Dr. Kirsner - Modern medicine

Transcription

Dermatology Times®
Clinical Analysis for Today’s Skincare Specialists
BUSINESS
July 2014
No advantages
from circulation of
physician payment
data, doctors say
Louise Gagnon | Staff Correspondent
July 2014
VOL. 35, NO. 7
DERMATOLOGISTS DEAL WITH
COSMETIC COMPETITION
Volume 35 No. 7
Best defense against unqualified injectors’
discounts involves patient education
DermatologyTimes.com
R elea s e of 2 012 phy s ic i a n
payment data from the Centers for
Medicare and Medicaid Services
(CMS) has perhaps done a disserJohn Jesitus | Senior Staff Correspondent
OB/GYNs to “medispas that barely have a medical
vice to the reputation of healthcare
director over them are purchasing fillers and
providers including dermatoloWith “discount” injectable treatments here to
neuromodulators online and marketing them as
gists, saySAFETY
several
clinicians.
stay, experts say, dermatologists must court
the real thing. This cheapens our whole marketIMPORTANT
INFORMATION
The
dissemination
of
Medisophisticated
consumers
willing
to
pay
for
the
place.” She is a dermatologist in private practice in
INDICATIONS: This product is indicated for use in the topical control of
care payments in early April, ƟƐ� quality and expertise that only dermatologists and
Montclair, N.J.
ĂĐŶĞǀƵůŐĂƌŝƐ�ĂĐŶĞƌŽƐĂĐĞĂĂŶĚƐĞďŽƌƌŚĞŝĐĚĞƌŵĂƟ
showing that 880,000
physicians
core
Economically, Dr. Downie says, “I call it a race
CONTRAINDICATIONS:
This product
is contraindicated inother
persons
with aesthetic specialists offer.
ŬŶŽǁŶŽƌƐƵƐƉĞĐƚĞĚŚǇƉĞƌƐĞŶƐŝƟ
and other healthcareǀŝƚǇƚŽĂŶǇŽĨƚŚĞŝŶŐƌĞĚŝĞŶƚƐŽĨƚŚĞ
providers
The problem of heavily discounted
to the bottom. Noncore competitors try to
ƉƌŽĚƵĐƚ�dŚŝƐƉƌŽĚƵĐƚŝƐŶŽƚƚŽďĞƵƐĞĚďǇƉĂƟĞŶƚƐǁŝƚŚŬŝĚŶĞǇĚŝƐĞĂƐĞ�
received $77 billion under the
injectables dates back to unit pricing
manipulate all the cosmetic dermaWARNINGS: Sulfonamides are known to cause Stevens-Johnson
of neuromodulators and laser
tologists into decreasing our prices.
PAYMENT DATA see page 56
ƐǇŶĚƌŽŵĞ ŝŶ ŚǇƉĞƌƐĞŶƐŝƟǀĞ ŝŶĚŝǀŝĚƵĂůƐ� ^ƚĞǀĞŶƐ�:ŽŚŶƐŽŶ ƐǇŶĚƌŽŵĞ
deals, says Vic Narurkar,
And we cannot and should not.
also has been reported following the use of sodium package
sulfacetamide
ƚŽƉŝĐĂůůǇ� ĂƐĞƐ ŽĨ ĚƌƵŐ�ŝŶĚƵĐĞĚ ƐǇƐƚĞŵŝĐ ůƵƉƵƐ ĞƌǇƚŚĞŵĂƚŽƐƵƐ
M.D. “IfĨƌŽŵ
someone only needs two
We need to maintain that we are
ƚŽƉŝĐĂůƐƵůĨĂĐĞƚĂŵŝĚĞĂůƐŽŚĂǀĞďĞĞŶƌĞƉŽƌƚĞĚ�/ŶŽŶĞŽĨƚŚĞƐĞĐĂƐĞƐ�
treatments to get the desired
board-certified and trained
In
This
Issue
ƚŚĞƌĞǁĂƐĂĨĂƚĂůŽƵƚĐŽŵĞ�KEEP OUT OF THE REACH OF CHILDREN.
results, selling them a package
in a l l aspects of cosmet ic
PRECAUTIONS: FOR EXTERNAL USE ONLY. NOT FOR OPHTHALMIC
of
five
or
six
is
unethical,”
he
and general dermatology. As
USE. CLINICAL 18
says. Dr. Narurkar is founder
a specialty, we should hold
'ĞŶĞƌĂů�
EŽŶƐƵƐĐĞƉƟ
ďůĞ can
ŽƌŐĂŶŝƐŵƐ� ŝŶĐůƵĚŝŶŐ ĨƵŶŐŝ� ŵĂǇ ƉƌŽůŝĨĞƌĂƚĞ
Small
pests
and director of the Bay Area
ourselves up as the skincare
ǁŝƚŚƚŚĞƵƐĞŽĨƚŚŝƐƉƌĞƉĂƌĂƟŽŶ�
cause big skin problems
Laser
Institute,
chairman
of
COMPETITION see page 38
ůƚŚŽƵŐŚƌĂƌĞ�ƐĞŶƐŝƟ
Most bug bitesǀŝƚǇƚŽƐŽĚŝƵŵƐƵůĨĂĐĞƚĂŵŝĚĞŵĂǇŽĐĐƵƌ�dŚĞƌĞ�
aren't life-threatening,
dermatology
ĨŽƌĞ� but
ĐĂƵƟproper
ŽŶ ĂŶĚ
ĐĂƌĞĨƵů is
ƐƵƉĞƌǀŝƐŝŽŶ
ƐŚŽƵůĚ ďĞ ŽďƐĞƌǀĞĚ
ǁŚĞŶ at California Pacific
diagnosis
instrumental
ƉƌĞƐĐƌŝďŝŶŐƚŚŝƐĚƌƵŐĨŽƌƉĂƟĞŶƚƐǁŚŽŵĂǇďĞƉƌŽŶĞƚŽŚǇƉĞƌƐĞŶƐŝƟ
MedicalǀŝƚǇ
Center, San Francisco,
ƚŽ ƚŽƉŝĐĂů
ƐƵůĨŽŶĂŵŝĚĞƐ�
ƐŝŐŶƐ ŽĨ
COSMETIC
24 /Ĩ ƚŚĞ ƵƐĞ ŽĨ ƚŚŝƐ ƉƌŽĚƵĐƚ ƉƌŽĚƵĐĞƐ
and
a
co-founder
of Cosmetic
Ś ƉĞƌƐĞŶƐŝƟǀŝƚǇ Žƌ ŽƚŚĞƌ ƵŶƚŽǁĂƌĚ ƌĞĂĐƟŽŶƐ� ĚŝƐĐŽŶƟŶƵĞ ƵƐĞ ŽĨ ƚŚĞ
Complementing
cultural
ƉƌĞƉĂƌĂƟ
ŽŶ� WĂƟĞŶƚƐ ƐŚŽƵůĚ ďĞ
ĐĂƌĞĨƵůůǇ ŽďƐĞƌǀĞĚ ĨŽƌBootcamp.
ƉŽƐƐŝďůĞ ůŽĐĂů
ŝƌƌŝƚĂƟŽŶ
Žƌ ƐĞŶƐŝƟǌĂƟŽŶ
ůŽŶŐ�ƚĞƌŵ ƚŚĞƌĂƉǇ� ^ǇƐƚĞŵŝĐ
perceptions
ofĚƵƌŝŶŐ
beauty
JohnƚŽǆŝĐ
E. Gross, M.D., president
ƌĞĂĐƟŽŶƐ
ƐƵĐŚ ĂƐ
ĂŐƌĂŶƵůŽĐǇƚŽƐŝƐ�
ĂĐƵƚĞ ŚĞŵŽůǇƟĐ ĂŶĞŵŝĂ� ƉƵƌƉƵƌĂ
Academic
departments
address
of
the
Physicians
Coalition for
ŚĞŵŽƌƌŚĂŐŝĐĂ� ĚƌƵŐ ĨĞǀĞƌ� ũĂƵŶĚŝĐĞ ĂŶĚ ĐŽŶƚĂĐƚ ĚĞƌŵĂƟƟƐ ŝŶĚŝĐĂƚĞ
cultural, ethnic influences on skin health
Injectable
ŚǇƉĞƌƐĞŶƐŝƟǀŝƚǇ ƚŽ ƐƵůĨŽŶĂŵŝĚĞƐ� WĂƌƟĐƵůĂƌ ĐĂƵƟŽŶ
ƐŚŽƵůĚ ďĞSafety (PCIS), says lowĞŵƉůŽǇĞĚŝĨĂƌĞĂƐŽĨĚĞŶƵĚĞĚŽƌĂďƌĂĚĞĚƐŬŝŶĂƌĞŝŶǀŽůǀĞĚ�^ǇƐƚĞŵŝĐ
priced imported or otherwise
ONCOLOGY 42
ĂďƐŽƌƉƟŽŶ ŽĨ ƚŽƉŝĐĂů ƐƵůĨŽŶĂŵŝĚĞƐ ŝƐ ŐƌĞĂƚĞƌ ĨŽůůŽǁŝŶŐ ĂƉƉůŝĐĂƟŽŶ
illicit neuromodulators have
Scalp
condition
ƚŽ ůĂƌŐĞ�
ŝŶĨĞĐƚĞĚ�
ĂďƌĂĚĞĚ� ĚĞŶƵĚĞĚ Žƌ ƐĞǀĞƌĞůǇ ďƵƌŶĞĚ ĂƌĞĂƐ�
been
available
to U.S. physicians
hŶĚĞƌmimics
ƚŚĞƐĞ ĐŝƌĐƵŵƐƚĂŶĐĞƐ�
ĂŶǇ
ŽĨ
ƚŚĞ
ĂĚǀĞƌƐĞ
Ğī
ĞĐƚƐ
ƉƌŽĚƵĐĞĚ
ďǇ
skin cancer
ƚŚĞ ƐǇƐƚĞŵŝĐ
ŽŶ ŽĨ ƚŚĞƐĞ
ŽĐĐƵƌ�
forĂůůǇ
more
than a decade.
Erosive ĂĚŵŝŶŝƐƚƌĂƟ
pustular dermatosis
ofĂŐĞŶƚƐ
scalp ĐŽƵůĚ ƉŽƚĞŶƟ
ĂŶĚ ĂƉƉƌŽƉƌŝĂƚĞ ŽďƐĞƌǀĂƟŽŶƐ ĂŶĚ ůĂďŽƌĂƚŽƌǇ ĚĞƚĞƌŵŝŶĂƟŽŶƐ ƐŚŽƵůĚ
“When the economy slid in
can be mistaken for skin cancer
ďĞƉĞƌĨŽƌŵĞĚ�
2007 to 2008, that encouraged
dŚĞ ŽďũĞĐƚ
ŽĨ ƚŚŝƐ 50
ƚŚĞƌĂƉǇ ŝƐ ƚŽ ĂĐŚŝĞǀĞ ĚĞƐƋƵĂŵĂƟŽŶ ǁŝƚŚŽƵƚ
BUSINESS
many
healthcare providers —
ŝƌƌŝƚĂƟŽŶ� ďƵƚ ƐŽĚŝƵŵ ƐƵůĨĂĐĞƚĂŵŝĚĞ ĂŶĚ ƐƵůĨƵƌ ĐĂŶ ĐĂƵƐĞ
ƌĞĚĚĞŶŝŶŐ
Expert
insight
including
non-core specialists —
ĂŶĚ ƐĐĂůŝŶŐ
ŽĨ ƚŚĞ
ĞƉŝĚĞƌŵŝƐ� dŚĞƐĞ ƐŝĚĞ ĞīĞĐƚƐ ĂƌĞ ŶŽƚ
ƵŶƵƐƵĂů ŝŶ
on brand definition ĞŶƚƐƐŚŽƵůĚďĞĐĂƵƟ
ƚŚĞƚƌĞĂƚŵĞŶƚŽĨĂĐŶĞǀƵůŐĂƌŝƐ�ďƵƚƉĂƟ
toŽŶĞĚĂďŽƵƚ
look for ways to augment their
ƚŚĞƉŽƐƐŝďŝůŝƚǇ�
Ideal time to craft brand identity is
income,” Dr. Gross says.
at theREACTIONS:
onset of the
practice's
creation
ADVERSE
ZĞƉŽƌƚƐ
ŽĨ ŝƌƌŝƚĂƟ
ŽŶ ĂŶĚ ŚǇƉĞƌƐĞŶƐŝƟǀŝƚǇ ƚŽ
T he A f fordable Ca re Ac t
ƐŽĚŝƵŵ ƐƵůĨĂĐĞƚĂŵŝĚĞ ĂƌĞ ƵŶĐŽŵŵŽŶ� dŚĞ ĨŽůůŽǁŝŶŐ ĂĚǀĞƌƐĞ
THE TAKEAWAY
62 ŽŶŽĨƐƚĞƌŝůĞŽƉŚƚŚĂůŵŝĐƐŽĚŝƵŵ
f ur t her spurred hea lt hcare
ƌĞĂĐƟŽŶƐ�ƌĞƉŽƌƚĞĚĂŌ
ĞƌĂĚŵŝŶŝƐƚƌĂƟ
sulfacetamide,
are noteworthy:
instances of Stevens-Johnson
providers of all stripes to pursue
Strategies
for
ƐǇŶĚƌŽŵĞ ĂŶĚ ŝŶƐƚĂŶĐĞƐ ŽĨ ůŽĐĂů ŚǇƉĞƌƐĞŶƐŝƟǀŝƚǇ ǁŚŝĐŚ ƉƌŽŐƌĞƐƐĞĚ
#
cash-based aesthetic business
managing
leg
ulcers
to a syndrome resembling systemic lupus erythematosus; in one case
Brand*
— and perhaps cut corners, says
Robert Kirsner, M.D., shares
ĂĨĂƚĂůŽƵƚĐŽŵĞǁĂƐƌĞƉŽƌƚĞĚ;ƐĞĞtZE/E'^��
Sodium Sulfacetamide
& Sulfur
insights on the diagnosis and
WůĞĂƐĞƐĞĞĨƵůůWƌĞƐĐƌŝďŝŶŐ/ŶĨŽƌŵĂƟŽŶŽŶƌĞǀĞƌƐĞƐŝĚĞ�Dr. Gross, who is also a plastic
A female patient who wanted to treat her leg veins at a
treatment of this type of wound
surgeon based in Pasadena, Calif.
medispa was treated with intense pulsed light, which resulted
As a resu lt, says Jeanine
FOLLOW US ONLINE:
in burns. She later sought care from a trained dermatologist.
Downie, M.D., noncore providers
Photos: H.L. Greenberg, M.D.
Copyright
© 2014 Mission Pharmacal Company.
ranging from family doctors and
1
All rights reserved.
AVA-14111
*Source Healthcare Analytics PHAST Prescription data, accessed October 2013.
®
AVAR Cleansing Pads
(sodium sulfacetamide 9.5%, sulfur 5%)
Rx Only
FOR EXTERNAL USE ONLY. NOT FOR OPHTHALMIC USE.
DESCRIPTION: Each pad is coated with a
cleanser-based formulation. Each gram of solution
contains 95 mg of sodium sulfacetamide and 50
mg of colloidal sulfur in a vehicle consisting of:
benzyl alcohol, cetyl alcohol, fragrance, glyceryl
stearate (and) PEG-100 stearate, magnesium
aluminum silicate, phenoxyethanol, propylene
glycol, purified water, sodium lauryl sulfate,
sodium magnesium silicate, sodium thiosulfate,
stearyl alcohol and xanthan gum.
Sodium sulfacetamide is a sulfonamide with
antibacterial activity while sulfur acts as a
keratolytic agent. Sodium sulfacetamide is
C8H9N2NaO3S·H2O with molecular weight of
254.24. Chemically, sodium sulfacetamide is
N-[(4-aminophenyl) sulfonyl]-acetamide,
monosodium salt, monohydrate. The structural
formula is:
The exact mode of action of sulfur in the treatment
of acne is unknown, but it has been reported that it
inhibits the growth of Propionibacterium acnes and
the formation of free fatty acids.
INDICATIONS: This product is indicated for use in
the topical control of acne vulgaris, acne rosacea
and seborrheic dermatitis.
CONTRAINDICATIONS: This product is contraindicated
in persons with known or suspected hypersensitivity
to any of the ingredients of the product. This product
is not to be used by patients with kidney disease.
WARNINGS: Sulfonamides are known to cause
Stevens-Johnson syndrome in hypersensitive
individuals. Stevens-Johnson syndrome also has
been reported following the use of sodium
sulfacetamide topically. Cases of drug-induced
systemic lupus erythematosus from topical
sulfacetamide also have been reported. In one of
these cases, there was a fatal outcome.
KEEP OUT OF THE REACH OF CHILDREN.
PRECAUTIONS: FOR EXTERNAL USE ONLY.
NOT FOR OPHTHALMIC USE.
General: Nonsusceptible organisms, including fungi,
may proliferate with the use of this preparation.
Sodium sulfacetamide is an odorless, white,
crystalline powder with a bitter taste. It is freely
soluble in water, sparingly soluble in alcohol,
while practically insoluble in benzene, in
chloroform and in ether.
CLINICAL PHARMACOLOGY: Sodium sulfacetamide
exerts a bacteriostatic effect against sulfonamide
sensitive Gram-positive and Gram-negative
microorganisms commonly isolated from secondary
cutaneous pyogenic infections. It acts by restricting
the synthesis of folic acid required by bacteria for
growth, by its competition with para-aminobenzoic
acid. There is no clinical data available on the
degree and rate of systemic absorption of this
product when applied to the skin or scalp. However,
significant absorption of sodium sulfacetamide
through the skin has been reported.
The following in vitro data is available but the clinical
significance is unknown. Organisms that show
susceptibility to sodium sulfacetamide are:
Streptococci, Staphylococci, E. coli, Klebsiella
pneumoniae, Pseudomonas pyocyanea, Salmonella
species, Proteus vulgaris, Nocardia and Actinomyces.
Although rare, sensitivity to sodium sulfacetamide
may occur. Therefore, caution and careful
supervision should be observed when prescribing
this drug for patients who may be prone to
hypersensitivity to topical sulfonamides. If the use
of this product produces signs of hypersensitivity
or other untoward reactions, discontinue use of the
preparation. Patients should be carefully observed
for possible local irritation or sensitization during
long-term therapy. Systemic toxic reactions such
as agranulocytosis, acute hemolytic anemia,
purpura hemorrhagica, drug fever, jaundice and
contact dermatitis indicate hypersensitivity to
sulfonamides. Particular caution should be
employed if areas of denuded or abraded skin are
involved. Systemic absorption of topical
sulfonamides is greater following application to
large, infected, abraded, denuded or severely
burned areas. Under these circumstances, any of
the adverse effects produced by the systemic
administration of these agents could potentially
occur, and appropriate observations and laboratory
determinations should be performed.
desquamation without irritation, but sodium
sulfacetamide and sulfur can cause reddening and
scaling of the epidermis. These side effects are
not unusual in the treatment of acne vulgaris, but
patients should be cautioned about the possibility.
Information for Patients: Patients should
discontinue the use of this product if the condition
becomes worse or if a rash develops in the area
being treated or elsewhere. The use of this
product also should be discontinued promptly and
the physician notified if any arthritis, fever or sores
in the mouth develop. Avoid contact with eyes, lips
and mucous membranes.
Drug Interactions: This product is incompatible
with silver preparations.
Carcinogenesis, Mutagenesis and Impairment
of Fertility: Long-term animal studies for
carcinogenic potential have not been performed on
this product to date. Studies on reproduction and
fertility also have not been performed.
Chromosomal nondisjunction has been reported in
the yeast, Saccharomyces cerevisiae, following
application of sodium sulfacetamide. The
significance of this finding to the topical use of
sodium sulfacetamide in the human is unknown.
Pregnancy: Category C. Animal reproduction
studies have not been conducted with this
product. It is also not known whether this product
can affect reproduction capacity or cause fetal
harm when administered to a pregnant woman.
This product should be used by a pregnant woman
only if clearly needed or when potential benefits
outweigh potential hazards to the fetus.
Nursing Mothers: It is not known whether this
drug is excreted in human milk. Because many
drugs are excreted in human milk, caution should
be exercised when this product is administered to
a nursing woman.
Pediatric Use: Safety and effectiveness in children
under the age of 12 years have not been established.
ADVERSE REACTIONS: Reports of irritation and
hypersensitivity to sodium sulfacetamide are
uncommon. The following adverse reactions,
reported after administration of sterile ophthalmic
sodium sulfacetamide, are noteworthy: instances of
Stevens-Johnson syndrome and instances of local
hypersensitivity which progressed to a syndrome
resembling systemic lupus erythematosus; in one
case a fatal outcome was reported (see WARNINGS).
OVERDOSAGE: The oral LD50 of sulfacetamide in
mice is 16.5 g/kg. In the event of overdosage,
emergency treatment should be started immediately.
Manifestations: Overdosage may cause nausea
and vomiting. Large oral overdosage may cause
hematuria, crystalluria and renal shutdown due to
the precipitation of sulfa crystals in the renal
tubules and the urinary tract. For treatment, contact
your local Poison Control Center or your doctor.
DOSAGE AND ADMINISTRATION: Wash affected
areas with this product once or twice daily or as
directed by a physician. Moisten skin and
cleansing pad with water. Work pad into full lather
and massage gently into skin for 10 to 20
seconds, rinse thoroughly and pat dry. Discard pad
in refuse container. If drying occurs, it may be
controlled by rinsing affected area sooner or using
product less frequently.
STORAGE: Store at 20°C to 25°C (68°F to 77°F),
excursions permitted between 15°C and 30°C
(between 59°F and 86°F). Brief exposure to
temperatures up to 40°C (104°F) may be tolerated
provided the mean kinetic temperature does not
exceed 25°C (77°F); however, such exposure
should be minimized.
NOTICE: Protect from freezing and excessive heat. The
product may tend to darken slightly on storage. Slight
discoloration does not impair the efficacy or safety of
the product. Keep dispensing container tightly closed.
Occasionally, a slight discoloration of fabric may
occur when an excessive amount of the product is
used and comes in contact with white fabrics. This
discoloration, however, presents no problem, as it
is readily removed by ordinary laundering without
bleaches.
HOW SUPPLIED: This product is supplied in the
following size(s):
30 count carton, NDC 0178-0640-30
60 count carton, NDC 0178-0640-60
To report a serious adverse event or obtain product
information, call 1-800-298-1087.
Manufactured for:
MISSION PHARMACAL COMPANY
San Antonio, TX 78230 1355
0640I.01
C01 Rev 007130
The object of this therapy is to achieve
AVA-14110
Dermatology Times®
BUSINESS
July 2014
No advantages
from circulation of
physician payment
data, doctors say
Volume 35 No. 7
R elea s e of 2 012 phy s ic i a n
payment data from the Centers for
Medicare and Medicaid Services
(CMS) has perhaps done a disservice to the reputation of healthcare
providers including dermatologists, say several clinicians.
The dissemination of Medicare payments in early April,
showing that 880,000 physicians
and other healthcare providers
received $77 billion under the
PAYMENT DATA see page 56
In This Issue
CLINICAL 18
Small pests can
cause big skin problems
Most bug bites aren't life-threatening,
but proper diagnosis is instrumental
COSMETIC 24
Complementing cultural
perceptions of beauty
Academic departments address
cultural, ethnic influences on skin health
ONCOLOGY 42
Scalp condition
mimics skin cancer
Erosive pustular dermatosis of scalp
can be mistaken for skin cancer
BUSINESS 50
Expert insight
on brand definition
Ideal time to craft brand identity is
at the onset of the practice's creation
THE TAKEAWAY 62
Strategies for
managing leg ulcers
Robert Kirsner, M.D., shares
insights on the diagnosis and
treatment of this type of wound
FOLLOW US ONLINE:
magenta
cyan
yellow
black
July 2014
VOL. 35, NO. 7
DERMATOLOGISTS DEAL WITH
COSMETIC COMPETITION
Best defense against unqualified injectorsÕ
discounts involves patient education
John Jesitus | Senior Staff Correspondent
OB/GYNs to “medispas that barely have a medical
director over them are purchasing fillers and
neuromodulators online and marketing them as
the real thing. This cheapens our whole marketplace.” She is a dermatologist in private practice in
Montclair, N.J.
Economically, Dr. Downie says, “I call it a race
to the bottom. Noncore competitors try to
manipulate all the cosmetic dermatologists into decreasing our prices.
And we cannot and should not.
We need to maintain that we are
board-certified and trained
in a l l aspects of cosmet ic
and general dermatology. As
a specialty, we should hold
ourselves up as the skincare
With “discount” injectable treatments here to
stay, experts say, dermatologists must court
sophisticated consumers willing to pay for the
quality and expertise that only dermatologists and
other core aesthetic specialists offer.
The problem of heavily discounted
injectables dates back to unit pricing
of neuromodulators and laser
package deals, says Vic Narurkar,
M.D. “If someone only needs two
treatments to get the desired
results, selling them a package
of five or six is unethical,” he
says. Dr. Narurkar is founder
and director of the Bay Area
COMPETITION see page 38
Laser Institute, chairman of
dermatology at California Pacific
Medical Center, San Francisco,
and a co-founder of Cosmetic
Bootcamp.
John E. Gross, M.D., president
of the Physicians Coalition for
Injectable Safety (PCIS), says lowpriced imported or otherwise
illicit neuromodulators have
been available to U.S. physicians
for more than a decade.
“When the economy slid in
2007 to 2008, that encouraged
many healthcare providers —
including non-core specialists —
to look for ways to augment their
income,” Dr. Gross says.
T he A f fordable Ca re Ac t
f ur t her spurred hea lt hcare
providers of all stripes to pursue
cash-based aesthetic business
— and perhaps cut corners, says
Dr. Gross, who is also a plastic
A female patient who wanted to treat her leg veins at a
surgeon based in Pasadena, Calif.
medispa was treated with intense pulsed light, which resulted
As a resu lt, says Jeanine
in burns. She later sought care from a trained dermatologist.
Downie, M.D., noncore providers
Photos: H.L. Greenberg, M.D.
ranging from family doctors and
ES461192_DT0714_cv1.pgs 06.26.2014 22:57
ADV
INDICATION
XEOMIN® (incobotulinumtoxinA) for injection, for intramuscular use is indicated for the temporary improvement in the appearance of
moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients.
IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING
WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of XEOMIN and all botulinum toxin products may spread from the area
of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized
muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and
breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing
difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest
in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions,
particularly in those patients who have underlying conditions that would predispose them to these symptoms. In
unapproved uses, including spasticity in children and adults, and in approved indications, cases of spread of effect
have been reported at doses comparable to those used to treat cervical dystonia and at lower doses.
CONTRAINDICATIONS
XEOMIN is contraindicated in patients with a known
hypersensitivity to the active substance botulinum toxin
type A or to any of the components in the formulation and in the
presence of infection at the proposed injection site(s), as injection
could lead to severe local or disseminated infection.
WARNINGS AND PRECAUTIONS
• The potency units of XEOMIN are not interchangeable with
other preparations of botulinum toxin products. Therefore, units
of biological activity of XEOMIN cannot be compared to or
converted into units of any other botulinum toxin products.
• Hypersensitivity reactions have been reported with botulinum
toxin products (anaphylaxis, serum sickness, urticaria, soft
tissue edema, and dyspnea). If serious and/or immediate
hypersensitivity reactions occur further injection of XEOMIN
should be discontinued and appropriate medical therapy
immediately instituted.
• Treatment with XEOMIN and other botulinum toxin products
can result in swallowing or breathing difficulties. Patients with
pre-existing swallowing or breathing difficulties may be more
susceptible to these complications. When distant effects occur,
additional respiratory muscles may be involved. Patients may
require immediate medical attention should they develop
problems with swallowing, speech, or respiratory disorders.
Dysphagia may persist for several months, which may require
use of a feeding tube and aspiration may result from severe
dysphagia [See Boxed Warning].
• Glabellar Lines: Do not exceed the recommended dosage and
frequency of administration of XEOMIN. In order to reduce the
complication of ptosis the following steps should be taken:
» avoid injection near the levator palpebrae superioris, particularly
in patients with larger brow depressor complexes;
» corrugator injections should be placed at least 1 cm above the
bony supraorbital ridge.
• Individuals with peripheral motor neuropathic diseases,
amyotrophic lateral sclerosis, or neuromuscular junctional disorders
(e.g., myasthenia gravis or Lambert-Eaton syndrome) should be
monitored particularly closely when given botulinum toxin. Patients
with neuromuscular disorders may be at increased risk of clinically
significant effects including severe dysphagia and respiratory
compromise from typical doses of XEOMIN.
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• XEOMIN contains human serum albumin. Based on effective
donor screening and product manufacturing processes,
it carries an extremely remote risk for transmission of viral
diseases and Creutzfeldt-Jakob disease (CJD). No cases of
transmission of viral diseases or CJD have ever been reported
for albumin.
ADVERSE REACTIONS
Glabellar Lines: The most commonly observed adverse reaction
(incidence ≥ 2% of patients and greater than placebo) for XEOMIN
was Headache (5.4%).
DRUG INTERACTIONS
Concomitant treatment of XEOMIN and aminoglycoside
antibiotics, spectinomycin, or other agents that interfere with
neuromuscular transmission (e.g., tubocurarine-like agents), or
muscle relaxants, should be observed closely because the effect
of XEOMIN may be potentiated. The effect of administering
different botulinum toxin products at the same time or
within several months of each other is unknown. Excessive
neuromuscular weakness may be exacerbated by administration of
another botulinum toxin prior to the resolution of the effects of a
previously administered botulinum toxin.
USE IN PREGNANCY
Pregnancy Category C: There are no adequate and wellcontrolled studies in pregnant women. XEOMIN should be
used during pregnancy only if the potential benefit justifies the
potential risk to the fetus.
PEDIATRIC USE
The safety and effectiveness of XEOMIN in patients less than 18
years of age have not been established.
Please see Brief Summary of full Prescribing
Information on the following pages.
© Copyright 2014 Merz North America, Inc. All rights reserved. XEOMIN is a
registered trademark of Merz Pharma GmbH & Co. KGaA. ML01021-00
ES459489_DT0714_CV2_FP.pgs 06.25.2014 22:26
ADV
A Highly
PuriƓed
Neurotoxin.
Call Your Merz Representative Today!
Please see Important Safety Information,
including Boxed WARNING on adjacent page.
www.xeominaesthetic.com
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ES459490_DT0714_003_FP.pgs 06.25.2014 22:26
ADV
XEOMIN (incobotulinumtoxinA) for injection, for intramuscular use
BRIEF SUMMARY. Visit www.XEOMIN.com for full Prescribing Information.
WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of XEOMIN and all botulinum toxin products may spread from
the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia,
generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence
and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and
breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably
greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other
conditions, particularly in those patients who have underlying conditions that would predispose them to these
symptoms. In unapproved uses, including spasticity in children and adults, and in approved indications, cases of
spread of effect have been reported at doses comparable to those used to treat cervical dystonia and at lower doses
[see Warnings and Precautions].
CONTRAINDICATIONS
Hypersensitivity-Use in patients with a known hypersensitivity to
the active substance botulinum neurotoxin type A, or to any of the
excipients (human albumin, sucrose), could lead to a life-threatening
allergic reaction. XEOMIN is contraindicated in patients with known
hypersensitivity to any botulinum toxin preparation or to any of the
components in the formulation [see Warnings and Precautions].
Infection at Injection Site-Use in patients with an infection at the
injection site could lead to severe local or disseminated infection.
XEOMIN is contraindicated in the presence of infection at the
proposed injection site(s).
• Spread of Toxin Effect-Postmarketing safety data from XEOMIN
and other approved botulinum toxins suggest that botulinum toxin
effects may, in some cases, be observed beyond the site of local
injection. The symptoms are consistent with the mechanism of
action of botulinum toxin and may include asthenia, generalized
muscle weakness, diplopia, blurred vision, ptosis, dysphagia,
dysphonia, dysarthria, urinary incontinence, and breathing
difficulties [see Boxed Warning (above)].
• Lack of Interchangeability between Botulinum Toxin ProductsThe potency Units of XEOMIN are specific to the preparation and
assay method utilized. They are not interchangeable with the other
preparations of botulinum toxin products and, therefore, Units of
biological activity of XEOMIN cannot be compared to or converted
into Units of any other botulinum toxin products assessed with any
other specific assay method.
• Hypersensitivity Reactions-Hypersensitivity reactions have
been reported with botulinum toxin products (anaphylaxis, serum
sickness, urticaria, soft tissue edema, and dyspnea). If serious and/
or immediate hypersensitivity reactions occur further injection of
XEOMIN should be discontinued and appropriate medical therapy
immediately instituted.
• Dysphagia and Breathing Difficulties in Treatment of Cervical
Dystonia-Treatment with XEOMIN and other botulinum toxin
products can result in swallowing or breathing difficulties. Patients
with pre-existing swallowing or breathing difficulties may be
more susceptible to these complications. In most cases, this is
a consequence of weakening of muscles in the area of injection
that are involved in breathing or swallowing. When distant effects
occur, additional respiratory muscles may be involved. Deaths
as a complication of severe dysphagia have been reported after
treatment with botulinum toxin. Dysphagia may persist for several
months, and require use of a feeding tube to maintain adequate
nutrition and hydration. Aspiration may result from severe
dysphagia and is a particular risk when treating patients in whom
swallowing or respiratory function is already compromised. In
general, limiting the dose injected into the sternocleidomastoid
black
muscle may decrease the occurrence of dysphagia. Patients
treated with botulinum toxin may require immediate medical
attention should they develop problems with swallowing, speech
or respiratory disorders. These reactions can occur within hours
to weeks after injection with botulinum toxin [see Warnings and
Precautions and Adverse Reactions in Full Prescribing Information
for more information].
• Pre-existing Neuromuscular Disorders and other Special
Populations-Individuals with peripheral motor neuropathic
diseases, amyotrophic lateral sclerosis, or neuromuscular junctional
disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome)
should be monitored particularly closely when given botulinum
toxin. Patients with neuromuscular disorders may be at increased
risk of clinically significant effects including severe dysphagia
and respiratory compromise from typical doses of XEOMIN [see
Adverse Reactions].
• Corneal Exposure, Corneal Ulceration, and Ectropion in Patients
Treated with XEOMIN for Blepharospasm-Reduced blinking from
injection of botulinum toxin products in the orbicularis muscle can
lead to corneal exposure, persistent epithelial defect and corneal
ulceration, especially in patients with VII nerve disorders. Careful
testing of corneal sensation in eyes previously operated upon,
avoidance of injection into the lower lid area to avoid ectropion,
and vigorous treatment of any epithelial defect should be
employed. This may require protective drops, ointment, therapeutic
soft contact lenses, or closure of the eye by patching or other
means. Because of its anticholinergic effects, XEOMIN should be
used with caution in patients at risk of developing narrow angle
glaucoma. To prevent ectropion, botulinum toxin products should
not be injected into the medial lower eyelid area. Ecchymosis easily
occurs in the soft tissues of the eyelid. Immediate gentle pressure
at the injection site can limit that risk.
• Risk of Ptosis in Patients Treated with XEOMIN for Glabellar
Lines-Do not exceed the recommended dosage and frequency of
administration of XEOMIN. In order to reduce the complication of
ptosis the following steps should be taken:
» Avoid injection near the levator palpebrae superioris, particularly
in patients with larger brow depressor complexes.
» Corrugator injections should be placed at least 1 cm above the
bony supraorbital ridge.
• Human Albumin and Transmission of Viral Diseases-This product
contains albumin, a derivative of human blood. Based on effective
donor screening and product manufacturing processes, it carries
an extremely remote risk for transmission of viral diseases. A
theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD)
is also considered extremely remote. No cases of transmission of
viral diseases or CJD have ever been reported for albumin.
ES459479_DT0714_004_FP.pgs 06.25.2014 22:26
ADV
6
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ES459987_DT0714_006.pgs 06.26.2014 01:07
ADV
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ES454814_DT0714_007_FP.pgs 06.18.2014 19:48
ADV
8
INTER
CTIVE
®
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?
A worried mother brings her
2-year-old boy to your offce for
evaluation of an asymptomatic
skin eruption that has been
present for two months. The
lesion developed six months
after he sustained an abrasion
to the same site when he
fell on concrete steps. The
patient’s right forearm displays
1.5 cm x 0.8 cm erythematous
plaque studded with frm white
1 mm to 2 mm papules.
Best practices in the evaluation and
management of actinic keratoses
CHOOSE ONE
ACNE VULGARIS
DermatologyTimes.com/actinickeratoses
QUI MILIA EN PLAQUE
SYRINGOMA
Current and emerging therapies
for psoriatic arthritis
DermatologyTimes.com/discussskineruption
DermatologyTimes.com/skineruption
Blog
Brand identity plays key role
in community awareness of
a practice
DermatologyTimes.com/psoriatic-arthritis
Fillers and Toxins:
Cosmetic and Therapeutic Options
Melanie Palm, M.D., M.B.A.
DermatologyTimes.com/branding
TWITTER.COM/DermTimesNow
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DermatologyTimes.com/injectables
Insights into managing
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DermatologyTimes.com/atopicdermatitis
ES460769_DT0714_008.pgs 06.26.2014 20:30
ADV
LOOK INSIDE THE CELL FOR A NEW PERSPECTIVE1
DISCOVER THE ROLE
OF PDE4 IN PSORIASIS
PDE4 promotes the dysregulation of proand anti-inflammatory mediators thought
to occur in inflammatory disease2,3 and
is present in key inflammatory cells
implicated in psoriasis.1
Learn more about the role of PDE4
at discoverPDE4.com.
PDE4
cAMP
AMP
AMP, adenosine monophosphate; cAMP, cyclic AMP; PDE4, phosphodiesterase 4.
Visual representation based on pre-clinical evidence.
References: 1. Baumer W, Hoppmann J, Rundfeldt C, Kietzmann M. Inflamm Allergy Drug Targets. 2007;67(1):17-26. 2. Houslay MD,
Schafer P, Zhang KYJ. Drug Discov Today. 2005;10(22):1503-1519. 3. Press NJ, Banner KH. In: Lawton G, Witty DR, eds. Progress in
Medicinal Chemistry. Amsterdam, The Netherlands: Elsevier; 2009:37-74.
© 2014 Celgene Corporation 04/14 USII-CELG130023(1)a
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ES454834_DT0714_009_FP.pgs 06.18.2014 19:48
ADV
10
NEWS EAGLE
LEGAL
UPDATE
David Goldberg, M.D., J.D.,
is director of Skin Laser &
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.
Fleshing out the physician-patient
relationship in a virtual world
D
r. B. runs an active dermatology practice. Seeking
to increase revenues in
his office, he considers
a variety of practice enhancement
options. He ultimately hires a Web
master who designs a new highly interactive website, which generates a flood
of new patients.
Dr. B. enjoy begins spending 60
minutes every day answering email
questions. He had been advised — and
has been very careful — not to “practice medicine” on the Web.
Eighteen months ago, he received
an email from a woman who lives five
hours from his practice. According to
the email, the patient had been seeing
her local dermatologist for three years
with a diagnosis of rosacea. She had
been treated with a variety of topical
and oral agents. One particular area
on her cheek was not responding.
The woman stated in her email that
she was unable to travel to Dr. B.’s
office and desperately needed his
help. Dr. B. corresponded with the
patient six times over the next two
months. He was very careful not to
discuss with her the actual diagnosis
of her condition. He did, however,
give her extensive advice about the
pros and cons of the treatments she
had received. Dr. B. never suggested
any changes in her treatment; he
never charged her for his time.
In his last email to the patient,
he advised her that she should join
a Web-based “chat group.” She
thanked him for this advice. She
joined such a group, and because of
the homeopathic and naturopathic
suggestions she received from the
chat group, she did not seek any
further dermatologic care for the next
three years.
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Three years later, the same area of
the patient’s cheek that had originally
resisted treatment began to bleed. She
went to see a new dermatologist. A
biopsy of the suspicious area revealed
basal cell carcinoma. She underwent
Mohs surgery, which resulted in an
infection, and she was hospitalized.
The patient ended up with a large scar
across her cheek.
The patient sued a variety of individuals, including Dr. B. The basis of
her claim against Dr. B. was that she
delayed treatment for three years
because he advised her to join a rosacea
chat group. Dr. B. knows that he cannot
lose the lawsuit unless his email advice
established a physician-patient relationship. Has that happened?
If the referral is
not determined
to be a form of
medical practice,
then such activity
cannot form the
basis for creating a
physician-patient
relationship.
Physician-patient relationship
The answer to this issue involves an
understanding of the physician-patient
relationship in our information-based
world. The lawsuit hinges on whether
the referral to a chat group constitutes the practice of medicine. If the
referral is not determined to be a form
of medical practice, then such activity
cannot form the basis for creating
a physician-patient relationship. To
determine if a given activity is medical
practice, one must look at the laws of
each jurisdiction. The laws may vary
from state to state.
For example, in Virginia there is a
generic statute that defines the practice of medicine as “the prevention,
diagnosis and treatment of human
physical or mental ailments, conditions, diseases, pain or infirmities by
any means or method.”
Maryland law goes further and articulates a list of elements to characterize
the practice of medicine. The Maryland
law states that the practice of medicine includes “… diagnosing, healing,
treating, preventing and prescribing.”
There are very few states that
apply this concept to telemedicine,
which is the practice of medicine via
the Web. In Arizona, a telemedicine
law defines this area as “the practice
of healthcare delivery, diagnosis,
consultation, treatment, transfer of
medical data and education through
interactive audio, video or data
communications.”
In those states where either statute
or boards of medicine examiner regulations exist, the question that must
always be asked is whether the electronic activity in question relates to
treatment or diagnosis.
Dr. B. referred his patient to a chat
group. Undoubtedly recommendations from members of the chat group
itself are outside the bounds of organized medicine. Whether the referral
itself would be outside the practice of
medicine would depend on the intent
behind Dr. B.’s referral. This will be
determined by a court of law. DT
ES457542_DT0714_010.pgs 06.24.2014 02:30
ADV
Barrier Protection
for the Ages
RxOnly
ELETONE ® CREAM
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Contains two100-gram tubes of Eletone® Cream
The TwinPack offers a supply of 2 tubes as an
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affected areas during the seasons when atopic
dermatitis tends to flare most. With one prescription,
patients can receive twice as much therapy for
the same pharmacy co-pay as with the single tube.
ELETONE ® CREAM
Nonsteroidal Atopic Dermatitis Therapy
PRODUCT DESCRIPTION:
®
Eletone Cream is a non-steroidal, lipid-rich,
fragrance free emulsion formulated with Hydrolipid Technology™ for the
management and relief of burning, itching, and redness associated with various
types of dermatoses. There are no restrictions on age or duration of use and the
product has a low potential for irritation.
INDICATIONS FOR USE:
Eletone ® Cream is indicated for the management and
relief of burning, itching, and redness associated with various types of dermatoses,
including atopic dermatitis, allergic contact dermatitis, and radiation dermatitis
(post-radiation treatment).
CONTRAINDICATIONS: THIS PRODUCT SHOULD NOT BE USED DURING THE
PERIOD OF TIME WHEN RADIATION TREATMENT IS OCCURRING BECAUSE OF THE
INCREASED RISK OF SKIN TOXICITY WHEN RADIATING THROUGH PETROLATUM AND
OIL. Eletone ® Cream is contraindicated in patients with a known hypersensitivity
to any of the components of the formulation.
PRECAUTIONS: Eletone ® Cream is for external use only. Eletone ® Cream
does not contain a sunscreen and should always be used in conjunction
with a sunscreen in sun exposed areas.
INSTRUCTIONS FOR USE:
Apply liberally to the affected areas three
times daily or as needed. If skin is broken, cover Eletone ® Cream with a
dressing of choice.
INGREDIENTS: Eletone ® Cream contains petrolatum, purified water,
mineral oil, cetostearyl alcohol, ceteth-20, citric acid, sodium citrate,
propylparaben, and butylparaben.
HOW SUPPLIED:
Eletone ® Cream is available in a 100 gram tube
NHRIC 0178-0368-01.
Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F)
[see USP Controlled Room Temperature].
CAUTION:
Rx only. Federal law restricts this device
to sale by or on the order of a physician.
Copyright © 2014 Mission Pharmacal Company. All rights reserved.
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ES459476_DT0714_011_FP.pgs 06.25.2014 22:25
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12
EDITORIAL ADVISORY BOARD
insight & opinion from our advisory board leaders
Elaine C. Siegfried, M.D.,
ical insignificance. For pediatric dermatologists, the person who needs help is
the parent rather than the patient, complicating the goal of achieving acceptance.
is professor of pediatrics and
dermatology, Saint Louis University
Health Sciences Center, St. Louis, Mo.
Open to criticism
Significance of
Serenity Prayer and
patient satisfaction
I
’m a fan of the Serenity Prayer: “God
grant me the serenity to accept the
things I cannot change, courage to
change the things I can, and wisdom
to know the difference.” The words are
simple but meaningful. The first segment
offers comfort, while the second inspires
strength to overcome obstacles. The final
phrase is the most difficult to achieve.
The prayer itself could be applied to
the controversy surrounding its origin.
Although it seems biblical, most sources
credit Reinhold Niebuhr, a protestant
pastor who was born just outside of my
St. Louis hometown and died in 1971 at
age 78. Mr. Niebuhr is said to have first
used the prayer during church group
services in the late 1930s. It spread like
wildfire via the United Services Organization to World War II troops and then to
Alcoholics Anonymous followers. Fame
generated an ironically intense dispute
about authorship, mostly potentiated by
Mr. Niebuhr’s daughter, whose efforts
seem hyposerene.
In recent years, I’ve been citing the
Serenity Prayer more often — to myself,
co-workers and patients — usually as
an attempt to counteract frustration.
Some days, everyone seems frustrated:
Colleagues feel underpaid, overworked,
unappreciated, challenged by bureaucracy, or burdened by personal problems.
Patients are suffering from or worried
about a disease. But the degree of frustration seems much more related to
the person than the magnitude of the
problem. This becomes a professional
issue when it impacts the increasingly
important quality health measure known
as “patient satisfaction.”
Patient satisfaction is particularly
important to hospital administrators and
government bureaucrats. This measure
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is a global assessment based on a
vague combination of ease of access
(wait time for an appointment and in the
office waiting room), and expectations,
confounded by advertising and medical
naiveté. Parameters like friendly staff,
popular magazines and comfortable
waiting rooms are important. Quality of
care carries much less weight. Nonintervention and prevention seem to be especially undervalued recommendations that
may even negatively impact satisfaction.
Active nonintervention
One of my biggest challenges comes
when attempting to provide realistic
expectations about the relative risks and
benefits of treating ditzels. “Ditzel” is a
medical term, but the origin is obscure.
Ditzels are not unique to dermatology.
Other specialists define ditzels as follows:
Radiologists: very small nodules in
the lung … usually benign … presenting
the dilemma of how to deal with these
tiny lesions.
Pathologists: specimens submitted
for histologic examination that do not
usually pose a diagnostic dilemma but
are time-consuming.
Surgeons: Small specimens with
limited educational potential … no
suspicion or history of malignancy. They
often have few possible diagnoses and a
reduced billing charge because of limited
complexity .… They slow you down …
as you struggle to get the “right” wording
and obsess over whether what you see is
pathologic or normal.
My definition of a ditzel is a skin finding
of minimal consequence that cannot
be quickly and easily changed. Many
ditzels resolve spontaneously. The ditzel
challenge for dermatologists is to help
patients understand and accept their clin-
Warts, molluscum, spider angiomas and
small birthmarks are common ditzels.
One of my mottos is: “The treatment
should never be worse than the disease.”
So, when I provide education about
therapeutic options for ditzels, merely
mentioning the Serenity Prayer usually
gets me an understanding nod from the
parent, and protects my patient from a
painful procedure.
I have also been blindsided by idiosyncratic parental hostility. Anger more often
comes from medically unsophisticated
parents who are probably hungry and tired
of waiting, but also disproportionately
frustrated about a relatively trivial problem
that bothers them much more than their
child. Rather than accepting the thing
that cannot be changed, these parents
seem to misinterpret my bias towards
active nonintervention as a sign that I am
somehow withholding an easy fix.
In these cases, mention of the prayer
seems to grant them the courage to
criticize my knowledge base, doubt my
best intentions and demand a different
answer. I know that in some situations, aggressive behavior can change
outcomes, but for a ditzel in my clinic,
attack only provokes suppressed,
conflicting reactions: aggravation (go
somewhere else) and apprehension (will
they complain?).
Circumventing hostility
I’m also pretty sure that plenty of snacks,
prizes and entertainment would be very
effective ways to circumvent hostility and
promote patient satisfaction. I have made
suggestions to my hospital administrators about incorporating these features
in the clinic waiting room. If patients and
parents were highly satisfied on their
way into the exam room, we could better
focus on medical care. Until then, God
grant me the serenity to accept the things
I cannot change, courage to change the
things I can, and wisdom to know the
difference. DT
Elaine C. Siegfried, M.D.
ES459988_DT0714_012.pgs 06.26.2014 01:07
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ADVANCES
Some melanomas present as
harmless-looking pimples
Australasian Journal of Dermatology
May 2014

http://onlinelibrary.wiley.com/doi/10.1111/ajd.2014.55.issue-s1/issuetoc
RESEARCHERS in Australia are
cautioning about an aggressive form of
melanoma that looks like a pimple, leading
many doctors to dismiss it as harmless.
According to the study, led by associate
professor John Kelly, M.D., of the Victorian
Melanoma Service, the lesions usually
present as red nodules rather than the
dark, ugly moles typical of melanoma.
This can lead doctors to mistake the
lesions for relatively harmless forms of
skin cancer or even pimples.
Seeking to compare dermoscopic characteristics of nodular squamous cell carcinoma (SCC) and keratoacanthoma (KA),
Dr. Kelly and colleagues did a retrospective analysis of 50 nodular SCC and eight
KA collected from a dermatology referral
center and a private dermatology practice
in Melbourne, Australia, from September
2009 to October 2012. Two examiners in
consensus evaluated clinical and dermoscopic images.
The researchers found that signs of
keratinization were common in both SCC
and KA. Vascular structures were often
polymorphic in both SCC and KA lesions,
and hemorrhage was common in both.
“Keratinization, hemorrhage and
polymorphic vascular structures ... are
common dermoscopic features shared by
both nodular SCC and KA,” study authors
concluded. “Dermoscopy does not reliably
differentiate between SCC and KA.”
Dr. Kelly is quoted in an Australian
news report as saying that if the red
nodules are firm and growing progressively for more than a month, they should
be checked as a nodular melanoma.
“I agree with just about everything
Professor Kelly (says), especially the fact
that anything ‘progressively growing for
a month’ should be investigated,” Ronald
G. Wheeland, M.D., of the University of
Missouri’s department of dermatology,
tells Dermatology Times. “However, I
personally wouldn’t stop there. The American Academy of Dermatology has for
some time been promoting the ‘ABCDEs’
of melanoma to help patients determine
which growths, including ‘pimples,’ are
worthy of investigation.”
In the “ABCDE” signs of melanoma,
A stands for asymmetry; B for irregular
border; C for irregular color; D for diameter of less than 1 cm; and E for evolution
with changes in size, shape, or symptoms
and surface characteristics.
“This is a little more comprehensive
and, I think, more useful than simply
counseling people to report ‘things’ that
grow for a month,” he says. DT
Researchers ID protein involved
in wound healing, tumor growth
Proceedings of the National Academy of Sciences
of the United States of America.
May 2014

http://www.pnas.org/content/111/21/E2200
A PROTEIN that plays a role in
hea l i ng wou nds a nd i n t u mor
growth could be a future therapeutic
target, recent research suggests.
Investigators with Jackson Laborator y, Bar Harbor, Maine, studied
iRhom2, a protein involved in epithelial regeneration (EGFR) and cancer
growth by way of constitutive activation
of epidermal growth factor receptor
sig na l i ng , accord i ng to t he st udy
abstract. Researchers introduced mutations in Rhbdf2, the gene responsible for
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encoding the iRhom2 protein. Doing so
allowed for an extension of the protein’s
duration and wound-healing capabilities, according to a news release.
Although the altered protein contributed
to the growth of existing tumors, it did not
cause new ones to develop.
“This study demonstrates the significance of mammalian iRhoms in regulating an EGFR signaling event that
promotes accelerated wound healing
and triggers tumorigenesis,” Lenny
Shultz, Ph.D., study co-author, said in a
statement. “Given their ability to regulate
EGFR signaling in parallel with metalloproteases, iRhoms can be potential
therapeutic targets in impaired wound
healing and cancer.” DT
15
Studies link skin
moles to breast
cancer risk
PLOS Medicine June 10, 2014

www.plosmedicine.org/article/info%3Adoi%2F10.
1371%2Fjournal.pmed.1001660
www.plosmedicine.org/article/info%3Adoi%2F10.
1371%2Fjournal.pmed.1001659
THE MORE MOLES a woman has,
the greater her risk of breast cancer,
findings from separate studies in France
and the United States have indicated.
In the U.S. study, led by Mingfeng
Zhang, M.D., of Brigham and Women’s
Hospital, Boston, and Jiali Han, Ph.D., of
Indiana University Simon Cancer Center,
Indianapolis, investigators found that
women who had 15 or more moles on a
single arm were 35 percent more likely to
develop breast cancer than women who
had no moles. A theory regarding the
correlation is that estrogen is the common
denominator of moles and breast cancer.
Estrogen is known to fuel the growth and
spread of many breast tumors, and is
thought to influence mole growth as well.
Researchers analyzed data on more
than 74,500 female nurses who participated in the Nurses’ Health Study that
began in 1986 when the women were ages
40 to 65. Participants tracked the number
of moles on their left arm. Over the next
24 years, nearly 5,500 of the women were
diagnosed with breast cancer. Overall,
women with the most moles were 35
percent more likely to develop breast
cancer than those with none.
The French study followed nearly
90,000 French women from ages 40 to 65.
The French team found links between
moles and an increased risk of breast
cancer only among women who developed it before menopause.
“Our findings indeed suggest that
nevi share genetic and/or hormonal
characteristics with breast cancer,” the
study’s lead author, Marie-Christine
Boutron-Ruault, M.D., of Institut Gustave
Roussy, Paris, tells Dermatology Times.
“However, our and Dr. Zhang’s studies
are the first to report such associations,
and they were of small magnitude, especially compared with associations of
nevus count with cutaneous melanoma.
These findings are thus too preliminary
to have implications in terms of clinical
practice and screening, but they should
prompt further research to understand
potential underlying mechanisms.” DT
ES459279_DT0714_015.pgs 06.25.2014 19:31
ADV
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936-1080
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©2014 Novartis
5/14
XDP-1301059
ES454815_DT0714_016_FP.pgs 06.18.2014 19:48
ADV
I’M TIRED OF BEING STARED AT. BUT WORSE,
I DON’T EVEN WANT TO SEE MYSELF.
Many patients with moderate to severe psoriasis (PsO)
have trouble expressing how they’re doing. You
probably have patients in your practice who still suffer
from embarrassment, poor self-image, and social isolation
but aren’t talking to you about it.1-4
But with just 1 revealing question, you can uncover the
dissatisfaction your patients may have trouble expressing
and help make a real difference in managing their PsO.
MAKE A CONNECTION. MAKE A DIFFERENCE.
Find out how you can help at PsOmuchmore.com
References: 1. Data on file. Kantar Health 2013. Novartis Pharmaceuticals Corp; 2014. 2. Gupta MA, Gupta AK, Watteel GN. Perceived deprivation
of social touch in psoriasis is associated with greater psychologic morbidity: an index of the stigma experience in dermatologic disorders. Cutis.
1998;61(6):339-342. 3. Schmid-Ott G, Jaeger B, Kuensebeck HW, Ott R, Lamprecht F. Dimensions of stigmatization in patients with psoriasis
in a ‘‘Questionnaire on Experience with Skin Complaints.’’ Dermatology. 1996;193(4):304-310. 4. Armstrong AW, Schupp C, Wu J, Bebo B. Quality
of life and work productivity impairment among psoriasis patients: findings from the National Psoriasis Foundation survey data 2003-2011.
PLoS One. 2012;7(12):e52935.
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ES454813_DT0714_017_FP.pgs 06.18.2014 19:47
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18
CLINICAL DERMATOLOGY
®
FIGHTING ITCH FROM FLORA
22 Dermatologists
can help to
dispel public misconceptions
about dangers of plant exposure
Small pests can cause
big skin problems
QUICK READ
Denver — Reactions to arthropod
Although life-threatening arthropod
attacks are rare, an expert says,
proper diagnosis and treatment
are instrumental in such cases.
attacks can range from minor skin
manifestations to life-threatening situations, an expert says.
Some arthropods’ bark is bigger than
their bite, says Julian Trevino, M.D.,
professor of dermatology at Boonshoft
School of Medicine
at Wright State
University, Dayton,
Ohio. Dr. Trevino
spoke at the annual
meet ing of t he
American Academy
Dr. Trevino
of Dermatology.
Due to misidentification and misinformation, he explains, the number of
encounters, bites and deaths attributed
to brown recluse spiders (Loxosceles
reclusa) and other arthropod encounters
Quotable
ÒToxin-mediated
contact urticaria is the
most common form of
plant-induced urticaria
and does not have an
immunological basis.Ó
Julian Trevino, M.D.
Dayton, Ohio
On common plant allergies
See story, page 22
is greatly exaggerated.
Brown recluse bites generally resolve
in one to two months with proper
wound treatment, he says, although 10
to 15 percent of cases result in severe
scarring. Additionally, Dr. Trevino
says, emergency department physicians commonly misdiagnose ulcerating or necrotic wounds from many
other sources such as insects, infections or physical trauma as the bites of
Loxosceles species.
However, he says, these brown
spiders (females bear a violin-shaped
pattern on the cephalothorax) are
generally unaggressive, biting only when
handled, trapped or pinned in garments
or linens. Bites of the Loxosceles species
are a major cause of necrotic araenism,
which is marked by a red, white and
blue targetoid lesion that develops 24
to 48 hours post-bite, Dr. Trevino says.
By 72 hours, it ulcerates in an eccentric
pattern, followed by eschar formation
and slow healing and scar formation
over weeks to months.
TREATING SEVERE CASES
Severe cases of necrotic araenism or
loxoscelism (a rare systemic reaction
usually in children) may require
hospitalization, Dr. Trevino says. In
treating necrotic araenism, he says, oral
leukocyte inhibitors such as dapsone
and colchicine are unsupported by
randomized, controlled trials, and they
may pose significant toxicity risks.
“Use of hyperbaric oxygen is also
unsupported by evidence. Early excision
PEST PROBLEMS see page 21
DTExtra
The Food and Drug Administration approved a
new drug application for Jublia (efinaconazole
10 percent, Valeant), a topical treatment for
onychomycosis of the toenails. Jublia, developed
to treat distal lateral subungual onychomycosis,
is the first topical triazole antifungal agent
approved to treat the condition, according to a
news release. The topical solution is applied daily
to the affected area using a built-in “flow-through”
brush applicator. Valeant projects to have Jublia
available in the United States and Canada by the
third quarter of 2014, according to a news release.
READ MORE: DERMATOLOGYTIMES.COM/JUBLIA
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ES459545_DT0714_018.pgs 06.25.2014 23:02
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NEW
STRENGTH!
Introducing
RETIN-A MICRO
®
(tretinoin) Gel microsphere,
Exclusively available in a 50g pump
Except as otherwise indicated, all product names, slogans, and other marks are trademarks of the Valeant family of companies.
© 2014 Valeant Pharmaceuticals North America LLC. DM/RAM/14/0003 06/14 Printed in USA.
NEW
STRENGTH!
Introducing
RETIN-A MICRO
®
(tretinoin) Gel microsphere,
Exclusively available in a 50g pump
Except as otherwise indicated, all product names, slogans, and other marks are trademarks of the Valeant family of companies.
© 2014 Valeant Pharmaceuticals North America LLC. DM/RAM/14/0003 06/14 Printed in USA.
21
PEST PROBLEMS:
Most bug bites aren’t life-threatening, but proper diagnosis is instrumental from page 18
and intralesional corticosteroids also
are contraindicated,” he says. No
antivenoms for Loxosceles bites are
universally available, he adds, except
in South America.
A neu rotox ic component of
Latrodectus (black widow) spider
venom can cause latrodectism, a
systemic reaction that results from
massive presynaptic release of neurotransmitters (e.g. acet ylcholine,
norepinephrine), according to Dr.
Trevino. Latrodectism occurs within
30 minutes to a few hours after a
stinging bite and is characterized by
generalized (especially back and leg)
pain, he says. It usually resolves over
three to seven days, he adds, but rarely
can result in respiratory arrest, seizures
and death. Severe cases may require
latrodectus antivenom, Dr. Trevino
says, though supportive care such
as wound cleansing, ice packs, oral
or parenteral analgesics and tetanus
prophylaxis usually suffice.
STINGING SENSATIONS
Much like the brown recluse, Dr. Trevino
says, “Scorpions are shy and sting
only with in self-defense.” Generally,
scorpions hide under stones, bark or
other debris during the daytime. Stings
occur when a victim walks barefoot in
scorpion-infested areas, or dons shoes
or clothing that a scorpion has found
its way into. Additionally, he says,
scorpions often cling to the underside
of tables — attempting to move such a
table may result in a sting.
Along with local wounding, a scorpion
sting in rare cases can lead to serious
respiratory and cardiovascular complications. Of particular concern in the
United States is Centruroides exilicauda
(formerly Centruroides sculpturatus), a
small scorpion whose sting is potentially fatal, Dr. Trevino says. C. exilicauda possesses a powerful neurotoxin
capable of producing muscle spasticity,
excessive salivation, nystagmus, blurred
vision, respiratory distress and slurred
speech, he says.
“Any child stung by a scorpion —
especially one identified as C. exilicauda
– should be admitted to a pediatric
intensive care unit, where respiratory,
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cardiac and neurologic status can be
monitored closely.”
For severe envenomations, Dr. Trevino
says, after life-supporting measures
are instituted, specific antivenin is the
treatment of choice.
“Untreated stings in infants and
young children may be fatal,” he says,
“while death is uncommon in adults.”
MORE COMMON THREATS
Other biting and stinging insects range
from mosquitoes — the most common
arthropod vector of infectious disease
worldwide — to bees, ants, chiggers,
flies and even caterpillars, Dr. Trevino
says. Among these, the imported fire
ant, Solenopsis invicta, now documented
in at least 12 states, brings a relatively
new threat. Because of this species has a
tendency to swarm and inflict multiple
stings, a single person can commonly
experience up to 3,000 stings.
The number of
bites and deaths
attributed to brown
recluse spiders other
arthropods is greatly
exaggerated.
“Fire ants may be the arthropod
which poses the greatest risk for anaphylaxis to adults who live in endemic
areas. Immunotherapy with fire ant
whole-body extract is effective and safe
for treatment of fire ant hypersensitivity,”
Dr. Trevino says.
Bees, wasps and ants belong to
the genus Hymenoptera. Generalized
systemic reactions to Hymenoptera
stings occur in up to 3 percent of
victims, he says. Symptoms can include
generalized urticaria, angioedema and
bronchospasm. Treatment requires
administering subcutaneous epinephrine
as soon as possible, along with oral or
parenteral diphenhydramine and, as
needed, oxygen and systemic steroids.
When removing a bee, ant or other
insect stinger from the skin, he says, “Be
careful not to break it off or cause more
venom to be released.” That’s why Dr.
Trevino recommends gentle removal by
scraping with a fingernail or knife-edge,
or perhaps applying a glue or adhesive
tape over the area to stick to and lift out
the stinger.
The latter technique also applies to
the setae (specialized hairs) of caterpillars, moths and butterflies, he says. Up
to 150 Lepidoptera species are believed
to produce irritant and allergic reactions
known as lepidopterism, Dr. Trevino
says. Mechanisms implicated include
mechanical irritation from pointed
setae, cell-mediated hypersensitivity to
the setae, and toxin injections through
hollow setae. Treatment is generally
symptomatic, he says. It includes
systemic antihistamines, topical menthol
or camphor-containing products to quell
pruritus and topical steroids (or systemic
steroids in more severe cases).
Of particular concern is Lonomia
obliqua, a venomous caterpillar that
lives in South American rainforests and
causes a handful of deaths annually, Dr.
Trevino says.
“Most incidents occur when a traveler
leans against a tree and brushes against
one or several of these caterpillars, which
release a very powerful anticoagulant
venom,” he says.
Symptoms of Lonomia obliqua
poisoning include severe internal
bleeding, renal failure and hemolysis.
Among insect repellents, Dr. Trevino
says, much of the evidence behind
botanical agents is anecdotal. However,
oil of lemon eucalyptus has been shown
to be effective against mosquitoes, biting
flies and gnats.
“I encourage dermatologists to
stick with the established products
that have shown efficacy in trials,”
he says. These include diethyltoluamide (DEET, various manufacturers)
permethrin and picaridin. Additionally,
he cautions that applying sunscreens
and DEET simultaneously can increase
DEET absorption and diminish the
sunscreen’s effectiveness. DT
Disclosures: Dr. Trevino reports no relevant financial
interests.
ES457543_DT0714_021.pgs 06.24.2014 02:30
ADV
22
CLINICAL
DERMATOLOGY
®
Backyard fora drive itch, irritation
Denver — Media reports sometimes
exaggerate or embellish the impact of
insect and plant exposures, says Julian
Trevino, M.D. “It’s important for dermatologists to be knowledgeable about the
facts relating to these exposures so we
can provide our patients and colleagues
with accurate information.” He is
professor of dermatology at Boonshoft
School of Medicine at Wright State
University, Dayton, Ohio. Dr. Trevino
spoke recently at the annual meeting of
the American Academy of Dermatology.
URTICARIA
“Toxin-mediated contact urticaria is the
most common form of plant-induced
urticaria and does not have an immunological basis,” Dr. Trevino says. The most
common culprits are Urticaceae plants
such as the stinging nettle. When people
rub against the sharp hairs (trichomes) on
the stems and leaves of such plants, he
says, a bulb within these hairs discharges
irritant chemicals such as histamine,
acetylcholine and serotonin into the skin.
“Wheals appear within three to five
minutes, with erythema, burning and
tingling typically lasting for several
hours,” he says. Moreover, Australian
stinging trees of the Dendrocnide species
have caused severe urticaria lasting for
weeks, at least one human death and
many equine fatalities.
Conversely, he adds, immunologic contact urticaria usually affects
atopics and food handlers. A variety
of fresh vegetables, fruits and nuts
can be responsible for such reactions.
Within 30 minutes of contact, susceptible individuals experience pruritus,
urticaria, erythema and perhaps even
dyshidrotic-like vesicles, Dr. Trevino says.
Rarely, a “contact urticaria syndrome,”
which includes wheals with systemic
symptoms (of the nose, throat, lungs,
gastrointestinal tract and cardiovascular
QUICK READ
To counter public misconceptions
regarding the potential
dangers of plant exposures,
dermatologists must stand
ready to provide accurate
information, an expert says.
system) can occur. Treatment for
anaphylactic reactions can include
epinephrine and antihistamines.
“Prevent ion is t he preferred
treatment,” he says. Cooking, deepfreezing, processing or crushing the
offending plant parts reduces allergenicity. Tests for immunologic contact
urticaria are the prick test and scratch
test versus the open application test for
toxin-mediated contact urticaria.
IRRITANT DERMATITIS
Mechanical irritant dermatitis represents the most common form of plantrelated dermatosis, Dr. Trevino says. Its
symptoms range from mild erythema
to hemorrhagic bullae and necrosis.
Common causes include cacti and
prickly pear bushes, as well as other
plants containing thorns, spines or
small emergences (glochids) that can
lodge within the skin, sometimes
causing foreign body granulomas and
inoculating microorganisms such as
Clostridium tetani, Staphylococcus
aureus or Sporothrix schenckii. Treatment
involves removing spines, thorns and
larger glochids with forceps, Dr. Trevino
says. To remove many smaller glochids,
“Apply glue and gauze to the site. Let it
dry, then peel off the gauze.”
Chemica l ir r ita nt der mat it is
commonly stems from contact with
calcium oxalate, which is found in plants
ranging from Dieffenbachia (“dumb
cane”) to daffodil bulbs. In the former
case, contact of Dieffenbachia leaves with
a wet surface such as the oral mucosa
releases the chemical, which causes
increased salivation, mucosal edema
“At least 50 percent of the adult
population in North America
is allergic to poison ivy/oak.”
Julian Trevino, M.D.
Dayton, Ohio
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and blistering, Dr. Trevino says. This
can result in hoarseness or aphonia
and require treatment with parenteral
steroids. Calcium oxalate in the sap and
bulbs of hyacinths and tulips also proves
very irritating, he says. Pineapple plants
contain calcium oxalate crystals and the
irritant enzyme bromelain, he says.
“[Buttercups (Ranunculaceae)] contain
the glycoside ranunculin, which is
converted to protoanemonin after plant
injury,” Dr. Trevino says. “This exposure
can cause linear vesiculation resembling
phytophotodermatitis.”
Capsaicin, a component of chili
peppers, can cause burns. Additionally,
plants of the Euphorbiaceae family
(which includes poinsettias and rubber
trees) contain a milky sap which can
cause skin irritation and, if leaves or
fruits are swallowed, can result in
vomiting and bloody diarrhea.
To prevent irritant chemical dermatitis
from plant exposures, Dr. Trevino recommends wearing gloves over moisturizers
or barrier creams applied to the hands.
One also can apply vegetable fats high in
linoleic acid (e.g., palm plant fats) before
handling irritating plants, he says, and it
never hurts to educate those who handle
plants to recognize potential irritants.
ALLERGIC CONTACT DERMATITIS
Several plants — most commonly the
genus Toxicodendron can cause allergic
contact dermatitis, Dr. Trevino says.
“The allergens responsible for poison
ivy/oak allergic contact dermatitis are
a mixture of penta- or heptadecylcatechols contained in the oleoresin
urushiol,” he says.
Intact plants are generally innocuous.
“Toxicodendron dermat it is is
produced by exposure to some
portion of the bruised plant, allowing
the oleoresin to contact the skin,” Dr.
Trevino says. In late fall, however,
plants spontaneously release urushiol,
and non-leaf portions of plants can
induce dermatitis even in winter.
The rash of poison ivy presents four
to 96 hours after exposure, with pruritic,
erythematous patches, often with vesicles
arranged in streaks (corresponding to
areas where the resin contacted the skin),
he says. The fluid within the vesicles and
bullae is not antigenic, he notes. As the
blisters break, the eruption becomes
ES459296_DT0714_022.pgs 06.25.2014 20:10
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23
n
“weepy,” and areas of crust form.
“Urushiol is water-soluble, so time
is of the essence in removing the resin
from the skin. Fifty percent of the resin
can be removed if rinsed off within 10
minutes; by 30 minutes only 10 percent
of the resin can be removed,” he says.
Rinsing the skin with water is sufficient
to remove urushiol; avoid use of soap as
this can potentially expand the area of
resin on the skin, he says.
Localized poison ivy rash can be
effectively treated with steroid creams,
lotions, ointments or foams. Conversely,
“A severe, extensive poison ivy rash may
require treatment with systemic steroids
— prednisone 1 to 2 mg/kg/day tapered
over two to three weeks,” Dr. Trevino
says. Tepid baths, bland shake lotions
(such as calamine), and wet-to-dry soaks
(such as aluminum acetate) may provide
additional relief. Oral antihistamines
also may decrease pruritus, he says.
Patients allergic to poison ivy/oak
should be advised that reaction to related
plants can occur, he adds. Oil from
cashew nut shells, skin of mangoes, and
the sap of the Japanese lacquer tree are
examples of plants containing substances
which cross-react with urushiol.
It’s For R
Cle el
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io
PHYTOPHOTODERMATITIS
Phytophotodermatitis is a phototoxic
reaction to furocoumarins that produces
erythema and delayed hyperpigmentation, Dr. Trevino says. The plant
species most often responsible include
the following:
Apiaceae (Umbelliferae) — This group
includes celery, dill, parsnip, parsley,
bishop’s weed (Ammi majus) and
hogweed (Heracleum species);
Rutaceae (citrus fruits) — Oranges,
lemons and limes contain phototoxins
in oil glands located in their outer rind.
Phytophotodermatitis initially
presents as an erythematous, vesicular
reaction in bizarre configurations 24 to
72 hours after UVA exposure, he says.
The reaction impacts sun-exposed areas
that also were exposed to the phototoxin. Hyperpigmentation follows one to
two weeks later and can last months to
years, Dr. Trevino adds. To prevent phytophotodermatitis, he says, avoid planting
furocoumarin-containing plants near play
areas, cover exposed skin when trimming
weeds and promptly wash exposed skin
with water (e.g., after squeezing limes for
guacamole or margaritas). DT
Disclosures: Dr. Trevino reports no relevant financial
interests.
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24
COSMETIC DERMATOLOGY
®
HAIR CARE
36 Identifying
age of onset
of pattern hair loss can
help to manage thinning
SAFETY
41 SELF-TANNER
A deeper look at the ingredients
contained in over-the-counter
self-tanning creams
Complementing cultural
perceptions of beauty
Lisette Hilton | Staff Correspondent
QUICK READ
beauty in the beholder’s eyes is
The creation of skin of color
academic departments and
organizations will help to address
cultural and ethnic infuences
on skin health and perceived
appearance, while also managing
a melting pot of patients’
concerns and aesthetic goals.
a collage of geographic, ethnic and
demographic influences, according to
research published in the March issue
of Journal of Craniofacial Surgery.
Researchers from universities in
Germany and the United States generated computerized images of a model’s
face. The nasal characteristics and lips
and chin projection in the images could
be altered. They then sent a survey with
the modifiable images to more than
13,000 plastic surgeons and lay people
in 50 countries, who, according to the
paper’s abstract, could virtually create
the faces they felt were aesthetically ideal
and pleasing.
The researchers found people’s
perceived ideal appearances of the
nose and projections of the lips and
chin depended greatly on their back-
Quotable
“The medical
management of
female pattern hair
loss requires agents
that prolong anagen
and reverse matrix
reduction.”
Vera H. Price, M.D.
San Francisco
On treating hair loss
See story, page 40
grounds, cultures, places of residence
and occupations.
The cultural effect on perceived
beaut y is so powerful that dermatologists have created skin of color
academic departments and organizations to address cultural and ethnic
influences on skin health and perceived
appearance. With this knowledge, they
hope to better address a melting pot of
patients’ concerns and aesthetic goals.
One of the great mistakes of dermatology in the United States is the lack of
understanding skin of color concerns
and treatments, says Maritza Perez,
M.D., director of cosmetic dermatology
at Mount Sinai St. Luke’s, New York.
UNDERSTANDING CULTURAL
NUANCES, PERCEPTIONS
Taking optimal care of patients from all
walks of life involves consideration of a
patient’s race, ethnicity, language, social
status, religion, sexual orientation, occupation and more, says Roopal V. Kundu,
M.D., founder and director, Center for
Ethnic Skin, Northwestern University,
Feinberg School of Medicine, Chicago.
“We have to all
be on the same page
in terms of understanding dermatologically what is
problematic to the
patient; then, how to
best treat them,” Dr.
Kundu says.
Dr. Kundu
To truly understand a patient’s needs, concerns and how
to best treat that patient, dermatologists
have to look at the biology and pathophysiology of the skin, hair and nails.
BEAUTY see page 27
DTExtra
The Food and Drug Administration has granted
marketing clearance for Restylane Silk (Valeant),
an injectable gel containing 0.3 percent lidocaine,
for lip augmentation and perioral rhytids in
patients age 21 and older. The injectable gel was
investigated in a clinical study to determine its
safety and efficacy in submucosal implantation
for lip augmentation and dermal implantation
for the treatment of perioral rhytids. The study
included 221 patients; 98 percent of those treated
reported an improvement in lip fullness at 14
days postprocedure, and 76 percent noted lip
improvement six months after the treatment.
READ MORE: DERMATOLOGYTIMES.COM/RESTYLANESILK
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ES460775_DT0714_024.pgs 06.26.2014 20:31
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Finacea® (azelaic acid) Gel, 15% is indicated for topical treatment of
inflammatory papules and pustules of mild to moderate rosacea.
Although some reduction of erythema which was present in patients
with papules and pustules of rosacea occurred in clinical studies,
efficacy for treatment of erythema in rosacea in the absence of
papules and pustules has not been evaluated.
Rosacea is with her
wherever she goes .
So is Finacea .
®
It’s true. Rosacea is complex and it’s with her for life. Pivotal
clinical studies showed reduction of inflammatory papules and
pustules of mild to moderate rosacea and some reduction of
associated erythema. Efficacy for treatment of erythema in rosacea
in the absence of papules and pustules has not been evaluated.
You have made Finacea® the #1 Dermatologist-prescribed
topical rosacea brand.1
INDICATION & USAGE
Finacea® (azelaic acid) Gel, 15% is indicated for topical treatment of inflammatory papules and pustules of mild to moderate rosacea.
Although some reduction of erythema which was present in patients with papules and pustules of rosacea occurred in clinical studies,
efficacy for treatment of erythema in rosacea in the absence of papules and pustules has not been evaluated.
IMPORTANT SAFETY INFORMATION
Skin irritation (e.g. pruritus, burning or stinging) may occur during use with Finacea®, usually during the first few weeks of treatment. If
sensitivity or severe irritation develops and persists during use with Finacea®, discontinue use and institute appropriate therapy. There
have been isolated reports of hypopigmentation after use of azelaic acid. Since azelaic acid has not been well studied in patients with
dark complexion, monitor these patients for early signs of hypopigmentation.
Avoid contact with the eyes, mouth, and other mucous membranes. In case of eye exposure, wash eyes with large amounts of water.
Wash hands immediately following application of Finacea®.
Avoid use of alcoholic cleansers, tinctures and astringents, abrasives and peeling agents. Avoid the use of occlusive dressings or wrappings.
In clinical trials with Finacea®, the most common treatment-related adverse events (AE’s) were: burning/stinging/tingling (29%),
pruritus (11%), scaling/dry skin/xerosis (8%) and erythema/irritation (4%). Contact dermatitis, edema and acne were observed at
frequencies of 1% or less.
Finacea® is for topical use only. It is not for ophthalmic, oral or intravaginal use. Patients should be reassessed if no improvement is observed
upon completing 12 weeks of therapy.
Please see Brief Summary of full Prescribing Information on adjacent page.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call
1-800-FDA-1088.
1. According to IMS NPATM (National Prescription Audit) July 2010-June 2014
© 2014 Bayer HealthCare Pharmaceuticals Inc. Bayer, the Bayer Cross, Finacea and the Finacea logo are registered trademarks of Bayer. All rights reserved. FIN-10-0001-14f | July 2014
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ES462690_DT0714_025_FP.pgs 06.28.2014 02:39
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®
FINACEA
(azelaic acid) Gel, 15%
For Dermatologic Use Only–Not for Ophthalmic, Oral, or Intravaginal Use
Rx only
BRIEF SUMMARY
CONSULT PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION
1 INDICATIONS AND USAGE
FINACEA® Gel is indicated for topical treatment of the inflammatory papules and
pustules of mild to moderate rosacea. Although some reduction of erythema which
was present in patients with papules and pustules of rosacea occurred in clinical studies,
efficacy for treatment of erythema in rosacea in the absence of papules and pustules
has not been evaluated.
5 WARNINGS AND PRECAUTIONS
5.1 Skin Reactions
Skin irritation (i.e. pruritus, burning or stinging) may occur during use of FINACEA Gel,
usually during the first few weeks of treatment. If sensitivity or severe irritation develops
and persists, discontinue treatment and institute appropriate therapy.
There have been isolated reports of hypopigmentation after use of azelaic acid. Since
azelaic acid has not been well studied in patients with dark complexion, monitor these
patients for early signs of hypopigmentation.
5.2 Eye and Mucous Membranes Irritation
Avoid contact with the eyes, mouth and other mucous membranes. If FINACEA Gel
does come in contact with the eyes, wash the eyes with large amounts of water and
consult a physician if eye irritation persists [see Adverse Reactions (6.2)].
6 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 two vehicle-controlled and one active-controlled U.S. clinical trials, treatment safety
was monitored in 788 subjects who used twice-daily FINACEA Gel for 12 weeks
(N=333) or 15 weeks (N=124), or the gel vehicle (N=331) for 12 weeks. In all three
trials, the most common treatment-related adverse events were:
burning/stinging/tingling (29%), pruritus (11%), scaling/dry skin/xerosis (8%) and
erythema/irritation (4%). In the active-controlled trial, overall adverse reactions
(including burning, stinging/tingling, dryness/tightness/scaling, itching, and
erythema/irritation/redness) were 19.4% (24/124) for FINACEA Gel compared to 7.1%
(9/127) for the active comparator gel at 15 weeks.
Table 1: Adverse Events Occurring in ≥1% of Subjects in the Rosacea Trials by
Treatment Group and Maximum Intensity*
FINACEA Gel, 15%
Vehicle
N=457 (100%)
N=331 (100%)
Mild
Moderate Severe
Mild
Moderate Severe
n=99
n=61
n=27
n=46
n=30
n=5
(22%)
(13%)
(6%)
(14%)
(9%)
(2%)
Burning/
71 (16%) 42 (9%) 17 (4%) 8 (2%)
6 (2%)
2 (1%)
stinging/
tingling
Pruritus
29 (6%)
18 (4%)
5 (1%) 9 (3%)
6 (2%)
0 (0%)
Scaling/
21 (5%)
10 (2%)
5 (1%) 31 (9%) 14 (4%) 1 (<1%)
dry skin/
xerosis
Erythema/
6 (1%)
7 (2%)
2 (<1%) 8 (2%)
4 (1%)
2 (1%)
irritation
Contact
2 (<1%)
3 (1%)
0 (0%) 1 (<1%) 0 (0%)
0 (0%)
dermatitis
Edema
3 (1%)
2 (<1%)
0 (0%) 3 (1%)
0 (0%)
0 (0%)
Acne
3 (1%)
1 (<1%)
0 (0%) 1 (<1%) 0 (0%)
0 (0%)
7 DRUG INTERACTIONS
There have been no formal studies of the interaction of FINACEA Gel with other drugs.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Teratogenic Effects: Pregnancy Category B
There are no adequate and well-controlled studies in pregnant women. Therefore,
FINACEA Gel should be used during pregnancy only if the potential benefit justifies the
potential risk to the fetus.
Dermal embryofetal developmental toxicology studies have not been performed with
azelaic acid, 15% gel. Oral embryofetal developmental studies were conducted with
azelaic acid in rats, rabbits, and cynomolgus monkeys. Azelaic acid was administered
during the period of organogenesis in all three animal species. Embryotoxicity was
observed in rats, rabbits, and monkeys at oral doses of azelaic acid that generated some
maternal toxicity. Embryotoxicity was observed in rats given 2500 mg/kg/day [162
times the maximum recommended human dose (MRHD) based on body surface area
(BSA)], rabbits given 150 or 500 mg/kg/day (19 or 65 times the MRHD based on BSA)
and cynomolgus monkeys given 500 mg/kg/day (65 times the MRHD based on BSA)
azelaic acid. No teratogenic effects were observed in the oral embryofetal developmental
studies conducted in rats, rabbits and cynomolgus monkeys.
An oral peri- and post-natal developmental study was conducted in rats. Azelaic acid
was administered from gestational day 15 through day 21 postpartum up to a dose
level of 2500 mg/kg/day. Embryotoxicity was observed in rats at an oral dose of 2500
mg/kg/day (162 times the MRHD based on BSA) that generated some maternal toxicity.
In addition, slight disturbances in the post-natal development of fetuses was noted in
rats at oral doses that generated some maternal toxicity (500 and 2500 mg/kg/day; 32
and 162 times the MRHD based on BSA). No effects on sexual maturation of the fetuses
were noted in this study.
8.3 Nursing Mothers
It is not known whether azelaic acid is excreted in human milk; however, in vitro studies
using equilibrium dialysis were conducted to assess the potential for human milk
partitioning. The studies demonstrated that, at an azelaic acid concentration of 25
µg/mL, the milk/plasma distribution coefficient was 0.7 and the milk/buffer distribution
was 1.0. These data indicate that passage of drug into maternal milk may occur. Since
less than 4% of a topically applied dose of 20% azelaic acid cream is systemically
absorbed, the uptake of azelaic acid into maternal milk is not expected to cause a
significant change from baseline azelaic acid levels in the milk. Nevertheless, a decision
should be made to discontinue nursing or to discontinue the drug, taking into account
the importance of the drug to the mother.
8.4 Pediatric Use
Safety and effectiveness of FINACEA Gel in pediatric patients have not been established.
8.5 Geriatric Use
Clinical studies of FINACEA Gel did not include sufficient numbers of subjects aged 65
and over to determine whether they respond differently from younger subjects.
17 PATIENT COUNSELING INFORMATION
Inform patients using FINACEA Gel of the following information and instructions:
Use only as directed by your physician.
• For external use only.
• Before applying FINACEA Gel, cleanse affected area(s) with a very mild soap or a
soapless cleansing lotion and pat dry with a soft towel.
• Avoid use of alcoholic cleansers, tinctures and astringents, abrasives and peeling
agents.
• Avoid contact with the eyes, mouth and other mucous membranes. If FINACEA Gel
does come in contact with the eyes, wash the eyes with large amounts of water and
consult your physician if eye irritation persists.
• Wash hands immediately following application of FINACEA Gel.
• Cosmetics may be applied after the application of FINACEA Gel has dried.
• Avoid the use of occlusive dressings or wrappings.
• Skin irritation (e.g., pruritus, burning, or stinging) may occur during use of FINACEA
Gel, usually during the first few weeks of treatment. If irritation is excessive or persists,
discontinue use and consult your physician.
• Report abnormal changes in skin color to your physician.
• To help manage rosacea, avoid any triggers that may provoke erythema, flushing, and
blushing. These triggers can include spicy and thermally hot food and drinks such as
hot coffee, tea, or alcoholic beverages.
* Subjects may have >1 cutaneous adverse event; thus, the sum of the frequencies
of preferred terms may exceed the number of subjects with at least 1 cutaneous
adverse event.
In patients using azelaic acid formulations, the following adverse events have been
reported: worsening of asthma, vitiligo, depigmentation, small depigmented spots,
hypertrichosis, reddening (signs of keratosis pilaris) and exacerbation of recurrent © 2014, Bayer HealthCare Pharmaceuticals Inc. All rights reserved.
herpes labialis.
Local Tolerability Studies
Manufactured for:
FINACEA Gel and its vehicle caused irritant reactions at the application site in human
dermal safety studies. FINACEA Gel caused significantly more irritation than its vehicle in
a cumulative irritation study. Some improvement in irritation was demonstrated over the
course of the clinical trials, but this improvement might be attributed to subject dropouts.
No phototoxicity or photoallergenicity were reported in human dermal safety studies.
Bayer Healthcare Pharmaceuticals Inc.
Whippany, NJ 07981
6.2 Post-Marketing Experience
The following adverse reactions have been identified post approval of FINACEA Gel.
Manufactured in Italy
Because these reactions are reported voluntarily from a population of uncertain size, it
is not always possible to reliably estimate the frequency or establish a causal
relationship to drug exposure:
Eyes: iridocyclitis upon accidental exposure of the eyes to FINACEA Gel
6706806BS2
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BEAUTY:
Academic departments address cultural, ethnic infuences on skin health from page 24
That’s compounded by the cultural
sk i n a nd ha i rc a re prac t ices, Dr.
Kundu says. What are the basic things
t hat people a re doi ng t hat cou ld
impact their conditions?
To illustrate her points, Dr. Kundu
refers to African haircare practices and
how those can come into play when a
dermatologist tries to connect with a
patient with a scalp or hair issue.
“They’re very distinctive and unique,
compared to the general Caucasian
haircare practices. (The dermatologist should understand) the norm for
African hair is to shampoo every week
or every two weeks. If you give them
a regimen to wash every day, you’re
not going to connect to that patient
and you’re not going to provide them a
feasible option or treatment that they
can abide to,” Dr. Kundu says.
On a biological level, the dermatologist would have to understand the
nuances of African-American versus
Caucasian hair: It’s curlier, drier, more
naturally complex knots, she says.
A LOOK AT ACNE
Andrew F. Alexis, M.D., M.P.H., director
of the Skin of Color Center, at St. Luke’s
Roosevelt Hospital, Mount Sinai Health
System, New York, says the most important message to get across to dermatologists regarding acne in darker skin
versus lighter skin types is the presence
of postinflammatory hyperpigmentation (PIH).
“When the pimples resolve, dark
spots remain. And those dark spots
can persist for several weeks to several
months — sometimes longer than a
year — depending on the severity and
where they’re located,” Dr. Alexis says.
“… Dark spots are frequently the driving
force for patients to see the dermatologist — more so than the acne.”
T here a re i mp or t a nt nu a nc e s
to treating acne patients, typically
with Fitzpatrick skin types V and VI,
Dr. Alexis says. Managing both the
acne a nd hy perpigmentation is an
impor ta nt t reatment goa l. A nd
wh i le ma nag i ng
the acne, you want
to avoid irritation.
“Any irritation
i nduced by t he
Dr. Alexis
prescription treat-
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Kundu says. “We will see people present
to us in terms of wanting to do cosmetic
procedures to remove their freckles.
What we see in Far East Asians is Hori’s
nevi, which is a variant of freckles. Not
having those is a sign of being youthful
and beautiful.”
SKIN-LIGHTENING AGENTS
A patient with acne and the presence of
severe postinflammatory hyperpigmentation.
(Photo: Andrew Alexis, M.D.)
ment can induce more dyspigmentation,” he says.
PIGMENT IS A BAD WORD
Many cultures with darker skin types
perceive lighter, even skin tones as
more beautiful. Many Caucasians, on
the other hand, try to darken their skin
in the sun.
Wendy Roberts, M.D., a dermatologist in Rancho Mirage, Calif.,
says dermatologists should be aware
of misperceptions t hat can affect
patients’ skin health and beauty. One
common misunderstanding among
darker skin types is they don’t think
they need sunblock. By the same token,
hyperpigmentation and skin darkening is not something people of darker
skin types typically want, she says.
“This is an area where we can really
help educate our patients and the public
that they are related,” Dr. Roberts says.
People of skin of color, who span
Fitzpatrick types IV through VI, react
differently to the sun than lighter skin
types, according to Dr. Perez.
“In the Caucasian patient you see
more precancerous
lesions and deep
wrinkles, whereas
i n t he pat ient of
skin of color, you see
more loss of volume
and discoloration
as a manifestation
of sun damage,” Dr.
Dr. Roberts
Perez says
When it comes to Asian and Indian
patients, Dr. Roberts says, commercialized beauty is all about skin color.
“Far East Asians want to have flawless
skin — no brown spots on their skin,” Dr.
As a result, there’s a huge market for
skin lightening products and services,
Dr. Roberts says.
Dermatologists should encourage
the use of hydroquinone alternative
treatments, such as non-hydroquinone
bleaching agents, cosmeceuticals that
lighten pigmentation, chemical peels
and emerging lasers and dev ices,
according to Dr. Roberts.
“Asian, African-American and East
Indian skin is a little more sensitive and
prone to atopic and contact dermatitis,
specifically. You want to avoid aggressive product use or peeling, because that
could result in increased pigmentation,”
Dr. Roberts says.
Understanding t he pigmentar y
concerns is one thing. Properly treating
them and not creating pigmentary
problems for other dermatologic problems is another.
Know that all people with skin of
color will respond to inf lammation
with hyperpigmentation, Dr. Perez says.
Any medication or
other treatment that
causes a little transient irritation in a
Caucasian patient
has the potential
of inf laming and
leaving hyperpigmentation in skin
Dr. Perez
of color.
Dermatologists can use similar treatments and devices to treat pigmentation
and other issues in skin of color, but there
are nuances, experts say.
“ T here a re c er t a i n l a s er s y ou
cannot use in skin of color because the
melanin in the skin will be absorbing
the energy and will cause blistering
and sequelae — either as hyperpigmentation or scarring,” Dr. Perez says.
“You’re not going to use ablative lasers,
like the CO2 laser, in a patient with skin
of color because if you ablate with a
CO2 laser and coagulate too much the
healing process might cause severe
BEAUTY see page 35
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COSMETIC
DERMATOLOGY
DERMATOLOGY
®
JULY 2014
2013 ∕ DERMATOLOGYTIMES.COM
Caring for African-American hair
H AIR
DISORDERS are an important
concern for especially African-American women, according to Amy McMichael, M.D., dermatology professor
and chairwoman, Wake Forest Baptist
Health, Winston-Salem, N.C.
Dr. McMichael and colleagues published a national study in the April 2012
issue of Journal of
Drugs and Dermatology looking why
people of color go
to dermatologists.
“The top fve
diagnoses for
African-American
patients in derDr. McMichael
matology clinics
were acne, unspecifed dermatitis or
eczema, seborrheic dermatitis, atopic
dermatitis and dyschromia. For Asian
or Pacif c Islander patients, the top
fve were acne, unspecifed dermatitis
or eczema, benign neoplasm of skin,
psoriasis and seborrheic keratosis,”
the researchers found. “By contrast, in
Caucasian patients, the top fve were
actinic keratosis, acne, benign neoplasm of skin, unspecifed dermatitis
or eczema, and nonmelanoma skin
cancer. In Hispanic patients of any
race, the leading diagnoses were acne,
unspecif ed dermatitis or eczema, psoriasis, benign neoplasm of skin, and
viral warts.”
African-Americans were the only
group in which hair made it to the
top 10 diagnoses, at number seven,
according to Dr. McMichael (Davis
SA, et al. J Drugs Dermatol. 2012;
11:466-473).
The dermatologist looked further
into the problem of hair issues among
African-American women.
“Many of my patients who were coming in were overweight and having issues
with diabetes or prediabetes. And it just
dawned on me that they were not exercising and, probably, hair care and hair
concerns were a reason for that,” she
says. “So, we did a small study looking
at just over 100 women and asked them
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if they exercise less because of their
hair are issues. Almost 40 percent of our
population said yes.”
HARSH HAIRCARE PRODUCTS
Part of the problem is AfricanAmericans have extremely fragile
hair. Add the haircare practices
common among African-Americans,
including heat, chemical relaxers
and tight braiding, and you have
a perfect storm for hair issues.
“We were able to look at this
population of women … and almost 50
percent had hair breakage, scalp itching, scalp faking,” Dr. McMichael says.
“We found out in this population of
women who were coming in for other
dermatologic issues, they not only
didn’t exercise because of their hair
but they also had underlying issues
with their scalp.”
The fndings underscore the importance of addressing hair issues
with African-American dermatology
patients, especially if they are women,
according to Dr. McMichael. Dermatologists can treat hair breakage by recommending that patients stop harmful
practices, including color, chemicals
and relaxers, as well as hair traction
hairstyles that might pull or break hair.
“Part of the problem is that we
all have a certain look that we want
to achieve. There are ways to try to
improve your appearance but also the
health of the hair shaft,” she says.
One way to minimize damage to the
hair shaft is with a layering, moisturizing regimen. Rather than stopping
at shampoo and conditioner, patients
should layer a leave-in conditioner and
silicone coating agent onto the hair
shaft, according to Dr. McMichael.
ADDRESSING HAIR LOSS
Certain forms of hair loss are prevalent
among African-Americans, though
good prevalence data is lacking, according to Dr. McMichael. Central
centrifugal cicatricial alopecia (CCCA)
occurs typically in women of African
descent and causes scars and hair
loss, Dr. McMichael says.
“It’s associated with symptoms such
as itching, burning, stinging or pain,”
she says. “We try to address the symptoms with topical corticosteroids…. We
also use injection techniques of corticosteroids right to the area. At times,
we use other anti-infammatory treatments including oral antibiotics. But our
goal is really to take down infammation.
What we have found is that white blood
cells are attacking the hair follicles. And
there is suggestion of a genetic component to the process.”
A hair-related condition that Dr. McMichael says is on the rise among AfricanAmericans is frontal fbrosing alopecia.
“In the past, we thought it affected mostly middle-aged Caucasian women,” she says. “Recently,
we’ve seen African-American women
with this, as well, and the reason it
might stump some dermatologists
is we’ve always thought of frontal
hairline changes in African-American
women as traction alopecia.”
Treating frontal fbrosing alopecia is
different than treating traction alopecia, according to the dermatologist.
Doctors should pay attention to differentiating signs. In traction alopecia,
patients typically have a lot of fne
hairs in the area where the traction has
been prominent. But in frontal fbrosing alopecia, dermatologists often
fnd very few hairs, if any, and none of
those fne hairs leading up to the receding hairline. Other frontal fbrosing
alopecia clues: hyperpigmentation on
the face and loss of eyebrows.
Treatment for the condition is the
same what dermatologists would use
for scarring alopecia of all kinds.
“We treat it, oftentimes, with topical
corticosteroids or intralesional corticosteroids. We also use a number of
oral anti-inf ammatory medications that
we would not use with CCCA, such
as Plaquenil (hydroxychloroquine) or
methotrexate,” Dr. McMichael says. DT
Disclosures: Dr. McMichael is a consultant for
Allergan, Galderma, Guthy-Renker, Procter &
Gamble and Johnson & Johnson. She also is a
researcher for Allergan and Procter & Gamble.
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35
BEAUTY:
Academic departments address cultural, ethnic infuences on skin health from page 27
scarring and hyperpigmentation in
skin of color.”
For hair removal on skin of color,
dermatologists should use a longer wavelength, such as a 1,064 nm, according to
Dr. Perez.
When using fillers to treat loss of
volume and more, the idea is to avoid
inducing inflammation, Dr. Perez says.
“The recommendation is do the
least amount of point-needle access.
For every pinpoint needle, you can get
inflammation leading to hyperpigmentation,” she says.
Sk in-tightening procedures are
useful and effective in skin of color
because of these patients’ tendency to
lose volume with age and sun exposure,
according to Dr. Perez. She says either
Thermage (Solta) or Titan (Cutera) work
well to tighten skin of color.
Be cautious when using chemical
peels on skin of color, Dr. Perez says. To
avoid inflammation, dermatologists
should turn to salicylic acid, glycolic
acid or fruity acid peels for discoloration.
“You have to start out at low percentages a nd t i me it wel l,” she say s.
“Trichloroacetic acid peels, which are
very caustic, are not indicated in skin
of color.”
Dermatologists can become more
culturally competent by listening and
learning, according to Dr. Kundu.
“I think, on an individual level,
it’s being very direct and asking the
patient what is bothersome to them and
understanding maybe there is a cultural
influence as to why that’s important to
them,” Dr. Kundu says. “Other things
are from learning … reading journals
and (attending) conferences. I think
(cultural competence) needs to be part
of our educational system … because we
have a beautiful, wonderful melting pot
in America.” DT
Disclosures: Dr. Alexis is a consultant for Amgen and
Galderma and is a consultant and investigator for
Allergan. Dr. Perez is a speaker for Cutera. Drs. Kundu
and Roberts report no relevant financial interests.
Psoriasis in nonwhite patients
PSORIASIS
IN nonwhite patient populations is not well described, according to
Andrew F. Alexis, M.D., M.P.H., director
of the Skin of Color Center, at St. Luke’s
Roosevelt Hospital, Mount Sinai Health
System, New York.
“If one were to research the published
medical literature on psoriasis in …
blacks, for example,
one would fnd very
little information
about any differences in clinical presentation or differences
in quality of life or in
the epidemiology.
The few studies that
Dr. Alexis
do report on the
epidemiology of psoriasis prior to 2005
reported psoriasis as being rare among
blacks, but subsequent studies in the last
10 years show it’s much more common
than previously reported,” Dr. Alexis says.
A study published in the March 2014
issue of the Journal of the American
Academy of Dermatology found the
prevalence of psoriasis to be 1.9 percent
in African-Americans versus 3.6 percent
in Caucasians (Rachakonda TD, Schupp
CW, Armstrong AW. J Am Acad Dermatol.
2014;70(3):512-516).
“A survey by the National Psoriasis
Foundation found that individuals in
nonwhite racial-ethnic groups, especially
African-Americans, reported a greater
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Clinicians treating patients with scalp
psoriasis should keep the patients’ haircare
practices in mind.
(Photo: Andrew Alexis, M.D.)
degree of negative impact of the psoriasis
on their quality of life,” Dr. Alexis says.
According to Dr. Alexis, psoriasis in
African-Americans tends to have less visible redness and can have a violaceous
hue in darkly pigmented skin types.
“In some cases psoriasis can be
slightly more diffcult to diagnose in
black skin, as the features can be similar
to other infammatory skin disorders with
scaly plaques (such as lichen planus
or lichen simplex chronicus) and less
typical of ‘text book’ psoriasis,” he says.
“Also, in all darker skin types (especially
black skin), there is a tendency to have
persistent dark patches at sites of psoriasis due to postinfammatory hyperpig-
mentation.… Psoriasis plaques can also
resolve with persistent light spots that
last several weeks (postinfammatory
hypopigmentation). When African-American females present with scalp psoriasis
there are nuances to treatment.”
Because of the different haircare
practices and hair characteristics
between African-American and others, treating scalp psoriasis with a daily
shampoo prescription could be met
with resistance on the part of the patient and possibly result in hair breakage (due to greater fragility and dryness
of Afro-textured hair), Dr. Alexis says.
“One has to take into account those
hair styles when prescribing a topical
regimen. Asking the patient whether a
water-based solution, versus a lotion,
foam or oil-based product is most suitable for their hairstyle and hair practices is important,” he says. “In other
words, you have to take an extra step to
consider the haircare practices of that
patient before you prescribe.
“My impression is that awareness
of psoriasis in the African-American
and Latino communities is lower than
that in the general population, and this
contributes to delays in diagnosis and
appropriate treatment.” DT
Disclosures: Dr. Alexis is a consultant for Amgen
and Galderma and is a consultant and investigator for Allergan. For more information: Shah
SK, Arthur A, Yang YC, et al. J Drugs Dermatol.
2011;10(8):866-872
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COSMETIC
DERMATOLOGY
®
Managing female pattern
hair loss: What works?
Ilya Petrou, M.D. | Senior Staff Correspondent
QUICK READ
Panama City, Panama — Female
Recognizing that pattern hair loss
in women includes three stages of
miniaturization based on the age of
onset will help in the management
of the hair loss in these patients.
pattern hair loss typically will present
with diffuse thinning of the hair on
the top and crown of the scalp without
hairline recession, and the hair loss
rarely progresses to total or near total
hair loss.
“Female pattern
hair loss is a
source of significant anx iet y and
dist ress in t he
af fected pat ient.
Identifying the age
of onset of pattern
hair loss is instruDr. Price
mental in helping
clinicians better manage the hair
thinning and lead to better patient
expectations,” says Vera H. Price, M.D.,
professor, department of dermatology,
University of California, San Francisco School of Medicine. Dr. Price
spoke recently at the North American
Dermatologic Society annual meeting.
Pattern hair loss is characterized by
hair miniaturization, or follicle downsizing, due to anagen shortening and
matrix reduction.
TYPES OF PATTERN HAIR LOSS
In women, pattern hair loss includes
three stages of hair miniaturization
based on age of onset, a nd t hese
stages are referred to by different
names. Androgenetic alopecia (AGA)
is a genetically determined androgenmediated trait that is generally considered the female equivalent of male
androgenetic alopecia.
The term female pattern hair loss
is ga ining in popu la r it y as a less
com m it ta l ter m when t he role of
androgens is less clear-cut and other
hormonal and non-hormonal factors
may play a role. The term senescent
alopecia refers to age-related hair thinning, and is distinct from AGA and is not
dihydrotestosterone (DHT)-mediated.
The onset of androgenetic alopecia
i s b e t w e en pub er t y a nd a ge 4 0,
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whereas female pattern hair loss is
a term reserved for pattern hair loss
that appears between ages 45 to 55.
Senescent alopecia refers to hair thinning that appears at about age 60 and
older. According to Dr. Price, medical
management should address hair loss
based on the age of onset.
“In pat ients w it h AGA, t here is
increased 5 alpha-reduction of testosterone to dihydrotestosterone (DHT)
in scalp hair follicles of affected patients,
and DHT activates genes responsible for
the miniaturization of the follicles. Treatments aimed at reversing the effects of
DHT in the scalp can be quite effective
when used appropriately,” Dr. Price says.
MANAGEMENT OF MINIATURIZATION
The medical management of miniaturization includes minoxidil, estrogen,
and various androgen-blocking agents
such as 5 alpha-reductase inhibitors
(f inasteride and dutasteride) and
androgen receptor inhibitors (spironolactone and cyproterone acetate).
Minoxidil, a potassium channel
opener, is a non-specific medication for
AGA that helps to prolong the anagen
phase in “suboptimal” or miniaturized follicles. Minoxidil foam 5 percent
is an effective hair-growth promoter
when applied to the scalp once daily,
whereas minoxidil solution 2 percent
or 5 percent must be applied twice daily.
In contrast, finasteride 1 mg oral
tablet is a 5 alpha-reductase inhibitor
that is specific for AGA. Both minoxidil
and finasteride can achieve excellent
results when used daily and consistently, and the extent of stabilization
and improvement in hair growth after
two years is similar in both. Finasteride,
however, is contraindicated in women
who are or may be pregnant and must
be used with caution, as exposure to the
drug will cause genital defects (hypospadias) in male fetuses.
According to Dr. Price, senescent
alopecia is not a continuum of AGA and
is a distinct entity. Studies in women and
men show a significant decrease in scalp
5 alpha-reductase types 1 and 2 and in
androgen receptor in patients with onset
of hair thinning at age 60.
Although AGA and age-related hair
thinning share a similar histology, they
differ significantly in hormonal activity
as well as in gene array studies. Studies
have shown that in hair follicles of men
ages 18 to 30 with AGA, there are higher
levels of 5 alpha-reductase types 1 and
2 and androgen receptor in the frontal
follicles than in the occipital follicles,
and in hair follicles in men with senescent alopecia, there is a nearly two-fold
decrease in levels of 5 alpha-reductase
types 1 and 2 and androgen receptor
when compared to males with AGA
(Sawaya ME, Price VH. J Invest Dermatol.
1997;109(3):296-300).
Gene expression profiles show that in
AGA, hair growth cycle genes are differentially expressed whereas in senescent
alopecia, systemic senescent/aging
genes are differentially expressed. The
very different gene expression profiles
suggest that AGA and senescent alopecia
are two distinct disorders. Minoxidil
can be useful in patients with senescent
alopecia whereas finasteride will not be
effective in this patient population.
Future treatment approaches for
hair growth promotion could be agents
that stimulate existing hair follicles
Dr. Price said, including prostaglandin analogues such as bimatoprost
(Latisse, Allergan). Another treatment
approach could be aimed at stimulating new hair follicle formation via
superficial skin wounding, first introduced by George Cotsarelis, M.D.
“The medical management of female
pattern hair loss requires agents that
prolong anagen and reverse matrix
reduction. Topical minoxidil is an
appropriate treatment, irrespective of
age of onset. While the judicious off-label
use of finasteride has shown efficacy in
selected pre-menopausal women, the
medication is not effective in senescent
or age-related alopecia, Dr. Price says. DT
Disclosures: Dr. Price is a consultant for Allergan
and Follica.
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COSMETIC
DERMATOLOGY
®
COMPETITION:
Dermatologists should hold the line on injectables pricing from page 1
specialists that we are, and therefore
shou ld cha rge a prem iu m for ou r
services.”
IT’S COMPLICATED
Unqualified injectors are more likely
than core specialists to create two kinds
of complications, Dr. Gross says:
➧ aesthetic complications such as asymmetries or lumps and bumps, which
stem from poor technique but may not
create medical hazards;
➧ medical complications such as infections and granulomas.
“Poor training can lead to poor results.
And if you never had the training, you’ll
never come close to knowing how to
manage a complication. Fortunately,
devastating complications are rare
across the board, Dr. Gross says.
Patients who choose to work with a
dermatologist get the benefit of more
than just a consultation on aesthetics,
says Elizabeth Tanzi, M.D.
“By choosing
a d e r m a t o lo g i s t ,
t he pat ient gets
the added value of
discussing skincare,
and a review of any
suspicious growths,
lesions a nd ot her
skin issues. UnforDr. Tanzi
tunately, I’ve seen
a number of new patients who were
previously injected at a medispa or by a
non-dermatologist, who had an obvious
facial skin cancer that I diagnosed during
consultation,” Dr. Tanzi says. She is
co-director of the Washington Institute
of Dermatologic Laser Surgery in Washington, D.C.
QUICK READ
The best defense against
unqualified injectors’ discounts
involves educating patients about
dermatologists’ expertise and
experience — and holding the
line on prices, experts say.
or four syringes of fillers to get a good
outcome, and based on syringe pricing
they can only afford one, I won’t do the
procedure,” he says. “I tell them they won’t
be happy with the result.”
However, Dr. Downie says, it’s rarely
possible to convince price-driven patients
that there’s anything wrong with this
approach until it’s too late.
“When we find that the neuromodulator is not really Botox, or the filler is not
really Juvéderm (hyaluronic acid/HA,
Allergan) or Restylane (HA, Medicis), then
they wonder, ‘What did that doctor inject
in me?’” she says.
This creates another challenge for
dermatologists. If a patient has a complication, they cannot always tell their
dermatologist exactly what was used in
their treatment from the noncore provider.
“I’ve seen practitioners who are giving
treatments that are not approved in the
United States for the specific indication,
or a patient gets a product from Mexico or
another neighboring country, and we have
no idea what was injected into their face,”
Dr. Narurkar says. “Not knowing, we don’t
know how to correct it.”
Regarding providers, Dr. Downie says,
“Some people will have a small account
with Allergan, for example, through which
they order 10 vials of Botox yearly. But
somehow they’re injecting a ton of toxins
per year,” often using materials purchased
online from Canada or Asia.
THOROUGH CONSULTATION
In discounters’ practices, “Physicians
delegate the consultation to an extender,"
Dr. Narurkar says. "That’s where we see
the worst outcomes, because the motivation may not be there to provide the best
outcome, but instead (to reap) financial
gain.”
Patients frequently present for aesthetic
treatment with one specific complaint, he
says. However, he says, “I look at the patient
as a whole” and formulate a treatment
plan based on patient desires, anatomical
knowledge and budget considerations.
Dr. Narurkar eschews unit- or packagebased pricing in favor of procedure-based
pricing. “If somebody really requires three
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PHYSICIAN GROUPS RESPOND
A s t h e p u b l i c ’s
comfort level with
injectables has
grown, Dr. Gross says,
“Sometimes patients
may not always do
their homework —
not as much as if they
w ere u nder goi ng
Dr. Gross
surgery.”
With minimal funding, he says, the
PCIS mainly encourages core specialty
societies to educate patients. Here, he
adds, the message may be changing.
“In the past, there’s been a lot of push
to educate patients about board certification. Now it’s not only board certification,
but also board certification in an appropriate specialty that mandates training in
aesthetic medicine,” he says. “You don’t
necessarily want a board-certified ER
physician injecting your fillers.”
Created in 2007, the PCIS exists to
“eradicate the practice of unqualified
persons providing injections, to promote
treatment supervised by properly qualified and trained, board-certified doctors
and to promote only the use of Food and
Drug Administration-approved, appropriately administered products,” according
to its website.
As for policing discount providers, he
says, “There’s no way we can knock on
someone’s door and say, ‘You have to raise
your prices.’”
IMPORTANCE OF EDUCATION
“Consumer education is the key,” Dr.
Gross says. “If it looks too good to be true,
it might be.”
To address this issue, the American
Society for Dermatologic Surgery (ASDS)
launched a campaign that educates the
public about why they should select a
dermatologic surgeon for certain procedures, according to Dr. Narurkar. The
campaign includes a video contest won by
H.L. Greenberg, M.D., owner of Las Vegas
Dermatology (see sidebar).
Although the American Academy of
Dermatology (AAD) has no program or
policy directed at discounting, it too has
been a pioneer in educating the public
about the importance of seeing a boardcertified dermatologist. Additionally, Dr.
Tanzi says, “The specialty societies —
particularly the AAD and ASDS — are at
the forefront of providing their members
access to learn the most advanced injection techniques through various meetings
and hands-on courses.”
Patients who insist on discounts should
be reminded of the risks of using someone
with less experience, according to Dr.
Downie. When patients push the discount
issue she refers them back to the discount
provider, “With a warning that he or she
doesn’t have the expertise that I do,” Dr.
Downie says. “And I tell them that their
face is their most important accessory.
Many of them stop, think, and agree with
me; some don’t.”
Dr. Narurkar adds that his practice
constantly attracts patients who are dissatCOMPETITION see page 40
ES461117_DT0714_038.pgs 06.26.2014 22:23
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COSMETIC
DERMATOLOGY
®
COMPETITION:
Dermatologists should hold the line on injectables pricing from page 38
isfied with bargain injectors because, “We
give the right treatment without gouging
them.” Dr. Narurkar never discusses prices
with patients — his coordinators do.
“Coordinators are trained to say (to
patients), ‘I respect that. Here is what
we charge.’ The worst thing to do is talk
negatively of the competition, because
that makes you look like you’re not being
up-front,” Dr. Narurkar says.
And if prodigal patients experience a
complication elsewhere, Dr. Downie says,
“They can still come back to me, and I’ll
take care of them. You can’t have a giant
ego when patients don’t listen to you.”
COMMODITIZATION EXPANDING
Henceforth, Drs. Downie, Tanzi and
Gross agree that, due to factors such as
the growing popularity of organizations
such as Groupon, the price-conscious tier
of the injectables market will persist — if
not grow.
“In procedures or offerings that can’t
easily show clear differentiation based on
quality, safety or results,” Dr. Gross says,
“commoditization will continue.”
Lasers are no exception. Ten to 15 years
ago, “Laser hair removal (LHR) was new,”
he says. “Various lasers did it, with varying
A patient with uneven eyebrows following poor
neuromodular placement.
(Photo: Elizabeth Tanzi, M.D.)
degrees of success. And different providers
had different techniques. Now, most of
the devices work well. All the providers
know how to use them,” and how much to
charge. Accordingly, “LHR is becoming a
commodity.”
That said, the devices are still best used
in the hands of someone with plenty of
training. “It is still a laser, and you can
burn someone with it,” a fact which highlights the professional component of any
aesthetic procedure, Dr. Gross says.
“What’s in the syringe is important, but
who’s behind the syringe, many times,
is much more important,” he says. “It’s
harder to commoditize the skill provided
by the injector.”
So far, he says, fillers have been less
affected by commoditization. “There’s too
much differentiation in the quality of results
between experienced and inexperienced
injectors,” Dr. Gross says.
Dr. Tanzi disagrees, however, saying that
fillers are just as vulnerable as neuromodulators to discounting.
Dr. Downie predicts that because of new
products such as Juvéderm Voluma (HA,
Allergan), public interest in injectable treatments will grow — as will patients’ appreciation of dermatologists’ pioneering efforts in
developing such products.
Whenever a product achieves widespread
acceptance, Dr. Narurkar says, “You’re going
to see price wars and competitiveness. Don’t
view that as a negative — patients are more
aware of aesthetic treatments than ever.
“Don’t worr y about what the guy or
woman down the street is up to,” he says.
“Provide the best service in your community,” and savvy patients will reward you. DT
Disclosures: This article grew from comments made by
Drs. Narurkar and Downie at Cosmetic Boot Camp, June
2013, Aspen, Colo. Dr. Narurkar has performed clinical
trials for Allergan and Merz. Dr. Downie is a consultant for
Allergan, Valeant and Merz. Dr. Gross has been a consultant and speaker for Allergan. Dr. Tanzi reports no relevant
financial interests.
Award-winning video touts
dermatologists’ training
LAS VEGAS — For one dermatologist, the
hands-an approach has helped not only
in growing his practice, but also in making a video that’s been honored by the
American Society for Dermatologic Surgery (ASDS) for promoting the specialty
of dermatology.
“Many consumers don’t understand the
amount of training that goes into becoming
a board-certifed dermatologist,” says H.L.
Greenberg, M.D., owner of Las Vegas Dermatology. “My video emphasizes that training and helps credential us as The Experts
in Skin Treatments,” which was the theme of
the 2013 ASDS contest that the video won.
With its colloquial tone and upbeat
backing tune, the 60-second video emphasizes that dermatologists spend eight
post-college years — including three after
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medical school — training to treat the skin.
“The video is something that we as
ASDS members, dermatologists and dermatologic surgeons can all agree is positive
and uplifting,” says Dr. Greenberg, whose
80-plus videos have garnered more than
900,000 total views on his YouTube channel
(YouTube.com/lvderm).
The contest gave him a chance to put
his long-standing passion for videography
and flmmaking to work. In creating the clip,
Dr. Greenberg says, “I was inspired to use
the tools I had learned working with a flmmaker friend in Las Vegas, Philip Marcus. I
wrote the script and created the video using
Final Cut Pro X for Mac (Apple), making key
frames, moving slides into place and adding
word frames and pictures.”
To record his script, “I hired a voiceover professional. Unfortunately, he
couldn’t get the infections correct, so I pur-
chased a Yeti USB mic (Blue Microphones)
and used the GarageBand application (Apple) to record my voiceover for the video.”
Dr. Greenberg recorded 10 takes, then
cut and pasted together the best portions
of each. For the background music, “I
used a song that I had created in GarageBand called ‘Indian Maracas Funk.’”
The entire process took about 10
hours, earning him a $2,500 prize and a
mention in the ASDS "Currents" newsletter.
Since then, Dr. Greenberg has made
a copy of the video, including the name of
his practice, for his website, where it has
captured more than 400 views. As for the
original ASDS video, “It’s downloadable
(vimeo.com/76719699) and can be used by
anyone on their website.” DT
Disclosures: Dr. Greenberg reports no
relevant financial interests.
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COSMETIC
DERMATOLOGY
41
A BETTER UNDERSTANDING OF
SELF-TANNER
SAFETY
Zoe Diana Draelos, M.D., is a
Dermatology Times editorial
adviser and consulting professor
of dermatology, Duke University
School of Medicine, Durham, N.C.
Questions may be submitted via
email to [email protected]
COSMETIC CONUNDRUMS
Q:
A:
Are self-tanning
creams safe?
Yes, self-tanning creams are safe, but perhaps an explanation is in order. There have been a very few reported cases
of allergic contact dermatitis to self-tanning creams. I think
the incidence is somewhat under-reported, however, as I see
at least five cases every summer in North Carolina. The active
agent in self tanning creams is dihydroxyacetone (DHA) and
there are no self tanning creams that do not possess this potential allergen.
DHA is considered a nontoxic ingredient both for ingestion
and topical application. The LD50 in rats is over 16 grams per
kilogram. The phosphate of DHA is actually one of the intermediates in the Kreb’s cycle, known as dihydroxyacetone monophosphate.
Topically applied DHA has not been detected in the urine or
serum of volunteers following topical application. The staining
reaction that occurs with DHA is limited strictly to the stratum
corneum and can be readily removed with tape stripping and
exfoliation. Thus, self-tanning creams can be considered safe
in those individuals who are not DHA-allergic.
Q:
A:
What are microsponges and how are they currently
being used in cosmeceuticals and dandruff shampoos?
Microsponges are very small sponges available in two sizes: below 50 micrometers and
between 100-200 micrometers. The sponges can be
loaded with substances for delivery to the skin.
There are two methods to load the sponges that yield
different delivery possibilities. One technique is to soak the
microsponge in a solvent solution containing the active ingredient followed by evaporation of the solvent, leaving the active
ingredient on the outside of the sponge. Another technique is
to mix the active ingredient with the sponge polymer when it
is being formed. Since the microsponges can be crushed when
they are rubbed into the skin, the second method insures better
time-released delivery.
The most interesting use of microsponges in OTC (overthe-counter) drug dermatologics is in dandruff shampoos.
Zinc pyrithione and selenium sulfide are commonly use antiinflammatory and antifungal agents, but both possess a foul
smell that consumers find distasteful on their hair. If the zinc
pyrithione or selenium sulfide are placed on a microsponge,
the odor is reduced while maintaining ingredient efficacy. This
same concept is being used to incorporate odor-releasing ingredients into cosmeceuticals. DT
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ES459295_DT0714_041.pgs 06.25.2014 20:10
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42
CUTANEOUS ONCOLOGY
®
BCC OPTIONS
45 Smoothened
inhibitors may
provide alternative to surgery
and radiotherapy
TO MELANOMA
46 PATHWAYS
Diagnostic technologies lead
to more accurate definitions of
dermatologic diseases
Scalp condition mimics skin cancer
QUICK READ
Quebec City, Quebec — Erosive
EPDS can be mistaken for skin
cancers, particularly since the
condition affects patients who
are elderly and have features
associated with the development
of skin cancers on the scalp.
pustular dermatosis of the scalp (EPDS),
an inflammatory crusted scalp condition, can go undiagnosed for many
years, and it can be mistaken for conditions such as squamous cell carcinoma,
so biopsies should be performed to
arrive at the diagnosis.
Discussing at the annual meeting
of the Canadian Dermatology Association a case of an elderly woman
who had EPDS that mimicked squamous cell carcinoma, Ariel Burns,
M.D., a fou r t h-yea r der matolog y
resident at Dalhousie University in
Halifax, Nova Scotia, notes that the
case had been referred to a dermatolog ist af ter a biopsy showed no
malignancy was present.
“The 86-year-old patient had a lot of
sun damage on her scalp and femalepattern baldness,” says Dr. Burns,
adding the patient was fair-skinned.
“She had crusty, scabbing lesions on
the scalp.”
Quotable
“Smoothened inhibitors
ofer a new promising
treatment option and
herald a new age for this
patient population.”
Jil Dreier, M.D.
Zurich, Switzerland
On treatment options
for basal cell carcinoma
See story, page 45
EPDS is an asymptomatic and chronic
condition that typically occurs in elderly
patients who have sun damage and skin
atrophy. There is usually scalp crusting
and variable erythema on presentation,
Dr. Burns says.
SUSPECTED SCC
The patient’s hairdresser was the
f i rst person to not ice t he lesion.
After being seen in primar y care,
the patient was referred to a plastic
su rgeon who was to excise t he
lesion. Squamous cell carcinoma
was suspected, a nd a biopsy was
ordered. The result, however, was not
consistent with the clinical impression of the lesion. There were fibrotic
changes but no malignancy.
“You might have thought it was a poor
biopsy which missed the lesion we were
trying to sample (squamous cell carcinoma),” Dr. Burns says.
Subsequently, a fungal infection
was suspected because there were
hyphal elements (fungi) and inflammation in the biopsy, but the culture
proved negative, she says. Still, topical
clotrimazole and oral terbenifine was
administered for two months, but there
was no resolution.
“The patient was treated for a fungal
infection just in case it was an atypical
presentation of a fungal infection,” Dr.
Burns explains.
Another biopsy was performed, and
the diagnosis of EPDS was made. The
fungal organisms were regarded as incidental colonizers of the chronic wound.
The therapy that was then administered
was betamethasone valerate 0.1 percent
cream, and the lesion improved significantly with this treatment.
“It responded beautifully (to topical
steroids),” Dr. Burns says. “It may be that a
SCALP CONDITION see page 48
DTExtra
Results of a phase 1b trial of nivolumab combined
with ipilimumab demonstrated one- and two-year
survival rates of 94 and 88 percent, respectively,
in patients with advanced melanoma. The doseranging trial examined the investigational drug
nivolumab (Bristol-Myers Squibb) combined
with ipilimumab (Yervoy, Bristol-Myers Squibb)
concurrently or sequentially in 127 patients with
advanced melanoma. The one-year survival rate
was 94 percent in patients receiving the concurrent
combination regimen of nivolumab 1 mg/kg plus
ipilimumab 3 mg/kg (n=17). Those doses are also
being used in ongoing phase 2 and 3 trials.
READ MORE: DERMATOLOGYTIMES.COM/NIVOLUMAB
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ES459997_DT0714_042.pgs 06.26.2014 01:08
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End with
relief.
1, 2
Topicort® (desoximetasone) is indicated
for the relief of the inflammatory
and pruritic manifestations of
corticosteroid-responsive dermatoses.
Important Safety Information
Topicort® (desoximetasone) is contraindicated
in those patients with a history of hypersensitivity
to any of the components of the preparation.
The following local adverse reactions are reported
infrequently with topical corticosteroids, but may occur
more frequently with the use of occlusive dressings.
These reactions are listed in an approximate decreasing
order of occurrence: Burning, itching, irritation, dryness,
folliculitis, hypertrichosis, acneiform eruptions, hypopigmentation,
perioral dermatitis, allergic contact dermatitis, maceration of the
skin, secondary infection, skin atrophy, striae, and miliaria. Because
of the potential for systemic absorption, use of topical corticosteroids may
require that patients be periodically evaluated for HPA axis suppression.
Pediatric patients may demonstrate greater susceptibility to topical
corticosteroid-induced HPA axis suppression and Cushing’s syndrome than
mature patients because of a larger skin surface area to body weight ratio.
Hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing’s syndrome, and
intracranial hypertension have been reported in pediatric patients receiving topical
corticosteroids. Administration of topical corticosteroids to pediatric patients should
be limited to the least amount compatible with an effective therapeutic regimen.
Chronic corticosteroid therapy may interfere with the growth and development of
pediatric patients.
References: 1. Topicort® Cream 0.05% Prescribing Information.
Taro Pharmaceuticals U.S.A., Inc. 2. Topicort® Ointment 0.05%
Prescribing Information. Taro Pharmaceuticals U.S.A., Inc.
®
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See brief summary of Prescribing Information on reverse side.
© 2014 Taro Pharmaceuticals U.S.A., Inc.
TaroPharma® and Topicort® are registered trademarks of Taro Pharmaceuticals U.S.A., Inc.
AD100-0037
April 2014
ES442014_DT0614_TOPICORT1_FP.pgs 05.21.2014 01:04
ADV
Topicort® (Desoximetasone Cream USP) 0.05%
Topicort® (Desoximetasone Ointment USP) 0.05%
Rx only
Rx only
As with other corticosteroids, therapy should be discontinued when control is
achieved. If no improvement is seen within 4 weeks, contact the physician.
Brief Summary of Prescribing Information. For complete prescribing information
consult official package insert.
Laboratory Tests
The following tests may be helpful in evaluating the hypothalamic-pituitaryadrenal (HPA) axis suppression:
Urinary free cortisol test
ACTH stimulation test
For topical use only. Not for oral, ophthalmic, or intravaginal use.
INDICATIONS AND USAGE
Topicort® (desoximetasone cream USP) 0.05% and Topicort® (desoximetasone
ointment USP) 0.05% are indicated for the relief of the inflammatory and pruritic
manifestations of corticosteroid-responsive dermatoses.
CONTRAINDICATIONS
Topical corticosteroids are contraindicated in those patients with a history of
hypersensitivity to any of the components of the preparation.
WARNINGS
Keep out of reach of children.
PRECAUTIONS
General
Systemic absorption of topical corticosteroids can produce reversible
hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for
clinical glucocorticosteroid insufficiency. This may occur during treatment or
upon withdrawal of the topical corticosteroid.
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 more potent steroids, use over large surface
areas, use over prolonged periods, use under occlusion, use on an altered skin
barrier, and use in patients with liver failure.
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.
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.
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.
Concomitant Skin Infections
Concomitant skin infections should be treated with an appropriate antimicrobial
agent. If the infection persists, Topicort® (desoximetasone cream USP) 0.05% or
Topicort® (desoximetasone ointment USP) 0.05% should be discontinued until the
infection has been adequately treated.
Information for the Patient
Patients using topical corticosteroids should receive the following information
and instructions:
1. This medication is to be used as directed by the physician. It is for external
use only. Avoid contact with the eyes.
2. Patients should be advised not to use this medication for any disorder other
than for which it was prescribed.
3. The treated skin area should not be bandaged or otherwise covered or 4.
wrapped as to be occlusive unless directed by the physician.
4. Patients should report any signs of local adverse reactions, especially under
occlusive dressings.
5. Other corticosteroid-containing products should not be used with Topicort®
(desoximetasone cream USP) 0.05% or Topicort® (desoximetasone ointment
USP) 0.05% without first consulting with the physician.
Carcinogenesis, Mutagenesis, and Impairment of Fertility
Long-term animal studies have not been performed to evaluate the carcinogenic
potential or the effect on fertility of topical corticosteroids.
Desoximetasone was nonmutagenic in the Ames test.
Pregnancy. Teratogenic Effects. Pregnancy Category C
Corticosteroids have been shown to be teratogenic in laboratory animals when
administered systemically at relatively low dosage levels. Some corticosteroids
have been shown to be teratogenic after dermal application in laboratory animals.
Desoximetasone has been shown to be teratogenic and embryotoxic in mice,
rats, and rabbits when given by subcutaneous or dermal routes of administration
in doses 15 to 150 times the human dose of Topicort® (desoximetasone cream
USP) 0.05%, or Topicort® (desoximetasone ointment USP) 0.05%.
There are no adequate and well-controlled studies in pregnant women on
teratogenic effects from topically applied corticosteroids. Therefore, Topicort®
(desoximetasone cream USP) 0.05% or Topicort® (desoximetasone ointment
USP) 0.05% should be used during pregnancy only if the potential benefit justifies
the potential risk to the fetus. Drugs of this class should not be used extensively
on pregnant patients, in large amounts, or for prolonged periods of time.
Nursing Mothers
It is not known whether topical administration of corticosteroids could result in
sufficient systemic absorption to produce detectable quantities in breast milk.
Systemically administered corticosteroids are secreted into breast milk in quantities
not likely to have a deleterious effect on the infant. Nevertheless, caution should
be exercised when topical corticosteroids are administered to a nursing woman.
Pediatric Use
Pediatric patients may demonstrate greater susceptibility to topical
corticosteroid-induced HPA axis suppression and Cushing’s syndrome than
mature patients because of a larger skin surface area to body weight ratio.
Hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushing’s syndrome,
and intracranial hypertension have been reported in pediatric patients receiving
topical corticosteroids. Manifestations of adrenal suppression in pediatric
patients include linear growth retardation, delayed weight gain, low plasma
cortisol levels, and absence of response to ACTH stimulation. Manifestations of
intracranial hypertension include bulging fontanelles, headaches, and bilateral
papilledema.
Administration of topical corticosteroids to pediatric patients should be limited
to the least amount compatible with an effective therapeutic regimen. Chronic
corticosteroid therapy may interfere with the growth and development of
pediatric patients.
ADVERSE REACTIONS
The following local adverse reactions are reported infrequently with topical
corticosteroids, but may occur more frequently with the use of occlusive
dressings. These reactions are listed in an approximate decreasing order of
occurrence:
Burning, itching, irritation, dryness, folliculitis, hypertrichosis, acneiform eruptions,
hypopigmentation, perioral dermatitis, allergic contact dermatitis, maceration of
the skin, secondary infection, skin atrophy, striae, and miliaria.
In controlled clinical studies the incidence of adverse reactions were low (0.8%) for
Topicort® (desoximetasone cream USP) 0.05% and included pruritus, erythema,
vesiculation, and burning sensation. The incidence of adverse reactions was low
(0.2%) for Topicort® (desoximetasone ointment USP) 0.05% and included mild
burning sensation at the site of application.
OVERDOSAGE
Topically applied corticosteroids can be absorbed in sufficient amounts to
produce systemic effects (see PRECAUTIONS).
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
Topicort® and TaroPharma® are registered trademarks of Taro Pharmaceuticals
U.S.A., Inc. and/or its affiliates.
You are encouraged to report negative side effects of prescription drugs to the
FDA. Visit www.fda.gov/Safety/MedWatch/default.htm, or call 1-800-FDA-1088.
Issued: April 2014
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ES442013_DT0614_TOPICORT2_FP.pgs 05.21.2014 01:04
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CUTANEOUS ONCOLOGY
45
Smoothened inhibitors provide
new options for BCC treatment
QUICK READ
Zurich, Switzerland — Since
New and emerging drugs such as
the smoothened inhibitors appear
to offer a treatment option for
patients with locally advanced
and metastatic BCC, in many
cases circumventing inappropriate
surgery and/or radiation therapy.
the dawn of smoothened inhibitors,
patients with locally advanced and
metastatic basal cell carcinoma (BCC)
now have a new and effective treatment
alternative beyond the traditional and
less optimal treatment approaches such
as surgery and radiotherapy.
“Before the era of the smoothened
inhibitors, treatment options for patients
with both locally advanced or metastatic
BCC were very poor,” says Jil Dreier,
M.D., department of dermatolog y,
University Hospital Zurich, Switzerland.
“Smoothened inhibitors offer a new
promising treatment option and herald
a new age for this patient population.”
Continued research has established
that BCC is driven by an activated
hedgehog pathway and smoothened
inhibitors are being developed and
used to specifically target and block the
hedgehog signaling cascades involved
in the development of BCC as well as
a host of other diseases. Dr. Dreier
and colleagues of professor Reinhard
Dummer’s research team and professor
Rainer Kunstfeld (Vienna), recently
performed a literature review study
looking at the current drugs that target
one or several of the hedgehog signaling
cascades, which might be successfully
used in BCC with special focus on
possible candidates for combination
therapy with hedgehog inhibitors.
TRIALS UNDER WAY
Recently approved by the Food and Drug
Administration (FDA) for the treatment
of locally advanced and metastatic BCC,
vismodegib (Erivedge, Genentech) is a
smoothened inhibitor that is proving to
be a good treatment option for patients
who previously may have had to undergo
multiple surgeries and/or radiation
therapy in order to control the progression of the disease.
Currently undergoing a phase 2 clinical trial, LDE225 (sonidegib, Novartis)
is one of the experimental smoothened
inhibitors in the pipeline that could
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have an advantage over vismodegib, as
interim results indicate that the novel
drug may have a dose-toxicity relationship, which could possibly result in a
decrease in side effects.
“Vismodegib and
sonidegib show
similar adverse
events such as
muscle toxicity,
dysgeusia and
alopecia.”
Jil Dreier, M.D.
Zurich, Switzerland
“In general, both vismodegib and
sonidegib show similar adverse events
such as muscle toxicity, dysgeusia and
alopecia,” Dr. Dreier says. “However, it
is too early to say which of these drugs
will fair better in the long run in terms of
AEs (adverse events), and head-to-head
randomized clinical trials would need to
be performed to address this question.”
Smoot hened i n h ibitors have
been shown to achieve an impressive tumor response in patents with
locally advanced and metastatic BCC,
witnessed in the positive FDA clinical
trial results with vismodegib and the
more recent trial results with sonidegib,
Dr. Dreier says. Vismodegib is relatively
well tolerated but has side effects that
can negatively impact the quality of life
of patients and sometimes lead to the
discontinuation of treatment.
Careful clinical evaluation of vismodegib identified a high affinity, reversible
binding to the plasma protein alpha1-acid glycoprotein and to albumin in
addition to solubility-limited absorption and slow metabolic elimination
properties, which may explain the drugs
nonlinear pharmacokinetic profile,
according to Dr. Dreier. This in part led
to the establishment of the drug’s current
150 mg/day dosing regimen.
DOSE REGIMENS
In a phase 1 dose-escalation clinical trial
with sonidegib, the pharmacokinetic
profile of the drug was found to be doseproportional, allowing for the first time
the identification of dose-limiting toxicities of smoothened inhibitors. Based on
the results of the study, a randomized,
double-blind phase 2 clinical trial was
launched comparing 200 mg/day versus
800 mg/day dose regimens, the interim
results of which will be announced at the
upcoming 2014 ASCO meeting.
The number of lasting complete
remissions achieved in the two study
arms might reflect the cure rate, Dr.
Dreier says, and may provide information whether a high-dose therapy
is more efficient than a low-therapy
dose. Because of the pharmacokinetic
profile of sonidegib, further information from the phase 2 trial may soon
become available regarding the dose
correlation to adverse events such as
muscle toxicity.
“Sonidegib shows a clear dose-toxicity
relationship, which allows us to address
the question whether there is a dosedependency of regression rate, cure
rate and progression-free survival,” Dr.
Dreier says. “In addition, if treatment
with sonidegib is found to be effective
at a lower dose and with less AEs, this
would of course be of significant benefit
to the patient and might also lead to a
higher compliance, as many patients
stop treatment due to the adverse events
of the drug.” DT
Disclosures: Dr. Dreier reports no relevant financial
interests.
ES457539_DT0714_045.pgs 06.24.2014 02:29
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46
CUTANEOUS
ONCOLOGY
®
Molecular techniques explain
potential nevoid pathways to melanoma
QUICK READ
Panama City, Panama — Many
Numerous advances in
diagnostic technologies have
helped clinicians to better
discern various skin diseases,
leading to more accurate
defnitions of diseases as
they are known today.
of t he current def init ions of sk in
diseases used in dermatology have
c h a n ge d a nd mor phe d ov er t he
years, as clinicians learn more and
amass volumes of new information
regarding many different features,
characteristics and associations of
dermatologic diseases.
The establishment of current ly
accepted def i n it ions of d i f ferent
dermatologic diseases was — and
in some cases still is — a work in
prog ress. In ma ny a reas t h is has
been refined by the current studies
in molecular pathology, according to
Steven Kossard, M.D., who spoke at
the North American Dermatological
Society meeting recently.
“I do think that there
are dysplastic nevi
in the elderly that
have not evolved
into melanoma
but still represent
a precursor rather
than a marker
for melanoma.”
Steven Kossard, M.D.
Darlinghurst, Australia
Dr. Kossard presented a 30-year
ret rospect ive of his obser vat ions
and publications. Under the theme
“Defining Dermatological Diseases,”
one of the topics was atypical lentiginous nevi of the elderly as a precursor
to lentigo maligna, originally defined
by his group in 1991.
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clinically as atypical by dermatologists. Significantly, these nevi shared
features with melanoma particularly
when examined by dermoscopy, a
tool that was introduced into clinical
practice at that time.
“Ultimately, the most significant
definitions combine distinct clinical
features with distinct histopathology
t hat per m it bot h c l i n ic ia n s a nd
pat holog ists to reach t he cor rect
diagnosis,” he says. “Others may have
either distinct clinical or distinct
histopathology features that can be
recognized and finally, both aspects
may be indistinct but in combination represent an important tissue
reaction such as urticarial dermatitis
defined by our group.”
Dr. Kossard is associate professor
of dermatology, Skin & Cancer Foundation Australia, Darlinghurst.
MELANOMA PRECURSORS
Follow ing his return to Aust ralia
in 1980 after training at the Mayo
Cl i n ic, Dr. Kossa rd says some of
t he big ge st c h a l lenge s were t he
boundaries in defining malignant
mela noma si mu lat i ng ne v i. T he
most common melanoma in elderly
patients with chronic sun exposure is
lentigo maligna, which traditionally
is mainly localized to the facial skin.
Dysplastic nevi had been defined at
the time by Wallace Clark, M.D., with
onset in young individuals and were
often multiple. These dysplastic nevi
were not usually a direct precursor
to melanoma except in the familial
cases but were a risk factor.
Dr. Kossard’s group recognized a
distinct subset of dysplastic (atypical) nevi occurring in elderly sundamaged patients that were usually
loc ated on t he t r u n k a nd l i mbs.
These nevi were usually recognized
Some of the biggest
challenges were
the boundaries in
defining malignant
melanoma
simulating nevi.
Lentiginous dysplastic nevus of
t he elderly is of ten a large lesion
greater than 1 cm in diameter and
typically solitary. According to Dr.
Kossard, t he main challenge and
controversy was the histopathology,
wh ich had a nevoid pat ter n w it h
nests of often-bland melanocy tes
lo c a l i z e d to t he t ip s of t he r e t e
ridges. Understandably, these nevi
were equated to the dysplastic nevi
described by Clark.
At least 60 percent of the nevi in
the original study by Dr. Kossard’s
g roup, however, showed a reas of
epidermal atrophy and conf luence
of sma l l hy perch romat ic nevoid
melanocytes as well as superficial
dermal fibrosis representing regression. These features closely matched
the histopathology seen with lentigo
maligna of t he face. At t hat time,
these lesions were not recognized as
a variant of lentigo maligna because
of the nevoid precursor. On the face,
lent igo malig na of ten star ts w it h
increased atypical melanocytes at
the junction, Dr. Kossard says, which
in time become confluent and extend
DEFINING DISEASE see page 48
ES459995_DT0714_046.pgs 06.26.2014 01:08
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ES454817_DT0714_047_FP.pgs 06.18.2014 19:47
ADV
48
CUTANEOUS
ONCOLOGY
DERMATOLOGY
®
JULY 2014
2013 ∕ DERMATOLOGYTIMES.COM
SCALP CONDITION:
Erosive pustular dermatosis of the scalp can be mistaken for skin cancer from page 42
few patients need systemic treatment, but
in most cases topical steroids will work.
In this case, they worked. Furthermore,
a malignancy or fungal infection would
not have responded to topical steroids the
way that the lesion did. Those two entities
would either not respond or get worse
with topical steroid treatment.”
Photodynamic therapy is also a treatment option for patients with EPDS.
ADEQUATE SAMPLES
One of the lessons from such a case
is that it is a challenge to obtain an
adequate sample for the purposes of
a pathology diagnosis when there is
scarring and erosion present. An insufficient sample will not provide sufficient
information for a pathologist to offer a
diagnosis, Dr. Burns says.
“The biopsy of an ulcer is very nonspecific,” she says. “An ulcer from any
cause looks very similar under a micro-
scope. The major issue is that we are not
really providing them with a good thing
to take a look at.”
“Thinning of the
skin increases
the likelihood of
a condition like
EPDS.”
Ariel Burns, M.D.
Halifax, Nova Scotia
An incorrect diagnosis would have
meant more invasive treatment, Dr.
Burns notes.
“It was a size of about 8 cm, so it would
have required a skin graft if surgery was
performed,” she says.
The incidence of EPDS is unknown
as is the pathogenesis of the condition. It is not uncommon for patients
to remain undiagnosed for years,
according to Dr. Burns.
“More and more case reports are
coming out,” she says. “It is probably
more common than we think. It is likely
under-recognized and under-treated
because it tends to present in older
patients. It may not be at the forefront
of their medical issues, and that may be
why it doesn’t get diagnosed.”
There can be triggers for EPDS,
such as local trauma or radiation
t reat ment. “Thinning of t he sk in
increases the likelihood of a condit ion l i ke E PDS,” Dr. Bu r n s say s.
“Various traumas can precipitate it
or make it worse.” DT
Disclosures: Dr. Burns reports no relevant financial
interests.
DEFINING DISEASE:
Advances help physicians hone defnitions, diagnoses from page 46
down the appendages but are usually
not nested or nevoid.
“At the time, it seemed that with
chronic sun-damaged skin, a pathway
to developing nevi existed but in this
setting, the nevi were atypical and were
unstable in contrast to the majority
of Clark’s nevi,” he says. “Our group
subsequently described more advanced
melanomas t hat were nevoid and
nested that evolved from the dysplastic
nevi of the elderly. These concepts were
very controversial at the time.”
NEVOID PROGRESSION
According to Dr. Kossard, it is only
recently that there has been molecular
work utilizing in situ hybridization and
comparative genomic analysis techniques that these variants have gained
more general recognition. The lentiginous dysplastic nevi of the elderly and
nevoid nested forms of melanoma and
the wider spectrum of lentigo maligna
has been recognized due to mutational
features detected by these techniques
that have been demonstrated in other
melanoma variants.
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“Our group
subsequently
described more
advanced
melanomas that
were nevoid and
nested that evolved
from the dysplastic
nevi of the elderly.”
Steven Kossard, M.D.
Darlinghurst, Australia
“I do think that there are dysplastic
nev i i n t he elderly t hat have not
evolved into melanoma but still represent a precursor rather than a marker
for melanoma. There are usually few
such nevi at any time and conservative removal is recommended,” Dr.
Kossard says. “Larger lesions with
transition to melanoma should be
treated as such. There are rare elderly
individuals who have multiple atypical nevi and melanomas and need
to be monitored and managed on a
regular basis.”
The controversy regarding t his
nevoid pathway to melanoma has
decreased as a result of the recent
findings provided by these molecular
techniques. However, the significance
and the ultimate prognosis of these
nevoid melanoma variants still need
to be established. According to Dr.
Kossard, lentigo maligna evolving from
dysplastic nevi of the elderly has the
same indolent in situ phase as those
observed on the face.
“The challenge of defining this
variant of melanoma was signif ica nt ly helped by cor relat i ng t he
clinical and dermoscopy features
with the histopatholog y and was a
lesson,” he says. DT
Disclosures: Dr. Kossard reports no relevant financial
interests.
ES459996_DT0714_048.pgs 06.26.2014 01:08
ADV
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ES454800_DT0714_049_FP.pgs 06.18.2014 19:46
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50
BUSINESS OF DERMATOLOGY
®
TAX STRATEGIES
52 Many
financial services are
not suitable for high-income,
high-liability specialists
Melanie D. Palm, M.D.,
is director of Art of
Skin MD in Solana
Beach, Calif.
Expert insight on brand defnition
The brand identity of dermatology
practices encompasses the culture of the
office as well as the vision of the organization. It is a communication to the world
at large of who you are — as a physician,
practice, product and business.
It is likely that few offices take the time
to really negotiate through the process
of developing a solid brand identity. If
done successfully, the creation of a strong
brand identity resonates through all
aspects of the practice – the website, logo,
clinic space, staff, physician, and any of
the associated ventures.
When is the best time for a dermatology practice to think about brand
identity? The ideal way is at the onset
of the practice’s creation. I had the rare
opportunity to think of brand identity
when I started my solo practice two years
ago. In the process of loan applications, I
had to develop a comprehensive business
plan including strategies for financial
success.
I was forced to perform a SWOT
analysis (Strengths, Weaknesses, Oppor-
Quotable
“Financial and legal
advice you get from
print and online
media and from large
national firms is
generally not appropriate for physicians.”
David B. Mandell, J.D., M.B.A.
H. Michael Lewellen, C.F.P.
On finding good
financial advice
See story, page 52
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tunities and Threats) which provided my
strategic approach to the local practice. It
also allowed me to think of who I was as
a physician and what image I wanted to
portray to the community.
From this, I constructed my website,
my clinic space, and all of the supplementary internal and external marketing
materials. One space, whether virtual or
real, feels like the other.
In reality, most practices are already
established. In this instance, a checklist
is completed in relation to items that
should encompass the practice brand.
Marketing needs are considered in order
to focus on what the physician wants.
In this case, you are building a brand
to hopefully appeal to a target group of
people and therefore they need to be
considered during the branding process.
Here, I elicited the insight of colleagues
who have been tremendously successful
in developing their own practice brand
identities:
Tina Alster, M.D. — founding director,
Washington Institute of Dermatologic
Laser Surgery, Washington, D.C.
Fredric Brandt, M.D. — founding
director, Dr. Brandt Dermatology Associates, Manhattan, N.Y., and Coral Cables,
Fla., creator of eponymous skincare line.
Melanie Palm, M.D., M.B.A. —
founding director, Art of Skin MD, Solana
Beach, Calif.
Tom Rohrer, M.D. — partner at SkinCare Physicians of Chestnut Hill, Mass.
How has your brand identity
➊
changed over time?
Dr. Alster: The brand identity for the
Washington Institute of Dermatologic
Laser Surgery has evolved since its inception in 1990 to incorporate changes in
the growing field of laser surgery. From
the beginning, it drew upon the most
advanced laser technology and medical
expertise for delivery of care for patients
with birthmarks and scars.
Over the years, the Institute has
grown in size and scope to include not
only additional laser technologies for a
wide range of conditions, but also other
DTExtra
Though doctors are still having productivity
complications with their electronic health
record (EHR) systems, they continue to invest in
them. Thirty-five percent of EHR users say they
are investing more money in patient portals
in 2014, according to findings of an ongoing
survey by consulting firm Software Advice.
More than half of EHR users surveyed said that
reduced productivity was a major or moderate
challenge. Integrating their EHR systems with
other systems was reported as a major or
moderate challenge by 55 percent of users.
READ MORE: DERMATOLOGYTIMES.COM/EHRPRODUCTIVITY
ES458204_DT0714_050.pgs 06.25.2014 00:21
ADV
medical techniques which are taught to
other physicians around the globe.
Dr. Brandt: We’ve tried to stay true
to our mission of providing the highest
grade products with in office benefits for
home use.
Dr. Palm: The brand identity of Art of
Skin MD has remained the same since
its inception in 2012. The creation of my
mission and vision of the practice were
crucial in developing a detailed but clear
brand identity.
Dr. Rohrer: SkinCare Physicians
was founded 14 years ago with a goal
to create a state of the art dermatology
practice that provided the highest
quality dermatologic care possible. The
original mission statement of SkinCare
Physicians of Chestnut Hill is “to deliver
unparalleled personalized service along
with ethical, skilled, and comprehensive
dermatologic care.” While this vision and
mission have not changed over the years,
we have found shorter mantras that are
easier for all of us to remember and to act
on a daily basis. These are:
➧ Put the patient first;
➧ Figure out a way to say yes to patient
requests;
➧ Don’t just meet expectations, exceed
them;
➧ Do ordinary things extraordinarily
well;
➧ A commitment to excellence.
How have your logo and practice
➋
branding developed and evolved?
Dr. Alster: The practice name was
established at the outset (1990) and the
corresponding logo was designed in
1994. The logo has subsequently been
incorporated in all written and electronic materials, including website and
Facebook pages.
Dr. Brandt: Our brand identit y
remains true to our core philosophy with
is universal.
Dr. Palm: The practice logo was developed in conjunction with an illustrator,
but all other marketing and branding
materials were created inhouse by myself,
my director of business development,
and our creative marketing independent
contractor — who made our vision of
brand identity concrete with consistent
design elements and messaging.
Dr. Rohrer: The practice logo has
remained the same since the start of
the practice.
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How do you ma ke decisions
➌
about brand identity given you
are a multi-physician and multiplelocation practice?
Dr. Alster: Although the Institute
was established by me, emphasis has
always been placed on the Institute
itself, rather than on any one individual. Consultation among the physicians is typical, however, at the end of
the day, I accept responsibility for the
decisions made.
Dr. Brandt: Our logo has changed
slightly over time and the practice
branding has revolved to encompass
our new associates.
Dr. Palm: I am currently in solo practice, but I purposefully created a logo
and brand image that is expandable
with the addition of other providers. It
will be important that future providers
“fit” the culture that has been carefully
groomed at Art of Skin MD in order to
thrive and be their most successful.
Dr. Rohrer: One of the driving principles that have helped us succeed as a
large group is that we build consensus
and make decisions that are unanimous
and good for all those in the practice.
Our brand identity is that we deliver
outstanding care in all aspects of dermatology, not just aesthetic or surgical
dermatology. We pride ourselves on being
able to offer state of the art care in medical
— pediatric, adult, geriatric, procedural,
aesthetic, and as well teach fellows and
students, and carry out clinical research.
How often do you re-evaluate
➍
your brand/mission/values?
Dr. Alster: Re-evaluation of brand
mission is made on the occasion of each
new physician hired in order to keep
things contemporary.
Dr. Brandt: We a re consta nt ly
reviewing and evolving our brand
mission on a monthly basis.
Dr. Palm: Our brand identity is echoed
through the Guiding Principles that were
developed by myself. These guiding principles are read aloud monthly at a staff
meeting. The brand/mission/and values
are being re-evaluated on a continual
basis although the core of this practice is
unlikely to change markedly.
Dr. Rohrer: We have monthly board
meetings for all eight of our partners
where we discuss all matters of the practice, including our mission. We make
51
sure all of our decisions fit into our practice mission and culture.
Do you think brand identity is
➎
something that the average physician/dermatology practice pays much
attention to?
Dr. Alster: Because marketing and
brand identity are not subjects taught in
medical school or during post-graduate
training, it is regrettable that most
physicians do not allocate more time
and resources to this important element
in practice management.
Dr. Palm: I think the importance
of brand identity is under-valued in
many practices. Unfortunately, this
aspect of business analysis is not
something taught during medical
courses. I do believe, however, that
most marketing-savvy practices have
considered the idea of brand identity
wholeheartedly.
How do you transmit the values
➏
of your brand identity to patients
and the community?
Dr. Alster: The practice’s values are
transmitted to patients through the
exceptional delivery of care provided
as well as by the educational resources
available to patients and colleagues
alike.
Dr. Brandt: We use a combination
of newsletters, social media and PR in
magazines and newspapers and television S well as my radio show.
Dr. Palm: Every morsel of marketing
material, guiding principles, employee
handbook, and website echoes my
belief in brand identity. This gives a
very clear picture of our brand to those
interacting with us in person or virtually. Our guiding principles, mission,
and vision guide the work culture that
predicts how we respond to the community at large.
Dr. Rohrer: We communicate and in
effect market our brand identity to every
patient that comes through our doors
by offering them the highest quality
service possible. By putting the needs
of the patient first and making their
experience with our practice the best it
can be, we create our own marketing.
We do not advertise in any of our local
publications or media outlets. Most of
our new patients are referred from our
existing patients. DT
ES458203_DT0714_051.pgs 06.25.2014 00:21
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52
BUSINESS
OF DERMATOLOGY
®
David B. Mandell, J.D., M.B.A., is an attorney,
author of five books for doctors, including “FOR
DOCTORS ONLY: A Guide to Working Less &
Building More,” and principal of the financial
planning firm OJM Group (www.ojmgroup.com),
where H. Michael Lewellen, C.F.P., serves as
director of Financial Planning. They can be reached
at 877-656-4362 or [email protected].
Doctors betrayed by
traditional fnancial strategies
Before you can understand why
many strategies and services are not
appropriate for doctors, you must
understand the dynamic of the “average
American,” for whom these products
and services are designed.
Most legal, accounting, insurance
and investment strategies have been
created for:
➧ The average American family whose
annual income tax liability is less
than 12 percent.
➧ The 98 percent of American families
who will never owe any estate taxes.
➧ An employee, not an employer, who
will likely never be sued and who has
no control over the choice of legal
entity or type of retirement vehicles
the employer will utilize.
➧ Someone whose income is based
on productivity, not government
regulation.
If the four statements above sound
like your life, then “off the rack” planning at most firms is likely sufficient
for your needs. For many doctors,
most if not all of these characteristics
are not true.
As authors of books and articles,
we regularly interact with publishers,
editors and talk show hosts. Radio
and telev ision stations, book and
magazine publishers, and Internet
c on t e n t e d i t or s a r e lo ok i n g f or
content for their “average” reader.
In general, they fear that providing
c ontent gener ated for fe w h ig hincome readers will alienate their
average readers and the advertisers
w ho pay good mone y to reac h a
specific audience. Practically, what
t his mea ns for physicia ns is t hat
many financial and legal advice you
get from print and online media and
from large national firms is generally
not appropriate for physicians.
Doctors who follow advice that is
generated for the masses and doesn’t
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take into consideration their unique
challenges should see themselves as
the patient who focuses on the results
of his own 10-minute Internet search
over the specialist’s educated diagnosis based on decades of experience
and the results of a personal exam and
test results.
There is no profession with as large
a set of unique challenges as physicians face. For this reason, it is imperative that doctors look for advisers
who spend the majority of their time
working with physicians. To take it a
step further, if you are a high-liability
or high-income specialist, you will
want to work with a team of advisers
who are acutely aware of these additional challenges. For example, an
obstetrician has a much greater need
for asset protection than a pediatrician, and a surgery center owner has
much greater tax challenges than a
primary care doctor. Nontraditional
planning can
offer higherincome physicians
opportunities
to contribute
larger annual
contributions.
CONVENTIONAL WISDOM
IS NOT YOUR FRIEND
In the beginning of the article, we
pointed out what characteristics are
common for U.S. ta xpayers. Solutions that are widely-accepted in the
media and by advisers are generally
tools that work for these people. One
hurdle that advisers who specialize
in helping high-income doctors face
is the fact that the solutions we (as a
group) espouse are appropriate for
less than 1 percent of the families in
the country.
For that reason, doctors who insist
on only implementing strategies they
have heard over and over again in the
media and from their colleagues will
miss out on valuable opportunities.
Once you embrace the fact that you
are different and require “different”
planning than your neighbors, you
will have taken one very significant
step to significantly improving your
financial situation. In the rest of this article, and in part
two of this article, we will share a few
examples of common mistakes physicians make when listening to bad, but
common, advice. These include:
Mistake 1 — “You don’t need a
corporation for your medical practice.” Despite what some CPAs may
say, in most cases the cost and aggravation of creating and maintaining
a corporation (or in many cases, two
corporations for most medical practices) are insignificant relative to
the asset protection and tax benefits
corporations offers physicians. With
recent tax law changes and with many
new proposals we will see over the next
year, the benefits will be compounded.
Though these corporate solutions can
reduce taxes by $5,000 to $50,000 per
year for the doctor, these particular
strategies are outside the scope of this
two-part article.
Mistake 2 — Ow ning assets in
your name, spouse’s name of jointly
with your spouse. We acknowledge
that owning assets in your own name
or jointly with a spouse are the most
FINANCE see page 55
ES460350_DT0714_052.pgs 06.26.2014 03:49
ADV
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Most cases reported product application with use under
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surface area which may increase the systemic absorption of
econazole nitrate. Monitoring of International Normalized Ratio
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patients who apply econazole to large body surface areas, in
the genital area, or under occlusion.
Please see Brief Summary of full Prescribing
Information on adjacent page.
References: 1. Ecoza [prescribing information]. Jamison, PA: Quinnova
Pharmaceuticals, LLC; 2013. 2. Ghadially R, Silvander M. Penetration study
results using proderm technology foam. Poster presented at: 7th Annual
Caribbean Dermatology Symposium; January 15-19, 2008;
St. Thomas, US Virgin Islands. 3. Fowler JF Jr. Efficacy of a skin-protective
foam in the treatment of chronic hand dermatitis. Am J Contact Dermat.
2000;11(3):165-169. 4. Man M-Q, Feingold KR, Thornfeldt CR, Elias PM.
Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol.
1996;106(5):1096-1101. 5. Kircik LH, Bikowski JB. The science of topical foam
formulations. Pract Dermatol. 2012;9(1):S1-S16.
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55
FINANCE:
Doctors make strategic mistakes when taking advice that targets general public from page 52
common ownership structures for
real estate and bank accounts. This is
OK for 95 percent of Americans. Hopefully, by now, you realize that you are
not in that common group. You have
potential lawsuit risk, probate fee
liability, and estate tax risks that more
than 95 percent of the population do
not have. That’s why, in most states,
owning assets jointly can be a mistake.
Something as simple as a living trust or
a limited liability company can often
solve these problems.
Mistake 3 — Making a questionable bet on qualified retirement
plans. This is perhaps t he sing le
most impor ta nt area of pla nning
for doc tors to add ress once t hey
understand that they are different.
Typical retirement plans are great
for rank-and-file employees because
t hey force employees to put away
funds for retirement. Employers may
match some percentage of employee
contributions (which is free money for
the employee). The investment grows
tax-free until funds are accessed in
retirement (when the employee is
living on modest Social Security and
these retirement plan funds.
As “the employer,” there is no “free
money ” for you as a l l t he money
that ends up in your plan account
was yours to begin with. In fact, you
are responsible for those matching
contributions so the retirement plan
does have some “friction” for you if
you want to make any reasonable
contribution on your ow n behalf.
On top of that, you will not be living
on $25,000 to $50,000 in retirement
like your employees will. You will
have ta x able i nvest ment s, much
larger retirement plan contributions
and greater Social Security income
(maybe). In any case, you w ill be
paying very significant tax on your
retirement plan withdrawals. Do you
think that tax rates will be lower than
they are now when you retire?
With rising costs for employees and
a possibility that you may actually
w ithdraw funds from your retirement plans at a higher tax rate than
the one you received for the original
deduction, the real benefit of retire-
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ment pla ns comes into quest ion.
When you add the potential costs and
aggravation of complying with ERISA,
Department of Labor and tax laws
surrounding retirement plans, and
the fact that any unused retirement
plan balances will be taxed at rates up
to 80 percent (see chapter on IRD in
the “For Doctors Only” book), you may
find that retirement plans are not all
they are cracked up to be. A growing
trend among successful doctors is to
implement nonqualified planning
alternatives instead of traditional
retirement plans.
You have
potential lawsuit
risk, probate fee
liability, and estate
tax risks that more
than 95 percent of
the population do
not have.
Suggestion: Use a better retirement plan to support your retirem e nt . Nont r ad it ion a l pl a n n i n g
can offer higher income physicians
opportunities to contribute significantly larger annual contributions.
W het her you are using nonqualif ied plans, “hybrid” plans, fringe
benefit plans or even a tool primarily designed for risk management
benefits — such a captive insurance
company — you could potentially
enjoy tax benefits up to $100,000 to
$1,000,000 or more annually. Most
of t hese tools allow you access to
the funds before age 59 1/2, will not
force you to take withdrawals at age
70 1/2 if you don’t need the money,
and will not be taxed at rates up to 70
or 80 percent when you pass away. For
these reasons, savvy doctors utilize
nont rad it iona l pla n s more t ha n
traditional retirement plans.
Note: Nonqualified or “hybrid” plans
vary significantly in their design, their
scope, and their applicability. Some
plans work great for smaller practices
with one or two partners. Others work
best in practices with three to 20 partners. Still others may work best for the
larger practices. To determine which
one is right for you, contact the authors
for a free no-cost consultation offered
to readers. UP NEXT
This is the first of a two-part article.
More tips on tax reduction and other
e le me nt s of f i n a nc i a l pl a n n i n g
that are specific to physicians and
u n necessa r y for average A mer icans w ill come in the subsequent
part of this continuing article. The
aut hors welcome your quest ions.
You can contact them at 877-6564362 or through their website, www.
ojmgroup.com. DT
Disclosures: OJM Group, LLC. (“OJM”) is an SEC
registered investment adviser with its principal
place of business in the State of Ohio. OJM and
its representatives are in compliance with the
current notice filing and registration requirements imposed upon registered investment
advisers by those states in which OJM maintains
clients. OJM may only transact business in those
states in which it is registered, or qualifies for
an exemption or exclusion from registration
requirements. For information pertaining to
the registration status of OJM, please contact
OJM or refer to the Investment Adviser Public
Disclosure web site (www.adviserinfo.sec.gov).
For additional information about OJM,
including fees and services, send for our
disclosure brochure as set forth on Form
ADV using the contact information herein.
Please read the disclosure statement carefully before you invest or send money.
This article contains general information
that is not suitable for everyone. The information contained herein should not be construed as
personalized legal or tax advice. There is no guarantee that the views and opinions expressed in
this article will be appropriate for your particular
circumstances. Tax law changes frequently,
accordingly information presented herein is
subject to change without notice. You should
seek professional tax and legal advice before
implementing any strategy discussed herein.
ES460349_DT0714_055.pgs 06.26.2014 03:49
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56
BUSINESS
OF DERMATOLOGY
®
PAYMENT DATA:
Release of payments made to doctors could be misinterpreted by public from page 1
federal program, received much attention in the lay media including in highprofile newspapers such as “The New
York Times.”
The data suggested that some specialists, such as ophthalmologists and
oncologists, were billing much more
than their confreres in dermatology.
The data also revealed that a small
minority of physicians — about 100 out
of a possible 880,000 physicians and
other healthcare providers — received
a total of $610 million that year. A small
fraction of the total was responsible for
about one-quarter of the $77 billion total
that was paid out that year.
The information has largely been
regarded as more damaging than helpful
to practicing dermatologists.
“There are efficiencies such as dermatologists managing skin cancer in their
offices, and the accompanying charges
that are submitted to
Medicare are lower
than if the patients
were treated in
hospital,” says Steven
R. Feldman, M.D., a
dermatologist and
professor of dermatology at Wake Forest
Dr. Feldman
University School of
Medicine, Winston-Salem, N.C.
LACKING INTERPRETATION
The data do not provide interpretation, such as where dermatologists
are geographically based or what their
particular area of specialization is, that
may explain some variation among
doctors, Dr. Feldman says.
“You might expect that rates of treatment for skin cancer would be higher for
dermatologists who work in Florida,” Dr.
Feldman says. “It may appear in some
cases that a dermatologist is prescribing
a ton of biologics. But that dermatologist
could be a psoriasis expert, who is being
referred the worst of the worst cases,
which is why so many biologics were
being prescribed.”
But Dr. Feldman stresses that “as
someone with libertarian tendencies I
am in favor of the public’s right to know.”
Indeed, making these data a matter of
public record provides patients with the
opportunity to look at services for which
physicians billed, he adds.
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QUICK READ
The dissemination of Medicare
payments made to healthcare
professionals in 2012 may strain
relationships between physicians
and their patients.
Moreover, bringing these data into
the public realm could shed light on
which doctors may be routinely billing
for unneeded measures, according to
Dr. Feldman.
“For example, there may be doctors
who are billing routinely for immunostaining on basal cell carcinomas which
is not necessary,” he says. “We should
all want to ferret out that kind of fraud.
Presentation of these data may make it
easier to identify problem outliers.”
CREATING DIVISIVENESS
The fallout from this CMS initiative is
that it will create divisiveness in the
physician community, contends Joel
Schlessinger, M.D., a board-certified
dermatologist in Omaha, Neb., and
chief editor, cosmetic surgery, “Practical
Dermatology” magazine.
“It i s pit t i n g s p e c i a lt y a g a i n s t
specialty,” Dr. Schlessinger says. “This
engenders greed and discord when salaries of dermatologists are published
in such a granular
fashion.”
Wit hout proper
analysis, the data
can be significantly
misunderstood, he
says.
“The information Dr. Schlessinger
is terribly open to misinterpretation,” Dr.
Schlessinger says. “There are so many
facets that the public does not understand, and none of these figures are easily
digestible to the public. The perception
is likely to be that unethical physicians
bilk the system. Some dermatologists
are in higher ranks of paid physicians
due to being in complex practices with
numerous physician extenders, tertiary
care referrals or medication costs, and
this could be misinterpreted as well.”
Still, the public circulation of these
data can perhaps serve to identify physicians who are displaying egregious
behavior by overbilling Medicare fees,
but it remains to be seen if these physi-
cians will modify their billing practices.
“The problem is that most of the
unethical physicians who are exhibiting
this sort of questionable behavior likely
already know they are out of line (with
their colleagues), and simply refuse to
understand that every Mohs surgery case
does not need to be three or four stages
and not every skin cancer requires a flap
or graft for closure,” Dr. Schlessinger says.
MORE ACCURATE BILLING
The “silver lining” to this news is that
it may produce changes in billing and
coding practices that could encourage
more proper coding/billing, he says.
Another spin-off of this news is that
it may also illuminate the fact that most
dermatologists are treating a less remunerable population that would likely go
without care were it not for Medicare.
“The majority of dermatologists who
accept Medicare patients are providing
services at a significant discount to insurance carriers and serving a population
that would otherwise go unserved,” Dr.
Schlessinger says. “If anything, dermatologists are underbilling for services.”
The dissemination has also raised the
issue of whether physicians will continue
to include Medicare patients in their
practices, he says.
“If the data start to have negative
repercussions on dermatologists and
their good standing amongst the public,
it could force some dermatologists to quit
Medicare entirely,” he says.
Terrence J. Cronin Jr., M.D., editorin-chief of “Dialogues in Dermatology,”
the monthly audio journal published by
the American Academy of Dermatology
(AAD), agrees with Dr. Schlessinger that
this diffusion of data will cause a rift in
the community of physicians.
“T h is w a s mea nt to be d iv isive
amongst physicians,” Dr. Cronin says. “I
am very disappointed that this was done.
It was a negligent and unwise measure.
“By the release of this information,
the government has made physicians
targets,” he continues. “Criminals may
victimize physicians listed in the data
dump. I also worry about the top billing
physicians being targeted by malpractice
attorneys as deep pockets. This could
have been done without identifying individuals publicly. It is really irresponsible,
and it's meant to harm all physicians.”
ES461119_DT0714_056.pgs 06.26.2014 22:23
ADV
AAD’S STANCE
For its part, the A AD has expressed
concer n about t he d issem i nat ion
of this information. While the A AD
apprec iates t he move w a s one to
increase transparency about Medicare
costs to the public at large, the absence
of perspect ive about t he mea ning
of the data could lead to inaccurate
conclusions, says AAD president Brett
Coldiron, M.D.
“T he broad release of Med ica re
phy s ic i a n pa y ment d at a w it hout
appropr iate contex t cou ld h i nder
patient understanding about the value
of appropriate, medically necessary
healthcare services as recommended
by their physician,” Dr. Coldiron stated
in an email response. “Reimbursement
data and procedure reimbursement
rates alone are not an indicator of
high-value care. These data must be
coupled with quality, outcomes, and
“We should all
want to ferret out …
fraud. Presentation
of these data may
make it easier to
identify problem
outliers.”
Steven Feldman, M.D.
Winston-Salem, N.C.
patient experience data, as well as a
specific analysis of individual physicians’ patient population and service
mix, to present a more accurate reflection of value.”
57
Dr. Coldiron went on to write: “It may
not be clear to patients, for example, that
practice expenses are included in the
CMS payments, which could account
for as much as 60 percent of payments.
Other items that were not included in
the data release include: how much of
a physician’s patient base consists of
Medicare patients; what types of cases
physicians typically treat; quality of
care; how many non-physician clinicians provider services bill under the
physician’s number. All of these factors
are important in interpreting the data
that was released by CMS.”
All physicians have “an ethical obligation to treatment,” Dr. Coldiron stated. “I
personally will continue to treat patients
according to their medical need, and not
their healthcare coverage.” DT
Disclosures: Drs. Feldman, Schlessinger and Cronin
report no relevant financial interests.
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ES461118_DT0714_057.pgs 06.26.2014 22:23
ADV
58
TRADE TOOLS
Broad-spectrum
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The actives in the cream are reinforced with Avène Thermal Spring
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The product is free of parabens,
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ES460762_DT0714_058.pgs 06.26.2014 20:30
ADV
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ES459478_DT0714_059_FP.pgs 06.25.2014 22:25
ADV
60
TRADE TOOLS
Exfoliator stimulates cell
renewal, rejuvenating skin
THE EXUVIANCE TRIPLE MICRO
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three-part approach to renewing skin
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contains a blend of physical, chemical
and enzymatic rejuvenators for immediate results, the company states.
The product contains glycolic acid
10 percent as well as papaya enzymes
to help unclog pores, remove impurities, loosen dead skin cells and resurface dull and dry patches. The exfoliator stimulates cell renewal, allowing
for clearer and more even skin tone.
The company states the product may
also boost the performance of other
skincare products a consumer uses.
The Exuviance exfoliator is expected
to be on the market in August.
THE SKIN ICE ROLLER from Icy
Roller by Benev is a virtually messfree device that helps to provide
a cooling effect for the skin after
certain skincare treatments.
The Skin Ice Roller uses no
water or solution, and is designed
in such a way to allow for quick
coverage of the entire affected
area, the company states. It can
be used after chemical peels,
microneedle treatments and other
noninvasive skincare procedures.
The product can be stored in a
freezer or refrigerator before use.
Clinicians can spray the patient's skin
with Benev Silicone Spray to lubricate
the area, and then apply the roller to
relieve discomfort and irritation.
NEOSTRATA
BENEV
www.neostrata.com
LIGHTWEIGHT SUNSCREEN FORMULA OFFERS
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CLEAR DEFENSE
SPF 45 is a lightweight sunscreen
formulated with
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to help protect the
skin from extrinsic
factors that cause
aging, such as
UVA, UVB and
infrared radiation.
The fastabsorbing
sunscreen
contains a botanically-based active
derived from
knotweed extract,
which works to
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radiation, according to
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The Clear Defense SPF
45 can improve the appearance of fine lines and wrinkles, and helps to reduce
facial redness, blotchiness
and hyperpigmentation,
the company states. It may
also provide greater skin
firmness and elasticity. The
sunscreen's active ingredients are zinc oxide 12
percent and octinoxate 7.5
percent.
BRANDMD SKIN CARE
www.brandmdskincare.com
www.benev.com
FDA APPROVES
COOLSCULPTING FOR
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COOLSCULPTING has been cleared by
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The CoolSmooth applicator uses
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treat "non-pinchable"
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to the company. The
CoolFit applicator
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A clinical study of
unilateral outer thigh
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states.
ZELTIQ
www.coolsculpting.com
ES460761_DT0714_060.pgs 06.26.2014 20:30
ADV
JULY 2014 ⁄ DERMATOLOGYTIMES.COM
upcoming
events
Dermatology Times lists meeting
announcements for the following
three months in our print issue.
2nd Workshop on Psoriasis
and Psoriatic Arthritis
Centers of North America
(CME)
http://cme.med.nyu.edu/psoriasis
July 9, 2014
New York
Society for Pediatric
Dermatology 40th Annual
Meeting
www.pedsderm.net
July 9-12, 2014
The Coeur d’Alene Resort
Coeur d’Alene, Idaho
Oregon Dermatology Society
& Washington State
Dermatology Association
Annual Summer Conference
www.oregonderm.org
July 17-20, 2014
Hyatt Seattle Downtown Hotel
Seattle
10th World Congress of the
International Academy of
Cosmetic Dermatology
www.iacdrio2014.com.br
July 18-20, 2014
Sul America Convention Center
Rio de Janeiro, Brazil
CALENDAR/ AD INDEX
Dermatology for the Dermatologist 2014 Update - Black
Sea Cruise Conference (CME)
Practical Dermatology &
Dermatopathology
Symposium
http://www.continuingeducation.net/
coursedescription.php?topic=Dermatology_
CME_Cruise_Black_Sea_Seabourn_August_2014
Aug. 2-9, 2014
Istanbul, Turkey
www.dermpath.com/vail
Aug. 14-17, 2014
Vail Mountain Resort
Vail, Colo.
Global Personal Care Market
& Regulatory Overview
www.cfpie.com
Aug. 4-6, 2014
Desmond Hotel & Conference Center
Malvern, Pa.
2014 CalDerm
Annual Meeting
www.calderm.org
Sept. 12-14, 2014
La Costa Resort & Spa
Carlsbad, Calif.
Kansas Society of
Dermatology & Dermatologic
Surgery 2014 Conference
www.kanderm.org
Aug. 23, 2014
Sheraton Hotel
Overland Park, Kan.
www.wccs2014.org
Sept. 3-6, 2014
Edinburgh International Conference Centre
Edinburgh, Scotland
www.aad.org
Aug. 6-10, 2014
Hyatt Regency Chicago
Chicago
AAD SkinCare Physicians Controversies and Conversations
in Cosmetic and Laser Surgery
www.skincarecontroversies.com
Aug. 8-10, 2014
Sun Valley Resort
Sun Valley, ID
Oral Dermatology and Oral
Pathology - Alaskan Cruise
Conference (CME)
http://www.continuingeducation.net/coursedescription.php?topic=Oral_Dermatology_CME_Alaskan_Cruise_August_2014
Aug. 8-15, 2014
Seattle, Washington
Pacific Dermatologic
Association 66th Annual
Meeting
www.pacificderm.org
Aug. 13-17, 2014
Fairmont Hotel Vancouver
Vancouver, British Columbia
www.asds.net/rejuvenation
Sept. 13-14, 2014
Renaissance Chicago Downtown Hotel
Chicago
5th World Congress
of Teledermatology
XV World Congress
on Cancers of the Skin
AAD 2014 Summer
Academy Meeting
ASDS — Total Body
Contouring and Rejuvenation
LaserInnsbruck 2014
http://www.laserinnsbruck.com/1/1/
english/1/3/index.htm
Sept. 3-6, 2014
Innsbruck, Austria
International Pigment
Cell Conference
www.teledermatology2014.com
Sept. 18-20, 2014
IDEC-Universitat Pompeu Fabra
Barcelona, Spain
33rd Annual Meeting
of the Florida Society
of Dermatologic Surgeons
www.fsds.org/event.php
Sept. 19-21, 2014
Ritz-Carlton Orlando, Grande Lakes
Orlando, Fla.
31st Annual Meeting
of the Ohio Dermatological
Association
www.ipcc2014.org
Sept. 4-7, 2014
Shangri-La Hotel
Singapore
44th Annual European
Society For Dermatological
Research (ESDR) Meeting
www.esdr2014.org
Sept. 10-13, 2014
København, Denmark
www.ohderm.org
Sept. 26-28, 2014
Hilton Columbus at Easton
Columbus, Ohio
American Society for
Dermatologic Surgery
www.asds.net/annualmeeting
Nov. 6-9, 2014
Manchester Grand Hyatt
San Diego
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41
61
62 THE
TAKEAWAY
®
STRATEGIES FOR
MANAGING LEG ULCERS
NORMAN LEVINE, M.D.
Leg ulcers are a common and
diffcult 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.
DR. LEVINE: What I’d like to talk about today is the
management of leg ulcers, which is a common
problem and one that’s often vexing for us. Could
you start by discussing the workup of a patient with
a typical leg ulcer that will come into your clinic?
A Dr. Kirsner: Ulcers of the lower
extremity are divided into foot
ulcers and leg ulcers. Foot ulcers
are most common on the bottom or
plantar aspect of the foot, and are
typically due to diabetes mellitus—
either patients with neuropathy or
near the ankle, and the vast majority
of those wounds —70 to 80 percent
— are due to venous insufficiency.
Many (probably up to 20 percent) of
those patients with venous insufficiency have concomitant arterial disease and the remainder of
leg ulcers due to atypical or less
common causes, such as vasculitis,
pyoderma gangrenosum or atypical
infections, for example.
DR. LEVINE: Should we as dermatologists
be dealing with foot ulcers? Is that in
our purview?
A Dr. Kirsner: There is
nothing magical about
treating a foot ulcer. The
standard of care is relatively simple. The first step
in assessing all lower extremity
wounds is to make sure there is good
blood flow. If there is not, then that
should be corrected because those
patients are at the highest risk of
having complications and possibly
leading to amputations. So assessing
arterial blood supply is critical.
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If you have a patient with diabetes
mellitus who has a foot ulcer and
their blood supply is good, then the
standard of care is typically getting
the person off of that wound using
some type of off-loading device: a
shoe or a boot. The real issue is not
prescribing it, but assuring that the
patient’s actually wearing it. The next
step is wound debridement. You have
to remove not only the abnormal
tissue in the wound bed, but the
abnormal calloused edge as well.
That’s a new concept. Debridement
includes not just removing necrotic
tissue but any cells in the wound bed
or edge that have been there for a
while, because cells that have been
present for a while change and are
less responsive to growth factors
and cytokines. So, in long-standing
wounds, the fibroblasts in the wound
“The first
step in
assessing
all lower
extremity
wounds is to
make sure there is
good blood flow. ”
Robert Kirsner, M.D.
Miami
bed are abnormal and the keratinocyte cells at the edges of the wound
are abnormal. So I think it is within
the purview of dermatologists, or at
least in working with other physicians, to care for foot ulcers.
Venous ulcers are common on
medial or lateral aspect of the ankle,
in the malleolus area, associated with
varicosities, surrounding hemosiderinand induration — lipodermatosclerosis. Venous ulcer location often
distinguishes it from arterial ulcers
of the lower extremity, which present
anteriorly on the leg and somewhat
more proximal, because they have
less reduplication of arterial blood
supply there. Atypical causes of
wounds often present in unusual
locations, for example, on the posterior aspect of the leg or dorsum of
the foot. However, even these ulcers
may be complicated by insufficient
arterial blood supply, so assessing
arterial supply in all lower extremity
wounds is the first step.
DR. LEVINE: How do we do that?
A Dr. Kirsner: The simplest way is to
palpate pulses and then perform
an ankle brachial index, which is the
systolic blood pressure in the ankle
over the arm. In healthy, supine
people, those measures should be
equivalent or a ratio of 1. If you have
diminished ankle brachial index
(ABI), meaning the systolic pressure
is lower, it correlates with worse arterial disease. A systolic pressure below
about 0.8 should trigger a dermatologist to do three things:
➧ A dermatologist may want to refer to
a vascular surgeon to determine if
opportunities to improve blood flow
surgically exist.
➧ A dermatologist might want to refer
to the primary care doctor or cardiologist, because vascular disease in
the legs is associated with vascular
disease in the coronary and carotid
arteries. So a low ABI in the lower
ES460357_DT0714_062.pgs 06.26.2014 03:49
ADV
®
THE
extremity may be an indicator of
cardiac or cerebral vascular disease.
➧ A dermatologist may wish to reduce
the strength of the compression
bandage prescribed, standard
care for venous ulcers, so as not to
restrict arterial blood flow.
DR. LEVINE: Could you describe exactly how one
does a blood pressure determination of the lower
extremities?
A Dr. Kirsner: Sure. It’s somewhat
similar to the upper extremities.
You place a cuff around the calf and
inflate it to about 200 mm Hg, and
then slowly release it. Then you are
looking for the first return of arterial flow or pulse. You can do this in
several ways:
➧ You can have a microphone or
Doppler that you can listen to for
the pulse;
➧ You could put your finger or hand
over the area where the pulse would
return, either the posterior malleolus or the dorsum of the foot;
➧ You could use the stethoscope.
When you first hear the blood
return, that’s the number you are
looking for, that’s the systolic blood
pressure. The ratio of that with the
blood pressure in the arm would give
you the ankle brachial index.
DR. LEVINE: If you could feel somebody’s distal
pulses, does that tell you something or is that not
good enough?
A Dr. Kirsner: It’s probably not good
enough. In situations such as a
young person who has a traumatic
wound to his leg, that is probably all
you need to do; but for other patients,
studies have shown that palpating
pulses is not reliable, due to its
subjective nature. We have all been
in the room where one person says, “I
feel the pulse;” the other person says
“I hardly feel it;” and you don’t know
where the truth lies. So obtaining
objective measures is better.
DR. LEVINE: Let’s talk about some of the agents
that you use to treat leg ulcers. I know that a lot
has changed in the last 150 years, but the Unna
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boot designed around the 1850s seems still to be
a useful tool. How do you use Unna boots and other
old-fashioned remedies for leg ulcers?
A Dr. Kirsner: There is no question that compression is the gold
standard for venous ulcers and
all lower extremity ulcers, if there
is good arterial flow. The Unna
boot, in its original form, would
harden almost like a cast and typically, provide compression when
the person was walking. When the
person’s calf muscle would activate
through walking, it would hit against
that hard material and to reinforce
the calf muscle.
For people with good arterial
supply, there may be a slight benefit
for using elastic compression as
opposed to inelastic compression to
speed healing, as it provides compression when a patient is walking and
when they are not. The Unna boot plus
an overlying elastic bandage transform the Unna boot from inelastic to
elastic compression and is likely as
good as any of the other systems that
are available that have two, three and
four layers. However, it is known that
multilayered elastic systems are better
than just a single layer and elastic
compression is better than inelastic.
However, if arterial disease is
present, then inelastic compression is preferred so that you
are not squeezing the limb,
for example, when the person
is supine in bed at night.
“The simplest
way (to assess
blood flow) is to
palpate pulses
and then perform
an ankle brachial
index, which is the
systolic blood pressure in the ankle
over the arm.”
Miami
TAKEAWAY
63
DR. LEVINE: Could you discuss the role of surgical
debridement of leg ulcers?
A Dr. Kirsner: There is fairly good
data for surgical debridement
for diabetic foot ulcers, and it’s
considered the standard of care as I
described earlier.
For venous leg ulcers, less data
exists for debridement. Some
studies have suggested it has been
beneficial, others have found no
benefit. As data is lacking, clinicians who debride do it based on
its rationale. That is they want to
remove the bacteria or biofilms that
are often in the base of a venous
leg ulcer — remove any senescent
or unresponsive cells within the
wound bed, as well as unresponsive
keratinocytes and fibrotic tissue
around the edge.
Currently debridement is
considered a two-phase approach.
Initially, when feasible, an excisional debridement is performed
initially and thereafter maintenance or selective debridement
is performed periodically.
The initial excisional debridement is performed following
anesthesia. Using a scalpel to the
wound is saucerized to remove
cells and unhealthy tissue in
the wound bed and wound
edge. The wound will get bigger
— slightly deeper and slightly
wider. This allows healthy cells
to migrate into the wound.
In subsequent visits, selective or maintenance debridement, is performed. Using a
curette selectively chosen tissue
within the wound bed that appear
unhealthy, such as necrotic
tissue or slough are removed.
DR. LEVINE: There are a number of so-called new
technologies which have come on the stage over
the last several years. It’s hard to understand
the data whether they are helpful or not. Two that
come to mind are Medihoney (Derma Sciences)
and some of these debriding enzymes. Could you
comment on those products?
A Dr. Kirsner: There are typically
five types of debridement.
TAKEAWAY see page 70
ES460356_DT0714_063.pgs 06.26.2014 03:49
ADV
64
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UPCOMING CME ACTIVITIES
Closure Course and Dermatologic Surgery:
Focus on Skin Cancer
Fundamentals of Mohs Pathology and
Fundamentals of Mohs Surgery
Hyatt Regency Tamaya Resort & Spa - Santa Ana Pueblo, New Mexico
DoubleTree Hotel San Diego, Mission Valley – San Diego, California
May 21-22, 2014 - Closure Course
This intense learning experience will provide didactic instruction and practical
demonstrations of multiple closure techniques, anatomic site-specific
discussions, and valuable pearls, designed to take dermatologists to the next
level of derm surgery practice. An elective lab session featuring realistic visco
elastic models will allow registrants to practice new and more complex closures,
proctored by highly experienced Mohs surgeons. The material presented in the
Closure Course is unique and will nicely complement the topics and activities
offered in Dermatologic Surgery: Focus on Skin Cancer (see below).
November 4-5, 2014 – Fundamentals of Mohs Pathology
This course will be a practical “pure pathology” experience for physicians who
are interested in understanding all the subtle characteristics of basal cell and
squamous cell carcinoma, the most common tumors treated with Mohs surgery.
Course will prepare attendees to accurately read and interpret BCC and SCC
in all its variations, as well differentiate these tumors from background findings
commonly encountered in practice.
May 22-25, 2014 - Dermatologic Surgery: Focus on Skin Cancer
Top experts in Cutaneous Oncology, Dermatologic Surgery and Dermatopathology
will provide updates on a wide range of surgical and Mohs topics. Interactive
forum and panel participants will discuss appropriate repair strategies for different
types of surgical wounds as well as innovative approaches to melanoma treatment
and a variety of medicolegal controversies in dermatologic surgery. Both Mohs
and non-Mohs histopathology cases provided by leading dermatopathologists
will be featured in the microscope laboratory. Mohs technicians and nursing
personnel are welcome to attend these sessions to further their understanding of
skin cancer treatment and enhance their contributions to quality patient care and
surgical efficiency.
November 6-9, 2014 – Fundamentals of Mohs Surgery
Physicians will be able to build upon and improve their skills in Mohs surgery
and related histopathologic interpretation. Experienced Mohs surgeons on faculty
will share intimate knowledge of the Mohs technique with new dermatologists
and others who wish to incorporate the procedure into their practices. Separate
instruction will be offered for Mohs technicians, emphasizing the “team approach’
so important for successful Mohs surgery.
For additional information, please contact:
Novella M. Rodgers, ASMS Executive Director
Tel. 800.616.2767 or Email [email protected]
Search for the company name you see in each of the ads in this section for FREE INFORMATION!
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Go to:
Products & Services
SHOWCASE
COSMECEUTICALS
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Dermatology Times |
Products & Services
SHOWCASE
Go to:
July 2014
SERVICES
LEAVITT
Search
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July 2014
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Marketplace
67
PRODUCTS & SERVICES
OTC PRODUCTS
PRACTICE FOR SALE
NATIONAL
KENTUCKY
PRACTICE SALES
& APPRAISAL
PRACTICE FOR SALE OR LEASE
ELIZABETHTOWN, KENTUCKY
Expert Services for:
Buying or Selling a Practice
Practice Appraisal
Practice Financing
Partner Buy-in or Buy-out
Call for a Free Consultation
PRACTICE FOR SALE
(800) 416-2055
www.TransitionConsultants.com
NATIONAL
36 YEAR ESTABLISHED FUNCTIONING
PRACTICE
Critical need for a Dermatologist in growing area
near Ft. Knox. Tremendous potential. Offce
is a 2-story converted home on 2/3 acres of
commercial land on main traffc route, across
from Hospital with a Human Resource center
located 10 miles from offce containing a large
Federally Employed population. Turn-key
operation with experienced staff. Located 40
miles south of Louisville, Kentucky on I-65. Call
or email to discuss generous terms.
Available at (877) 769-6327 [email protected]
or (423) 821-8230 jmgalex@epbfi.com
PRODUCTS
We Buy Practices
• Retiring
• Monetization of your practice
• Locking in your value now
• Succession planning
• Sell all or part of your practice
Please call Jeff Queen at
(866) 488-4100 or
email [email protected]
www.MyDermGroup.com
RECRUITMENT
MARKETPLACE
ADVERTISING
Call
Karen Gerome
to place your
Marketplace ad
at 800.225.4569
ARIZONA
COLORADO
Busy General/Surgical Dermatology
& MOHS practice in Phoenix, AZ area
looking for a 3rd dedicated, caring
and ambitious BE/BC dermatologist
for gen & surg derm w/ MOHS. Great
earning potential w/ partnership path.
Please email C-V to: [email protected]
MONTROSE, COLORADO
Partnership available. Established practice.
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com
DISTRICT OF COLUMBIA
WASHINGTON, DC
CALIFORNIA
Seeking associate. Established practice.
www.MyDermGroup.com
PORTERVILLE, CA
www.MyDermGroup.com
ext. 2670
[email protected]
AD VERT ISE T OD AY!
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Repeating an ad
ENSURES it will be seen
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68
Marketplace
Dermatology Times |
July 2014
RECRUITMENT
FLORIDA
NEW JERSEY
NEW YORK
OCALA, FLORIDA
DERMATOLOGIST
BRONX, MANHATTAN, NYC
www.MyDermGroup.com
STarT a new PracTice in MiaMi Beach!
Busy Derm offce seeking PT or FT Dermatologist
• Job available immediately
• Stable long term position
• Salary negotiable
Please email resume to [email protected]
ILLINOIS
DERMATOLOGIST BC/BE
General/Cosmetic/Surgical Dermatology
Medford, NJ (near Philadelphia, PA and
Cherry Hill, NJ). Brand new state of the art
offce, fabulous opportunity, benefts offered.
FT/PT position available.
Email inquiry or CV to:
[email protected]
BERGEN COUNTY, NJ
)stabPisLed pVactice in sUYaVe
Joot JaciPit] seeOs &'&) (eVmatoPoKist
and 4ediatVic (eVmatoPoKist to VoYnd
oYt oYV nine pL]sician KVoYp [LicL
incPYdes in LoYse 13,7 sYVKeon and
deVmatopatLoPoKist. 1i\ oJ KeneVaP
medsYVK deVm and cosmetic deVm. *8
and 48 positions aZaiPabPe. 'ompetitiZe
compensation and bene½ts.
Fax resumes to 201-391-7038
[email protected]
Please Call Lori 708-460-7890
Fax Resume 708-460-5537
Email: [email protected]
NEW YORK
PROFESSIONAL
OPPORTUNITIES
ANN ARBOR, MICHIGAN
Ann Arbor Dermatology is looking
for a Career oriented, conscientious,
well-trained dermatologist to join a busy,
growing practice. This position offers an
opportunity to build a comprehensive
practice that encompasses all aspects of
dermatology including Mohs surgery and
cosmetic work with a highly competitive
salary plus bonuses, full bene½ts and
early partnership.
For more information please contact
A. Craig Cattell, M.D by phone
(734) 996-8757, fax (734) 996-8767,
or email : [email protected]
NEVADA
RENO, NEVADA
www.MyDermGroup.com
Seeking Board Certified
Dermatologist to join 6
physician dermatology practice
General Derm, Cosmetics, Lasers, Mohs Surgery
Located 20 minutes North of NYC
in a suburban community
Fax CV to 845-359-0017 or
email:[email protected]
Flushing, Queens, NYC
Very busy 2 physician practice seeking full or
part time BC/BE Dermatologist and
Physician’s Assistant.
Mix of general medical/surgical and cosmetic
derm. Preferably bilingual Chinese or Spanish.
Highly competitive compensation and benefts.
Well established, thriving, multi-center Dermatology
practice seeking a Supervising Dermatologist
with limited patient care responsibilities.
Highly competitive compensation.
NORTH CAROLINA
HICKORY, NORTH CAROLINA
www.MyDermGroup.com
SANFORD, NORTH CAROLINA
www.MyDermGroup.com
OREGON
EUGENE, OREGON
Part Time/Full Time Position
General/Cosmetic/Surgical
Dermatology
Spectacular Scenic Beauty
Excellent Benefts
Fax CV & Cover Letter to
541-683-5206 Or Call 541-681-5090
VIRGINIA
FAIRFAX, VIRGINIA
www.MyDermGroup.com
Email CV: [email protected]
BAY SHORE, NEW YORK
Join very busy, highly regarded Bay Shore,
New York practice in newly renovated office.
General, surgical, cosmetic dermatology,
lasers, cloud EMR, Mohs in-house.
One hour to Manhattan, one hour to the
Hamptons, 5 minutes to the Fire Island Ferry.
Great patients. FT/PT: Maximum earnings
and partnership potential for BC/BE derm,
benefits included.
Email: [email protected]
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Retired?
Looking to go Part Time?
Looking to spend more time with the family?
EMAIL CV: [email protected]
CHICAGO AND ORLAND PARK
MICHIGAN
SEEKING SUPERVISING DERMATOLOGIST
RECRUITMENT
ADVERTISING
Can Work For You!
Reach highly-targeted, market-specific
business professionals,
industry experts and prospects
by placing your ad here!
ES459355_dt0714_068_CL.pgs 06.25.2014 21:03
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July 2014
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Marketplace
69
RECRUITMENT
WISCONSIN
WISCONSIN
Heal the sick, Advance the Science, Share the knowledge.
Mayo Clinic Health System – Eau Claire, WI is seeking a Board Certified/Board Eligible
Dermatologist to join an established practice of 6 clinical and surgical dermatologists.
• State of the art procedural suites and latest laser technology
• Mohs Surgeon and dermatopathologist on staff
• Dedicated nursing staff
• Competitive salary and generous signing incentive
MAYO CLINIC HEALTH SYSTEM links Mayo Clinic’s respected expertise in patient care,
research, and education with Mayo’s community-focused multi-specialty groups in
Minnesota, Wisconsin, and Iowa. Today, more than 1000 physicians practice in over
72 Mayo Clinic Health System communities. Mayo Clinic offers a highly competitive
compensation package, which includes exceptional benefits, and has been recognized
by FORTUNE magazine as one of the “100 Best Companies to Work for.”
Eau Claire is a university community located 90 minutes from Minneapolis/St. Paul.
Contact:
Cyndi Edwards, Physician Recruiter | Phone: 715-838-3156 | E-mail: [email protected]
Mayo Foundation is an affirmative action and equal opportunity employer and educator. Post-offer/pre-employment
drug screening is required.
Content Licensing for Every
Marketing Strategy
Marketing solutions fit for:
Outdoor | Direct | MailPrint Advertising
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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.
Contact: Kalah Haug, Medical Staff
Recruitment, (608) 775-1005 or email
[email protected].
Visit: gundersenhealth.org/MedCareers
Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.
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 fnd out more about
how we can customize your acknowledgements and
recognitions to enhance your marketing strategies.
For information, call
Wright’s Media at 877.652.5295
or visit our website at
www.wrightsmedia.com
EOE/AA/LEP
La Crosse, Wisconsin
Call Joanna Shippoli
to place your
Recruitment ad at
800.225.4569, ext. 2615
[email protected]
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70 THE
TAKEAWAY
®
Listen to the discussion here.
Send your comments to us: [email protected]
TAKEAWAY:
Dr. Kirsner ofers insight and best practices for managing leg ulcers
➧ Surgical debridement or sharp
debridement is most preferable if
your patients can tolerate it.
➧ Autolytic debridement uses an
occlusive dressing to keep the
patient’s own proteolytic enzymes
in the wound area help to debride.
➧ Mechanical debridement, in which
you apply and remove dry dressing,
can be painful and is not optimal.
➧ Enzymatic debridement includes
the enzymes, like collagenase
to have the ability to debride by
sloughing off dead tissue. Some
people consider Medihoney under
this category while others suggest
it works as an autolytic debriding
agent.
➧ Biological larval debridement
involves the use of a specific type
of maggot to dissolve dead tissue
and disinfect the wound.
These are different tools to get
to the same outcome. The major
obstacle with using some of the
enzymatic debriding agents is that
these topical debridement agents
were meant to be applied frequently.
Typically, when you treat a
patient with a venous leg ulcer, you
place a compression wrap on and
you leave it on for up to a week or
longer, depending on the amount of
drainage. So, the enzymatic debriding tools don’t work the way that
they should, because they are not
being applied as frequently as they
should be. I relegate those enzymatic debriding agents to patients
who aren’t getting weekly dressing
changes, but rather daily dressing
changes, such as those patients in
nursing homes.
DR. LEVINE: My old mentor Gerald Lazarus, M.D.,
used to say that the ulcers have plenty of their
own enzymes and adding them is not helpful. What
is your view of that?
A That’s exactly the concept
behind autolytic debridement:
You cover the wound and let the
patients’ own wound proteases help
debride the wound. Sometimes
proteases are excessive and they
can be destructive to the wound.
So there is really a balance. New
technologies are being developed
to detect how much proteases are in
the wound so that you can know if
there is a healthy balance.
“The major obstacle
with using some
of the enzymatic
debriding agents is
that these topical
debridement agents
were meant to be
applied frequently.”
Miami
DR. LEVINE: Could you comment on these sophisticated woundcare systems that people use with
multiple agents applied in various ways?
A Yes. There are two ways to think
of systems. The first way is that
there has been development of
many wound centers throughout
the country. There are probably
from page
63
about 1,500 wound centers often
associated with hospitals; often
with a multidisciplinary panel
of physicians. A patient visits a
setting in which they see physicians and nurses who have a
special interest and expertise in
wound healing and who follow
evidence-based algorithms in their
treatment. For many patients that’s
beneficial, because most physicians may not have much knowledge about wounds.
The second idea of a “system”
to treat wounds is based on why
these wound centers were initially
developed. They were initially
developed to deliver something
called platelet-derived wound
healing formula, or Procuren. With
this treatment, a patient has their
blood taken and then platelets
are separated and then activated.
Activated platelets contain growth
factors, which can be reapplied
onto the wound. While it appears
to be effective, other treatments
may be equally or more effective.
For example, recombinant
platelet-derived growth factors
seem to be even better than platelet
extracts. Perhaps it is because every
patient’s platelet extract is not
the same. An elderly person may
not have a good platelet extract or
wound-healing formula as a younger
person, or it even varies day to day
or week to week. There are currently
no biomarkers to know whether
this treatment has consistent
biologic activity. If that would be
developed, then you can be more
selective with this therapy. DT
Dermatology Times (Print: ISSN 0196-6197, Digital ISSN 2150-6523) is published monthly by Advanstar Communications Inc., 131 W. First St., Duluth, MN 55802-2065. Subscription rates: $95 for one year in the United States and Possessions; $140 for one year in Canada and Mexico; all other countries,
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ES460355_DT0714_070.pgs 06.26.2014 03:49
ADV
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ES454804_DT0714_CV3_FP.pgs 06.18.2014 19:47
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3. Kauvar A, Kilmer S, Ross EV, et al. A pilot study of a novel non-invasive topical under-eye contouring technology. Poster presented at: 71st Annual
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Neotensil and Living Proof are trademarks of Living Proof, Inc. used under license.
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Dr. Kirsner - Modern medicine

Transcription

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