our programs and resources are easy to access
for any dermatologists who are interested in taking their skin cancer prevention efforts that next step, outside
their office,” Dr. Mahar says.
OPPORTUNITIES FOR SUN PROTECTION
ASDS offers ready-made programs that
dermatologists can implement in their
communities.
One is Choose Skin Health, which
is a partnership with Neutrogena that
focuses on offering free skin cancer
screenings and educational materials.
Dermatologists can volunteer to give
the free screenings on ASDS’s website.
In turn, ASDS sends those dermatologists skin cancer screening forms and
sunscreen samples to hand out to consumers who attend. ASDS promotes
the program in national and regional
publications, and the society is having a competition for the ASDS member who does the most screening in his
or her geographic area. In its fifth year,
the program has resulted in nearly
15,000 skin cancer screenings.
“We have a program called Sun
Safe Soccer which helps educate soccer coaches about skin cancer basics
… and encourages them to pass that
knowledge on to their players,” Dr.
Maher says.
Still another ASDS outreach program is Sun Safe Surfing, which offers
easy-to-remember sun protection tips
for surfers, as well as screenings and
other events. In 2013, Sun Safe Surfing teamed up with the Colette Coyne
Foundation for a skin cancer screening
on the Jones Beach boardwalk in New
York, where dermatologists screened
more than 220 people. The program
also sponsors surf camps.
There are other opportunities to
make a difference. For example, dermatologists and others might not know
CALL TO ACTION see page 44
DTExtra
Israeli, Australian and U.S. researchers collaborated to study 501 genomes
and protein-building sequences. They found that a newly identified member of
a group of tumor suppressor genes is mutated in about 5.4% of melanomas.
These melanomas make up a particularly deadly subset in the skin cancer.
The findings mark a different approach for targeted cancer therapies, which
are focused on inhibiting oncogenic overactivity in melanoma cells.
SOURCE: BIT.LY/MELANOMAMUTATION
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Important Safety Information: Bellafill® is indicated for the correction of nasolabial folds and moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of
21 years. Patients who have had a positive reaction to the Bellafill® Skin Test, have a history of severe allergies, have known bovine collagen allergies, are allergic to lidocaine, have bleeding
disorders or are prone to thick scar formation and/or excessive scarring should not receive Bellafill.® The safety of Bellafill® for use during pregnancy, breastfeeding, or in patients under 21 has
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You may experience temporary swelling, redness, pain, bruising, lumps/bumps, itching, and discoloration at the treatment site. These side effects are usually transient and typically resolve
within 1–7 days. You may experience lumps/bumps/papules that may occur more than one month after injection and that may persist. Less common side effects include rash and itching more
than 48 hours after treatment, persistent swelling or redness, lumps/bumps, acne, and increased sensitivity at treatment sites. Infrequently, granulomas may occur and may be treated by your
licensed physician provider. Be sure to call your licensed provider immediately if you notice any unusual skin reactions around the treatment area. Based on the 5-year Post Approval Study on
nasolabial folds with 1,008 patients, long-term safety of Bellafill® for up to 5-years has been established. For more safety information, please consult with your physician and the patient labeling
that can be found by visiting our website www.bellafill.com.
Toll-free call (U.S. & Canada): 844-Bellafill (844-235-5234). Local calls: 858-550-9999. International calls: ++ 858-550-9999.
© 2015 Suneva Medical, Inc. *Suneva Medical, data on file SM1981REV00
44
CUTANEOUS
®
ONCOLOGY
CALL TO ACTION:
Community activism and the importance of being informed from page 42
this, but some schools ban students
from applying, carrying and storing
sunscreen at schools. Dr. Maher says
it’s often a liability issue, but since it’s
usually school or district policy, it is
something that dermatologists and
others can work to change on a local
level. Dr. Maher went to his children’s
school to change the policy and said
some schools are willing to change;
some are not.
BANNING INDOOR TANNING
The American Society for Dermatologic
Surgery Association (ASDSA), the advocacy group for ASDS, is behind lobbying efforts for legislation to ban indoor tanning for minors. The ASDSA
also supports required posting of health
risks for tanners.
A tool that could be useful for dermatologists who want to get in on the
fight to ban indoor tanning is the ASDSA’s position statement about the dangers of indoor tanning.
Indoor tanning is an issue that’s normally regulated at the state level, according to Dr. Maher.
“We have been active in working
with states and supporting state dermatology societies, which are normally
the ones that are taking on the tanning
legislation,” Dr. Maher says.
Dermatologists can contact ASDSA
to find out about specific lobbying opportunities to ban indoor tanning in
their states, according to Dr. Maher.
Lobbying and talking with legislators is important but isn’t necessarily something that dermatologists
feel comfortable doing, according to
Ramona Behshad, M.D., who is an
adjunct assistant professor of dermatology, St. Louis University, and practices in Chesterfield, Mo. She recommends that dermatologists who are
interested in lobbying for and against
laws in their states and nationally
should attend ASDS and AAD meetings, which often offer education in
this area.
There are other options for learning, Dr.
Behshad says. She advocates joining state medical societies, where dermatologists can join
Dr. Behshad
other medical special-
Five goals for
combating
skin cancer
According to ASDS, the call to action
includes these five goals aimed at
combating skin cancer:
opportunities for sun
protection in outdoor settings.
➊ Increase
individuals with the
information they need to make
➋ Provide
informed, healthy choices
about UV exposure.
policies that advance
the national goal of preventing
➌ Promote
skin cancer.
harms from
indoor tanning.
➍ Reduce
research, surveillance, monitoring and evalu➎ Strengthen
ation related to skin cancer
prevention.
ties to influence the laws being passed.
“Our state medical association, at
least once a year, has a full weekend,
where you can learn how to advocate
and learn what’s involved when you
call your senator,” Dr. Behshad says.
Last May, ASDS released its first consensus recommendations for the treatment and management of basal cell
carcinoma. The release of the recommendations not only helps to standardize evidence-based practice in the specialty, but also shows legislators and
the public that there is a concerted effort to effectively and efficiently treat
and manage this common skin cancer.
“These types of consensus statements are needed now because there
is an increase in regulation in healthcare, and we need to have well-defined
standards of practice that are based on
evidence,” Dr. Maher says.
ADVOCACY IN PRACTICE
Dr. Behshad knows the power of advocacy. She started the Stylists against Skin
Cancer program through ASDS’s Future
Leaders Network. Like Sun Safe Surfing and Sun Safe Soccer, Stylists against
Skin Cancer is a turnkey program. Dermatologists go to local beauty schools
and teach future stylists the basics of
how to determine if something they see
on the scalp should result in a referral
to a dermatologist. ASDS has continued to expand the program, which includes a ready-made lecture and educational materials for dermatologists to
distribute to those who attend the lectures. These items and more are available for download at the ASDS website.
Dr. Behshad has given the lecture at
her community’s beauty schools and
says the stylists are hungry for the information. They also learn more about
skin cancer and how to detect it early,
as well as build relationships with local
dermatologists.
“We came up with a referral card, so
that the hair stylists could have a diagram on which they mark an x on the
scalp. On the backside, there is a ‘find
a dermatologist’ website,” Dr. Behshad
says. “Projects like this are a great way
to get into the community and, pretty
quickly, you’ll become the expert in the
community. I think projects like this by
the ASDS are very easy for any dermatologist. The work is already done.”
ASDS is not alone in offering programs
that dermatologists can implement and
get involved in to prevent skin cancer in
their communities. The AAD, state dermatology societies and medical societies
offer resources, too. The goal is for dermatologists to find programs that work
for them, so they get involved in local,
regional and national efforts to prevent
skin cancer, according to Dr. Maher. DT
For more information:
U.S. Department of Health and Human Services
web page on the Surgeon General’s Call to Action
to Prevent Skin Cancer:
bit.ly/SurgeonGeneralPreventSkinCancer
American Society for Dermatologic Surgery:
www.asds.net
Choose Skin Health:
bit.ly/ASDSSkinCancerVolunteers
Sun Safe Soccer:
bit.ly/ASDSSunSafeSoccer
Sun Safe Surfing:
bit.ly/ASDSSunSafeSurfing
46
BUSINESS
®
OF DERMATOLOGY
SMART MOVES TO SAVE TIME &
53 4MONEY
Eliminate time-sappers from your practice
CLINIC EFFICIENCY
59 INCREASE
Experts offer tips for smooth scheduling
Three fast marketing
tactics for lasers
Marketing is what fuels the success
of laser practices, says Michael H. Gold,
M.D., medical director of a Nashville,
Tenn. laser practice with more than 40
devices.
But, like anything else, marketing
has to be done strategically. The goal
is to keep business coming in the door
without breaking the bank.
Start with those you know
➊
Marketing your laser practice
should first focus internally—on your
staff and patients. The often more expensive external marketing comes later,
experts say.
Marketing to patients and staff is a
more intimate, grassroots approach,
which might include staff training,
patient communications and social
media.
Terrence Keaney, M.D., clinical
professor of dermatology and urology
at George Washington Universit y
Medical Center and director of W for
Men, the men’s cosmetic center at the
Washington Institute of Dermatologic
Laser Surgery, says patients and staff
should know all the procedures available at your practice.
“Our staff members know exactly
what our treatments entail and the results that can be expected. They can be
a great advocate for these procedures to
your existing patients. I think the best
bang for your buck is maximizing your
internal marketing,” Dr. Keaney says.
Use different channels to communicate the message about your new technology to patients, according to dermatologist Bruce Katz, M.D., who directs
the Cosmetic Surgery and Laser Clinic
at Mount Sinai Medical Center, as well
as his own Juva Skin and Laser Center
in Midtown Manhattan.
“I’ll do an email blast, e-newsletters.
We have a TV monitor in the waiting
room with different types of lasers that
we’re using for different conditions,”
Dr. Katz says “Certainly, put informa-
Quotable
Amy Taub, M.D.
Chicago, Ill.
As long as your blog functions as a part of your
website, not someone else’s (which should be
forever), it will offer more opportunities to attract,
engage, convert and retain an audience than
any other channel, for a fraction of the cost.
So how do you “still care” about your blog? It all
starts with a choice — three of them, actually:
1. Generate Demand
2. Stick to Your Strengths
3. Champion Consistency
SOURCE: BIT.LY/YOURBLOGRELEVANT
See story page 59
MARKETING LASERS see page 54
DTExtra
It’s important to have a
monthly meeting... By
bringing everyone together we are able to
identify errors in our
processes, determin a solution, and put our solution into action.”
On practice efficiency
tion about any new devices on your
Facebook page, on social media.”
Laser companies often develop consumer-friendly collateral, including
in-office brochures. Dermatologists
can use those in their waiting rooms,
or create their own.
Dr. Gold, who directs Gold Skin
Care Center and Tennessee Clinical
Research Center, Nashville, says his
strategy is not only to inform but also
to entice patients. His website focuses
on his laser expertise and promotes
the practice’s successful VIP loyalty
rewards program.
Why focus so much on patients? The
dermatologist’s patient base is a rich referral and business resource, according to Elizabeth L. Tanzi, M.D., clinical professor of dermatology at George
Washington University Medical Center
and co-director, Washington Institute
of Dermatologic Laser Surgery, Washington, DC.
“Rather than spend a lot of money on
Cheryl Bisera is a marketing consultant, author and
speaker with extensive experience in marketing and
business promotion. She is founder of Cheryl Bisera
Consulting, a California-based image development and
marketing company that focuses on the healthcare industry.
Ms. Bisera is also the co-author of The Patient-Centered
Payoff, published by Greenbranch Publishing.
4 smart moves to
save time & money
ere are four ways to eliminate unnecessary steps
and time sappers from your daily operations.
These actions will make patient care more streamlined and pleasant for you and your patients, while
boosting practice profitability.
H
➊Hire a scribe
Physicians are at the top tier of revenue producers and salary
scales in practices. Protect that investment by keeping physicians
doing what only they can do. Hire a scribe for charting in the EHR in
real time. This best practice has been shown to increase physician
productivity, patient satisfaction and charting accuracy1. Be aware that
physicians must still review and sign off on all charting and that hiring
for this new position should be done with care. Pre-med students and
existing staff who are familiar with the terminology of your dermatology practice can be good candidates. Keep in mind that it will take
one to two months for a scribe to acclimate to your particular practice.
➋ Doctor-ready patients
Too often, physicians step into the exam room only to find that
the patient and/or room are not ready. If the intake nurse knows it’s
likely the physician will want to perform a biopsy, why not get the kit
out? Does the patient need to undress for an exam? Back-office staff
need to be sure they are doing everything they can to keep doctors
and patient visits moving forward.
➌ Standardize exam rooms
Do all that you can to have products and tools in the same
place in every room, every day. When a doctor or staff member
needs to reach for something, it should be there. Period. For a
physician to search for a tool or product is a tremendous waste
of time and energy that saps profits while detracting from the
patient experience, practice image and physician satisfaction.
➍ Establish a morning huddle
A quick overview of the day’s patient load and communication
between staff members can go a long way. Get on the same page,
head off schedule glitches early, and prepare for what lies ahead.
This quick team meeting can build morale and reduce miscommunication—a big win-win! This practice is easy to let slide, so it must be
built into your schedule with intention and considered a high priority.
Time is money, and physician time is at an absolute premium in any
dermatology practice. Let the doctors focus on their expertise and try to
delegate related care and services.
BUSINESS OF DERMATOLOGY
Start by identifying the time-sappers in your dermatology practice and prioritizing them by which ones cost you
the most. Tackle them one at a time if necessary. If you are
making these changes consistently, you are on your way to
becoming, and remaining, a best dermatology practice! DT
References:
1.
http://www.physicianspractice.com/physician-productivity/medical-scribespros-and-cons
53
54
BUSINESS
®
OF DERMATOLOGY
MARKETING LASERS:
The biggest bang for your buck from page 46
radio advertisements and all of these
different things, go to your patients,
first,” Dr. Tanzi says. “They want to
know that you are now providing these
new services to them, and they don’t
have to go to another physician to get
them.”
Being active on social media can be
time-consuming. The trick, according
to Dr. Keaney, is to have a systematic
approach and pick certain platforms
to focus on, whether it’s Facebook or
Twitter.
➋
Tap potential referral sources
Tina S. Alster, M.D., who opened
the Washington Institute of Dermatologic Laser Surgery in Washington, DC,
in 1990, says she has never been one to
use traditional advertising. Dermatologists should look to community referral sources and start there, according to
Dr. Alster.
“Look at what your referral base is
going to be in terms of other physicians
or lay groups. Maybe you can give talks
at some of the clubs—whether they’re
sports clubs, dining clubs, university
clubs—to let them know what you’re
doing,” Dr. Alster says.
Dermatologists should look into giving lectures to residents in training.
They should also educate other types
of medical specialists about what they
do. For example, dermatologists near a
teaching or community hospital could
approach the hospital’s cardiac and orthopedic surgeons. Why? They create
scars with surgery.
“… a lot of other types of surgeons
(orthopedic surgeons, cardiac surgeons) may not realize that the scars
they create can look that much better
after doing a pulsed dye laser treatment,” Dr. Alster says. “You can talk to
pediatricians who can refer the vascular birthmarks and other types of birthmarks to your practice. That’s how I got
started.”
Market for the long-term
➌
Marketing might evolve but it
doesn’t end.
Dermatologists should look for
trends and capitalize on them with
timely, focused marketing, whether
that’s to patients or to the community. Your placement on the internet
when potential patients do key word
searches for local laser experts depends
on how much effort you put into getting good placement with Google and
others.
Some dermatologists go so far as to
hire or contract with marketing professionals who understand how to gain
internet visibility.
“I work closely with an in-house marketing director, who focuses in on the
trends of the day and is very knowledgeable on how to maximize our marketing efforts and what we do on the internet,” Dr. Gold says.
Vic Narurkar, M.D., chairman of
dermatolog y at California Pacific
Medical Center, San Francisco, who
has a cosmetic-only dermatolog y
practice featuring 16 lasers, says that
organic, grassroots marketing through
e-blasts, brochures in the office and
social media are great ways to announce new laser services.
More elaborate ma rket i ng
campaigns, with print advertising,
radio spots or television, are expensive and best left after a laser business
is profitable.
“The time to do t hose external
types of marketing is when you get
busy enough, and you can brand
yourself,” Dr. Narurkar says. “For example, now that my practice is mature, I now use marketing and advertising to brand myself as a laser
specialist. But I didn’t do that early
on. Early on, I used organic marketing to get the patients and, then, it
became sort of on autopilot. That’s
when I started using external marketing.” DT
Disclosures: Dr. Keaney has no relevant disclosures. Dr. Tanzi is on the medical advisory board of
Zeltiq, Miramar and Clarisonic. Dr. Alster’s relevant
disclosures include consulting for Cynosure, Home
Skinovations, Palomar and Syneron. Dr. Narurkar
has performed clinical trials for Palomar, Solta and
Zeltiq. Dr. Katz is on Clinical Advisory Boards for
Allergan, Alma, Valeant, and Merz Pharmaceuticals,
and is a consultant for Pacific Biosciences and
El-En Engineering. Dr. Katz is also a stockholder
with Cynosure. Dr. Gold has no consulting arrangements with any company but receives compensation for research initiatives and speaking engagements. Dr. Gold works with Alma Lasers, Lumenia,
Syneron, Ellman, Ulthera, and Venus.
From the pages of
10 tips for physicians
to be better leaders
BY MEDICAL ECONOMICS STAFF
In a recent talk, Robert Taylor, MD,
provided 10 ways to help physicians
cultivate their leadership skills.
Define a vision: Good leaders not
➊
only have a compelling vision.
They will not rest until that vision becomes a reality
Share the vision: Leadership is
not passive; it is an active activity.
Persuade others to join the quest.
Recognize your leadership style:
There are six styles of leadership,
including autocratic, dictatorial, facilitative, bureaucratic, parental, and
charismatic. Which style are you?
Differentiate between leader
ship and management: Leaders
have a vision, and managers carry out
the vision. Leaders do the right thing,
whereas managers do things right.
Learn and play by the rules:
Although you don’t have to think
by the rules, they are the scar tissue of
past errors. Learn from past mistakes.
Earn the trust of those you lead:
Make rational, mission-based decisions, reconcile your vision with your
values, and guard your credibility.
Recognize the power of leadership: Power is being at the table.
Power is being able to control what
happens to others. Use power sparingly, and share power appropriately
and progressively.
Act like a leader: If you are cho
sen to lead, then play the part.
Turn followers into leaders:
Empower your employees to
make decisions. When you see an
employee making a sound decision,
acknowledge it.
Maintain balance in your life:
Turn work into play, and play
hard.
➋
➌
➍
➎
➏
➐
➑
➒
➓
Read the full article:
bit.ly/physicianscanbeleaders
From the pages of
Don’t skimp on your HIPAA risk assessment
ART GROSS | STAFF CORRESPONDENT
The electronic protected health information (ePHI) that sits on your network
is vulnerable to a security breach because
you haven’t plugged all the leaks. And the
threat of an auditor from the U.S. Department of Health and Human Services’ Office
of Civil Rights (OCR) handing out a steep fine
for noncompliance can be waiting around
the corner.
Here are the steps your practice should
take to protect your patients’ information –
and pass an audit:
Inventory patient information. Capture and inventory where patient information is stored, accessed, or transmitted. Aside from your electronic health record system, patient information can be
in a word processing document , billing
report,emails, or text messages.
Assess security policy. How often does
the practice perform data backups? Are
employees logging into public Wi-Fi networks or sharing information on social
media? Is there a termination procedure
when employees leave the company?
Evaluate common threats. How is the
practice protecting information in the
case of a natural disaster, or the loss or
theft of a laptop computer containing patient information, or sending an email to
the wrong patient? Again, have a policy
in place and make sure patient information is secure and protected if it’s stored
on a laptop.
Perform security risk assessment. A
thorough security risk assessment will help
®
a medical practice identify the additional security and procedures needed to lower the
risk of patient data breaches and to satisfy
OCR auditors.
Audit your systems. Track access to
ePHI and patient data to detect unauthorized access.
Encrypt your data. Don’t just protect
against attacks but help alleviate any potential penalties as auditors will take into
account whether a practice did all it could
to protect the data.
Stay vigilant. Train employees to recognize “phishing” and telephone scams.
Track the movement of visitors and patients
while they are in the organization’s facility. Don’t assume there will be no problems:
Have documented disaster recovery procedures in place. DT
Redefining the vision of skin care.
www.CanfieldScientific.com
[email protected] | +1.973.276.0336
55
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Melanie D. Palm, M.D.,
is director of Art of Skin in
Solana Beach, California
Pearls to increase clinic efficiency
new patient to my practice told
me she wanted to make a good
impression. She made sure she
was 15 minutes early because a Yelp
review said a patient who was late had to
be rescheduled.
I was astonished that my 1-star review on Yelp (it still pains me to admit
this) was actually having a positive effect: Showing my patient population
that I respect their time enough to stay
on schedule for them. In honor of my
patient, I explore with two other dermatologists pearls of clinic efficiency.
My experts this month bring a wealth
of knowledge with respect to running
a practice efficiently. Amy Taub, M.D.,
founder and medical director of Advanced Dermatology has a large and
well-established practice in the North
Chicago area of Lincolnshire, Ill. Recently, she has added a second location complete with a medical spa center. Kavita Mariwalla, M.D., founded Mariwalla Dermatology in the Long Island,
New York area several years ago and has
added several providers to a rapidly expanding practice of medical, surgical,
and cosmetic dermatology.
A
ORGANIZATION IS KEY
“It is important to have a monthly meeting with all departmental managers to
discuss efficiency,” Dr. Taub says. “By
bringing everyone together we are able
to identify errors in our processes, determine a solution, and put our solution
into action.”
Dr. Taub also reinforces the importance
of appointment rules, which are are wellknown by the staff, flexible over time, but
identify unique scheduling by patient issues to avoid scheduling back-ups.
In my practice, our full staff comes together bimonthly and separate departments meet monthly. As aberrations in the
schedule are identified they are added to
the meeting agenda for discussion, which
ensurs both front and back office teams
are on the same page.
SCHEDULING
All three of our practices are on electronic medical records and practice
management systems. Two of the three
of us schedule visits through our scheduling software by both provider and by
the room/device.
“Our schedule is displayed by provider
but we also have equipment columns to
ensure that devices do not become double booked,” Dr. Taub says.
Both Drs. Taub and Mariwalla divide
clinic blocks by different services, such
as a half-day of medical dermatology,
Mohs, or cosmetics.
Dr. Mariwalla describes the evolution
of her current scheduling layout: “As my
practice has grown, I have found it helpful to separate surgical, medical, and
cosmetic appointments into separate
days/time blocks. A Mohs session for example has a very different workflow and
pace than an afternoon of total body skin
examinations,” she says. This allows her
staff to mentally prepare for each time
block and flow, and it prevents mental fatigue from too many total body skin examinations in a row. “It is important that
my first and last TBSE of the day receive
the same amount of attention,” she says.
Dr. Taub says that her practice management software is set up to populate
specific times for each procedure or visit.
Her system even accommodates for differences between providers, allotting different time blocks for certain procedures
based on provider needs and abilities.
Dr. Mariwalla also has pre-set scheduling blocks depending on the type of
visit.
“I leave 30 minutes for excisions, 10
minutes for follow-up visits, and pre-set
times for laser procedures, including a
block for topical anesthetic application,”
she says.
We each schedule lunch breaks to
allow for catch-up, to provide staff a
needed and legally required break, and
to conduct other business such as interviews or business meetings.
A TEAM EFFORT
Staying on time is a group effort. The
office manager oversees correct templating of the patient schedule and trouble shoots any scheduling challenges
throughout the day.
“Client services helps with different
check-in procedures, and schedules
the majority of appointments,” crucial
to running a timely clinic, Dr. Taub says.
Dr. Mariwalla says back office staff help
with flow, anticipating physician needs,
and reducing provider downtime. Her
MA’s bring patients to rooms, assigning
a room number where, a glance, she has
a full picture of her patients and where
they are in the facility from her iPad.
EMERGENCY VISITS
Each physician handles emergency visits differently. I always see urgent patient
visits same day, accommodating them
at lunch, after clinic, or in between quick
follow-up or acne visits. Dr. Taub provides slots in her day for such events,
and if the appointments are not taken,
patients on a waiting list fill the time gap.
Dr. Mariwalla has found most urgent visits come from phone calls made in the
morning so she provides afternoon and
evening availability for emergency visits.
Lastly, all three of us are in agreement
about cosmetic visits. We each treat same
day for minor cosmetic procedures such as
laser spot treatments or botulinum toxin injection. However, a comprehensive cosmetic consultation and longer-term treatment plan may be indicated for many aesthetic patients, with procedures scheduled
at future visits after appropriate patient education and preparation.
Finally, it is sometimes difficult for
physicians to truly identify their limits,
and without an honest appraisal, scheduling delays are likely to occur. If you’re
healthy and relatively unstressed, this
sets the tone for your staff and patients.
Have patience for your patients, gratitude
for your staff, and respect for yourself,
and a successful clinic will follow. DT
59
60 THE
TAKEAWAY
®
CLINICAL PEARLS IN
PEDIATRIC DERMATOLOGY
TAKEAWAY:
Recognizing sinus tracts and keratinous cysts from page 8
graphs of all the people in the study and
I identified 37 patients who had lesions
that I said would not go away with the
drug, because I thought they were either a sinus tract or keratinous cyst, and
I was right with 37 out of 37.
Once you have learned to recognize
these things clinically and to distinguish them from nodular areas of
inflammation that you can’t get your
hands around and feel, they’re pretty
easy to recognize. But until you do, it is
a little bit like listening to mitral murmurs; somebody can hear them, but
you’re having trouble hearing them.
DR. SIEGFRIED: When you recognize those
patients, what do you do?
A Dr. Leyden: I think intralesional steroids are very useful for keratinous cysts if they are inflamed. Sometimes when you inject an inflamed keratinous cyst, the whole thing seems to
melt, or enough of it melts that nothing
more needs to be done. But if it’s constantly recurring, it has to be removed
the same way the sinus tract lesion is.
If it is persistent and doesn’t
respond to intralesional steroid, I
think then it should be removed.
DR. SIEGFRIED: So when you inject cysts, do you
do it into the cyst cavity or in the periphery?
A Dr. Leyden: I mostly put it into the
cavity, because I think a lot of it diffuses. The question is: Could you do
better by injecting the periphery? That’s
an interesting question. I think one of
the things that is most interesting about
If you (suspect a
keratinous cyst), feel
... under the surface.
You can feel the
rest of the lesion as
something you can
define and get your
fingers around.
James Leyden, M.D.
University of Pennsylvania
ADDITIONAL TAKEAWAYS
injecting steroids in the skin is if you get
anywhere near the subcutaneous layer,
significant atrophy can develop.
DR. SIEGFRIED: But injecting into the cyst cavity
has the potential to cause micro-rupture of the
cyst resulting in terrible inflammation. If you inject around the cyst, then you get atrophy. How
do you manage that?
A Dr. Leyden: I use a 30-gauge needle
— and my general rule is, depending
on the size, no more than 1-3 mg of steroid. I do not believe in injecting until it
blanches. Once you see blanching, that’s a
sign of increased pressure, and that’s usually when it hurts and may rupture.
It is the amount you want to put in that
is important, not the volume. You figure
out how to put in 1 mg, but you could put
in 5 cc if you dilute it enough. If you have
a 10 mg/mL syringe, then a 0.1 mL will
have 1 mg. If you inject 0.2 mg into an inflamed keratinous cyst, you’re not going
to get rupture of the cyst and it’s not going
to hurt.
This way, you put in the amount you
want, but the volume is not big enough to
cause blanching and distention and/or
rupture of the cyst.
DR. SIEGFRIED: That’s a good pearl. It is another
area of constant and common-use treatment
that all dermatologists are taught to do with
such variation in technique and dose, and I think
the outcomes can vary.
A Dr. Leyden: Right from the time I
started, I noticed when patients started
commenting on the pain. That always
seemed to be just as it blanched. I started
backtracking the volume and paying attention to amount and how often I would
get atrophy. That’s how I came to the 1-3
mg dose per cyst.
DR. SIEGFRIED: You can try that with sinus
tracts as well?
A Dr. Leyden: For sure. Once you learn, if
you take your time, you can actually get
into the tract and you can get much more
easily into the cyst. You can follow the epithelium, the actual sinus and inject it with
a lot less discomfort. DT
Pediatric dermatology is a
rewarding area of special
interest for dermatologists.
Overlapping conditions, the need
for extra-gentle skin care, patient compliance,
and medication adherence all present unique
challenges for pediatric dermatologists. In a series
of discussions, Kelly Cordoro, M.D., associate
professor of dermatology and pediatrics at
the University of California in San Francisco,
discusses differentiating diseases and treatment
recommendations, environmental and microbial
triggers of eczema, when to choose systemic
therapies, screening labs, avoiding complacency,
and the ABCDEs of melanoma with Dermatology
Times editorial advisor, Elaine Siegfried, M.D.
bit.ly/pediatricdermatology
DOES GLUTEN
DRIVE SKIN DISEASE?
Gluten and gluten-sensitive
enteropathy have become hot
topics among the lay public and in
medical practices. Dermatologists
have historically concerned themselves
with gluten only as it relates to dermatitis
herpetiformis. This may be changing. John Zone,
M.D., from the University of Utah, Salt Lake City,
discusses how gluten sensitive enteropathy
may impact many areas of dermatology.
DermatologyTimes.com/gluten-sensitivity
ADVANCEMENTS IN
PSORIASIS TREATMENT
The past few years have been
an exciting time for those
who treat psoriasis and for
many patients with severe
disease because of excellent new therapies
for this often intractable problem. Alan
Menter, M.D., Baylor University Medical
Center, Dallas, shares insight into recent
developments in the treatment of psoriasis.
DermatologyTimes.com/psoriasisadvances
STRATEGIES FOR
MANAGING LEG ULCERS
Leg ulcers are a common and
difficult management problem
for all dermatologists. Robert
S. Kirsner, M.D., professor and
vice chairman of dermatology,
University of Miami Miller School of Medicine,
and director of the University of Miami Hospital
Wound Center, elucidates the diagnosis and
management of these challenging skin problems.
DermatologyTimes.com/legulcers
Hear more at: bit.ly/takeawaypodcasts
See it.
Share it.
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64
Marketplace
Dermatology Times |
December 2015
CAREERS
FELLOWSHIP
NATIONAL
MEDICAL DERMATOLOGY
FELLOWSHIP
1 – 2 years experience in management of
complex medical dermatology patients in both
private practice & teaching clinic.
Biologics, immunsuppressants,
immunomodulators, clinical trials. PGY 5/6.
Send CV & 2 LOR to:
David Fivenson, MD.
²YHQVRQGHUPDWRORJ\#FRPFDVWQHW
NATIONAL
MOHS SURGEON
MULTIPLE PART TIME OPPORTUNITIES
Montrose, CO
1-2 days/mo
Enfield, CT
2-3 days/mo
Groton, CT
1-2 days/mo
Hickory, NC
1-2 days/mo
Sanford, NC
2-3 days/mo
Bountiful, UT
3-4 days/mo
Tampa, FL
1-2 days/mo
Calumet City, IL
1-2 days/mo
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com
ARIZONA
Dr. Matt Leavitt, Founder & CEO
Advanced Dermatology and Cosmetic Surgery, the largest dermatology
practice in the country with over 120 locations, is seeking immediate full time
Fellowship Trained Mohs Surgeons and General/Cosmetic Dermatologists.
The group is going through expansive growth and positions are immediately
available. Excellent opportunity to build an office practice!
t )JHIMZDPNQFUJUJWFTBMBSZ t 'VMMCFOFåUT t .VMUJQMFMPDBUJPOT
For immediate consideration, send your CV today!
Submit CV to
Christie Knowles at [email protected]
or call 904-354-4488
COLORADO
DISTRICT OF COLUMBIA
WASHINGTON, DC
PHOENIX/SCOTTSDALE AREA, ARIZONA
Mohs Surgeon Opportunities
Contact Christie Knowles, (904) 354-4488 or
[email protected]
CALIFORNIA
DENVER AREA, COLORADO
General Dermatologist Opportunities
[email protected]
CONNECTICUT
Partnership available. Established practice.
www.MyDermGroup.com
FLORIDA
PORTERVILLE, CALIFORNIA
www.MyDermGroup.com
GROTON, CONNECTICUT
www.MyDermGroup.com
COLORADO
BOULDER, COLORADO
www.MyDermGroup.com
SOUTHBURY, CONNECTICUT
www.MyDermGroup.com
DELAND (WITH SIGNING BONUS), FLORIDA
[email protected]
BOCA RATON, FLORIDA
Dermatology of Boca seeks an Associate/Partner
to join rapidly growing practice.
Please email CV to
[email protected] or call (561) 362-8000
MONTROSE, COLORADO
WATERBURY, CONNECTICUT
MIAMI, FLORIDA
www.MyDermGroup.com
www.MyDermGroup.com
www.MyDermGroup.com
December 2015
|
Marketplace
CAREERS
FLORIDA
FLORIDA
ORLANDO, FLORIDA
DERMATOLOGIST NEEDED
www.MyDermGroup.com
TAMPA, FLORIDA
www.MyDermGroup.com
WEST PALM BEACH, FLORIDA
www.MyDermGroup.com
OPPORTUNITY FOR AN ESTABLISHED
SARASOTA-BASED BC DERMATOLOGIST
If you are looking for a change, our practice
is looking for you. We have a clean, modern,
state-of-the-art facility and offer a generous
profit incentive. All inquiries strictly confidential.
Respond to:
American Dermatology Associates
Attn: Angie Phone (941) 379-0877 or
email: [email protected]
RECRUITMENT
ADVERTISING
Call Joanna Shippoli
to place your
Recruitment ad at
800.225.4569 ext. 2615
[email protected]
HAWAII
Beautiful Florida West Coast
$10,000 Signing Bonus
Desirable, resort-style living near
beautiful Gulf beaches & golf courses
Close to Tampa for cultural & sports
6 West FL Coast locations in Sarasota,
Bradenton, Ellenton, Sun City Center,
and Venice
14 multi-specialty referral physicians
Competitive salary with bonus structure
Paid malpractice
401k, profit sharing, vacation, CME
reimbursement, insurance, & more
Email: [email protected]
Work and play in Hawaii !
Unique opportunity for
DERMATOLOGIST
(Medical and Cosmetic)
to work in one or all locations
) Honolulu
) Pearl City
) Hilo
) Kona
) Guam
Entrepreneurial:
You keep 45% of profits.
CENTRAL FLORIDA
[email protected]
Contact Dr. Barthlen
(808) 291-8909
or [email protected]
ILLINOIS
CALUMET CITY/DYER, IN
FLORIDA
GENERAL DERMATOLOGIST OPPORTUNITIES
Heathrow
Jacksonville
Lakeland
Winter Park
www.MyDermGroup.com
MARYLAND
[email protected]
TOWSON, MARYLAND
GEORGIA
ALBANY (WITH SIGNING BONUS), GEORGIA
[email protected]
Repeating an ad ENSURES
it will be seen
and remembered!
[email protected]
WHITE PLAINS, MARYLAND
www.MyDermGroup.com
MICHIGAN
PETOSKEY and TRAVERSE CITY, MICHIGAN
[email protected]
65
66
Marketplace
Dermatology Times |
December 2015
CAREERS
MONTANA
NEW MEXICO
SANTA FE, NEW MEXICO
www.MyDermGroup.com
DERMATOLOGIST PHYSICIAN – BILLINGS, MT
Motivated by its mission to provide compassionate care and service, St. Vincent
has become one of Montana’s leading comprehensive healthcare providers.
Modern medical technology has been integrated into our commitment to provide
care for the sick, to respect life, to serve the poor and to provide compassion and
charity for all who need it.
t
t
t
t
t
t
t
t
Competitive salary with productivity incentives and loan repayment
Start date bonus, Moving Allowances and CME reimbursement
Large patient base and potential to grow, utilizes EMR
Full time employed position.
Opportunity for MOHS and Cosmetic if there is interest
Thriving medical community in a family-oriented suburban location.
Large newly renovated clinic
Abundant recreational activities year round
NORTH CAROLINA
HICKORY, NC
www.MyDermGroup.com
OHIO
For more information, please contact a physician recruiter:
Carrie Ballard at (406) 237-4002 or [email protected]
OHIO
GENERAL DERMATOLOGIST OPPORTUNITIES
Beaver Creek
Dayton
Mason
NEW YORK
Contact Christie Knowles,
(904) 354-4488 or
[email protected]
Academic Medical Dermatologist (Skin Cancer)
CENTERVILLE, OHIO
Memorial Sloan Kettering Cancer Center (MSK) is an internationally renowned cancer center located
in New York City. MSK is expanding its clinical services with an emphasis on the early detection and
treatment of skin cancer. The Dermatology Service has 15 full time clinical faculty and is recruiting for
positions in its expanded facilities in New York, NY and Basking Ridge, NJ.
[email protected]
The Dermatology Section is seeking a full time medical dermatologist to join a busy academic dermatology
practice specialized in the diagnosis and management of skin cancer. Applicants must have strong clinical
skills and an interest in public health, clinical research, or teaching. Opportunities for clinical research and
multidisciplinary collaborative projects are numerous.
NORTHWESTERN OHIO
Rank and salary will be based on background and experience. Interested candidates should send their resumes
to: Allan C. Halpern, MD, Chief, Dermatology Service, c/o Erich Stingelin, MD, Administrative
Secretary, Memorial Sloan Kettering Cancer Center, 16 East 60th Street, New York, NY 10022;
E-mail: [email protected]; Phone: (646) 888-6012.
Memorial Sloan Kettering is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of
recruiting and employment. All qualified individuals are encouraged to apply.
Partnership available for BC/BE Dermatologist
in solo Dermatology practice. Established
over 40 years, General Dermatology, surgery
and cosmeceuticals. Drawing area over
500,000. Great boating, fishing, camping,
skiing, hiking, biking with a family oriented
location. Competitive reimbursements and
productivity bonuses.
[email protected]
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,MKLP]GSQTIXMXMZIGSQTIRWEXMSR
)1%-0':()612=1$KQEMPGSQ
BUFFALO, NEW YORK
Associate Opportunity
www.MyDermGroup.com
A D V E R T I S E T O D AY !
Repeating an ad ENSURES
it will be seen
and remembered!
December 2015
|
Marketplace
CAREERS
OREGON
PENNSYLVANIA
RECRUITMENT
ADVERTISING
EUGENE, OREGON
Part Time/Full Time Position
General/Cosmetic/Surgical
Dermatology
Spectacular Scenic Beauty
Excellent Benefits
Fax CV & Cover Letter to
541-683-5206 Or Call 541-681-5090
WISCONSIN
PHILADELPHIA, PENNSYLVANIA
[email protected]
PHILADELPHIA, PENNSYLVANIA
[email protected]
VIRGINIA
FREDERICKSBURG, VIRGINIA
www.MyDermGroup.com
Call Joanna Shippoli
to place your
Recruitment ad
at 800.225.4569 ext. 2615
[email protected]
WASHINGTON
Physician - Dermatology
EOE/AA/LEP
DERMATOLOGIST
Gundersen Health System in La Crosse,
Wisconsin, is seeking a BC/BE dermatologist
to work in our new state-of-the-art facility.
Your practice will consist of general
medical dermatology with opportunities
for dermatologic surgery (regular and
cosmetic), medical education and clinical
research within one of the nation’s largest
multi-specialty group practices. Services
currently offered include MOHS Surgery,
Photodynamic Therapy, PUVA, Broad and
Narrow Band UVB, Vascular Laser
Treatment and multiple IPLs.
Virginia Mason Medical Center in Seattle, WA is recruiting Dermatologists for both the main campus and
selected surrounding regions. Our dermatologist provide medical dermatology and if desired, cosmetics.
The Dermatology section is recognized for high quality work and collegial environment. We have a
very high volume of patients, many of whom also receive both their primary and specialty care in our
multispecialty clinic. We have an excellent team of dermatopathologists who both support the clinical
work and jointly share education and quality initiatives. We have a dedicated Moh’s surgeon who is a
member of the Dermatology section. We have a generous compensation and benefits package.
Virginia Mason Medical Center is a multi-specialty clinic and 340 bed acute care hospital that stresses
Team Medicine for the ideal management of patients. We are a recognized leader in quality and safety.
Our organization has received numerous awards from organizations such as Healthgrades and Leap Frog.
We are associated with an immunology focused research institute. There are multiple opportunities for
clinical research if desired.
Seattle is an exceptional place that combines the amenities of urban experience with proximity for many
outdoor activities such as skiing, boating, hiking, and innumerable sports. Seattle is a great place for family
and children with excellent schools, parks, music, and educational programs. It is considered
one of America’s most livable cities.
Our ideal candidate is BE/BC in dermatology and prefers to work in a
multi-specialty clinic that is focused on maximizing the patient experience.
To apply visit jobs.VirginiaMason.org or contact Nancy Longcoy,
[email protected]. EOE.
Contact: Kalah Haug, Medical Staff
Recruitment, (608) 775-1005 or email
[email protected].
Visit: gundersenhealth.org/MedCareers
Visit us at
AAD Booth
#7348
Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.
La Crosse, Wisconsin
Recruitment
Advertising
Can Work For You!
Content Licensing for Every Marketing Strategy
Leverage branded content from Dermatology Times to create a
more powerful and sophisticated statement about your product, service,
or company in your next marketing campaign. Contact Wright’s Media to
find out more about how we can customize your acknowledgements and
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For information, call Wright’s Media at 877.652.5295
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67
68
LEGAL
®
EAGLE
David J. Goldberg, M.D., J.D.
is director of Skin Laser and Surgery
Specialists of New York and New
Jersey; director of laser research, Mount
Sinai School of Medicine; and adjunct
professor of law, Fordham Law School.
My patient’s law firm is suing over
medical record copy fees. Can I win?
r. Doc practices in a small town.
His patient filed a medical malpractice lawsuit against him simultaneously with his attorney demanding a
copy of Dr. Doc’s medical records. The
law firm had a previous copy of the medical records because the plaintiff patient
had requested them a year ago and then
passed them onto the suing lawyer. Dr.
Doc is annoyed that he now has to send
the records a second time and discusses
this with his friend, a local pharmacist.
His friend says that, while he knows
there are rules related to fees that offices
can charge for sending medical records,
his pharmacy charges whatever it wants.
D
THE LAWSUIT
Dr. Doc sends a bill to the attorney for
$50/page of the 100-page medical record. His bill stipulates that the expenses are for research and preparation of files, clerical expenses, photocopying expenses, and postage and
handling. The law firm pays the full
$5,000, and Dr. Doc promptly sends
the records. As soon as the law firm
gets the medical records, it sues Dr.
Doc for charging too much. Dr. Doc
reports this second lawsuit to his
medical malpractice carrier, who tells
him he is not covered for such a lawsuit. Dr. Doc has to hire a second lawyer to defend him in this case. The second lawyer requires a $10,000 retainer
and informs him that the defense of
such a case may cost him in excess of
$100,000. Dr. Doc is understandably
upset. What is he to do?
A SIMILAR CASE
A somewhat similar case was decided
by the Supreme Court of Pennsylvania
in 2014. In Landy v. Rite Aid, the Pennsylvania Court looked at the state’s
Medical Record Act (MRA) as it applies to physicians and pharmacies. All
states have such acts. The purpose of
an MRA is to be sure that a “patient”
of that patient’s representative (in this
case, the attorney) has a right to his or
her own medical records. The Act also
addresses what medical record providers can charge for the provided copies. Most such acts specifically limit
what healthcare provider’s and health
care facility’s fees can be for the reproduction of medical charts or records. In
general, the MRA was enacted by most
legislatures because of its focus on
problems concerning access to hospital and physician records.
Of note, Medical Records Acts generally do not address pharmacies.
The Pennsylvania court, in addressing pharmacies, looked at whether the
patient of a doctor was also a patient
versus a customer of a pharmacy. The
Pennsylvania Supreme Court looked
at whether the MRA was limited to
healthcare facilities and, if so, whether
Most MRAs
specifically limit
what health care
provider’s and
health care facility’s
fees can be for the
reproduction of
medical charts or
records.
pharmacies fell within the meaning
of “healthcare facility”. The Court explained that legislative intent is best
determined by examining a statute’s
plain language and that statutory interpretation requires a holistic view of
the statute and that effect be given to
all the statute’s provisions. Words and
phrases will then be considered in light
of grammatical rules and commonly
approved usage, and statutory words
should be considered, not in isolation,
but in the context of the entire statute.
INTERPRETATION
Applying the rules of statutory interpretation, the Court first considered the
meaning of the term “healthcare facility”. In doing so, it addressed a pharmacy’s contention that the use of the terms
“healthcare provider” and “healthcare
facility” in the same statute suggested
that the terms were interchangeable. Ultimately, the Court ruled that the pharmacy was neither. In doing so, the Court
looked at the state’s Pharmacy Act.
The Pharmacy Act makes no mention
of pharmacy consumers as “patients”.
Rather, it limits the practice of pharmacy
to preparing, compounding, dispensing,
storing and distributing drugs, as well
as maintaining records and providing information related to drugs. In the end,
pharmacies are not considered healthcare providers under the MRA. They
can charge whatever they desire for the
delivery of patient records.
Dr. Doc, on the other hand, is a
provider as defined by his state’s
MRA. He cannot charge $5,000 to the
plaintiff’s attorney. He may hope to
win the lawsuit filed by his patient, but
he has no chance at winning the MRA
lawsuit brought on by his patient’s
attorney. DT
IMPORTANT INFORMATION ABOUT
EPIDUO® FORTE
(adapalene and benzoyl peroxide) GEL, 0.3% / 2.5%
BRIEF SUMMARY
This summary contains important information about EPIDUO FORTE
(Ep-E-Do-Oh For-Tay) Gel. It is not meant to take the place of your doctor’s
instructions. Read this information carefully before you start using EPIDUO
FORTE Gel. Ask your doctor or pharmacist if you do not understand any
of this information or if you want to know more about EPIDUO FORTE Gel.
For full Prescribing Information and Patient Information, please see the
package insert.
WHAT IS EPIDUO FORTE GEL?
EPIDUO FORTE Gel is a prescription medicine used on the skin (topical)
to treat acne vulgaris. Acne vulgaris is a condition in which the skin has
blackheads, whiteheads and pimples.
WHO IS EPIDUO FORTE GEL FOR?
EPIDUO FORTE Gel is for use in people 12 years of age and older. It is not
known if EPIDUO FORTE Gel is safe and effective for children younger than
12 years old.
Do not use EPIDUO FORTE Gel for a condition for which it was not
prescribed. Do not give EPIDUO FORTE Gel to other people, even if they
have the same symptoms you have. It may harm them.
WHAT SHOULD I TELL MY DOCTOR BEFORE USING
EPIDUO FORTE GEL?
Before you use EPIDUO FORTE Gel, tell your doctor if you:
B have other skin problems, including cuts or sunburn.
B have any other medical conditions.
B are pregnant or planning to become pregnant. It is not known if
EPIDUO FORTE Gel can harm your unborn baby. Talk to your doctor
if you are pregnant or planning to become pregnant.
B are breastfeeding or plan to breastfeed. It is not known if EPIDUO
FORTE Gel passes into your breast milk and if it can harm your
baby. Talk to your doctor about the best way to feed your baby if
you use EPIDUO FORTE Gel.
Tell your doctor about all of the medicines you take, including
prescription and over-the-counter medicines, vitamins and herbal
supplements. Using other topical acne products may increase the
irritation of your skin when used with EPIDUO FORTE Gel.
WHAT SHOULD I AVOID WHILE USING EPIDUO FORTE GEL?
B You should avoid spending time in sunlight or artificial sunlight,
such as tanning beds or sunlamps. EPIDUO FORTE Gel can make
your skin sensitive to sun and the light from tanning beds and
sunlamps. You should use sunscreen and wear a hat and clothes
that cover the areas treated with EPIDUO FORTE Gel if you have to
be in the sunlight.
B You should avoid weather extremes such as wind and cold as this
may cause irritation to your skin.
B You should avoid applying EPIDUO FORTE Gel to cuts, abrasions
and sunburned skin.
B You should avoid skin products that may dry or irritate your skin
such as medicated or harsh soaps, astringents, cosmetics that have
strong skin drying effects and products containing high levels of
alcohol, spices or limes.
B You should avoid the use of “waxing” as a hair removal method
on skin treated with EPIDUO FORTE Gel.
B EPIDUO FORTE Gel may bleach your clothes or hair.
Allow EPIDUO FORTE Gel to dry completely before dressing to
prevent bleaching of your clothes.
WHAT ARE THE MOST COMMON SIDE EFFECTS OF
EPIDUO FORTE GEL?
EPIDUO FORTE Gel may cause serious side effects including:
B Local skin reactions. Local skin reactions are most likely to happen
during the first 4 weeks of treatment and usually lessen with
continued use of EPIDUO FORTE Gel. Signs and symptoms of
local skin reaction include:
B Redness
B Dryness
B Scaling
B Stinging or burning
Tell your doctor right away if these side effects continue for longer than 4
weeks or get worse; you may have to stop using EPIDUO FORTE Gel.
These are not all of the possible side effects of EPIDUO FORTE Gel. For
more information, ask your doctor or pharmacist.
You are encouraged to report negative side effects of prescription drugs to
the FDA at www.fda.gov/medwatch or call 1-800-FDA-1088. You may also
contact GALDERMA LABORATORIES, L.P. at 1-866-735-4137.
HOW SHOULD I USE EPIDUO FORTE GEL?
B Use EPIDUO FORTE Gel exactly as your doctor tells you to use it.
EPIDUO FORTE Gel is for use on the skin only (topical). Do not use
EPIDUO FORTE Gel in or on your mouth, eyes or vagina.
B Apply EPIDUO FORTE Gel 1 time a day.
B Do not use more EPIDUO FORTE Gel than you need to cover the
treatment area. Using too much EPIDUO FORTE Gel or using it more
than 1 time a day may increase your chance of skin irritation.
APPLYING EPIDUO FORTE GEL:
B Wash the area where the Gel will be applied with a mild or soapless
cleanser and pat dry.
B EPIDUO FORTE Gel comes in a pump. Depress the pump to dispense
a small amount (about the size of a pea) of EPIDUO FORTE Gel and
spread a thin layer over the affected area.
B Wash your hands after applying the Gel.
WHERE SHOULD I GO FOR MORE INFORMATION ABOUT
EPIDUO FORTE GEL?
B Talk to your doctor or pharmacist.
B Go to www.EPIDUOFORTE.com or call 1-866-735-4137.
All trademarks are the property of their respective owners.
GALDERMA LABORATORIES, L.P., Fort Worth, Texas 76177 USA
Revised: July 2015
20089-0415-BS
Reference: 1. Epiduo Forte Clinical Study Report (SRE 18240). Data on file.
Galderma Laboratories, L.P.
©2015 Galderma Laboratories, L.P.
Galderma Laboratories, L.P.
14501 N. Freeway
Fort Worth, TX 76177
EPI-00007 Printed in USA 07/15
www.epiduoforte.com/hcp

Dr. Leyden - Modern medicine

Transcription

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