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Archives of "What's New in...”

May 2019

What's New in Eczema (atopic dermatitis)

What's new in Eczema

The largest, to my knowledge, epidemiological survey of atopic dermatitis to examine prevalence and severity has been released. It was an Internet based survey by Dr. Silverberg of more than 273,645 infants, children, and adults in 18 countries. In it, atopic dermatitis was defined by the U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. This meant patients had "itchy skin plus three or more of the following features: (i) onset under the age of 2 y; (ii) a history of flexural involvement; (iii) a history of asthma or hay fever (or a history of atopic disease in siblings and parents if the child is under 4 y); (iv) a history of generally dry skin in the last year; and (v) visible flexural dermatitis."

The results correlated which what I've been seeing in practice. There were more adults (10% prevalence) than younger cohorts (4-9%). In addition, there were more Asians & Hispanics adults affected than other races.  The highest rate of atopic dermatitis in adults was in China at 15%. Mexico and Brazil were close at 12-14%, which correlates with the many patients I've seen from all three countries in my practice.

The highest rate in both children (2-11 years) and adolescents (12-17 years) was in South Korea at 14-16%. The highest rate in infants (<2 years) was in France & UK at 7%. In addition, the UK had the percentage of infants with severe disease at 49%.

For all age groups, the least was in Israel & Switzerland at 2-4%.

In addition, the prevalence showed it being least common in infants (but can be severe when it does occur), becomes more common in children, becomes less common in adolescence, then peaks in adulthood. This correlates with my seeing children having eczema "for the first time," it "going away" as a teenager, then "came back' as an adult.

Patients are not alone with sensitive skin. If you have eczema or another skin condition, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
-Williams HC, et al. The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 1994

-Jancin B. Worldwide atopic dermatitis survey brings big surprises. Dermatology News 2019

-Silverberg JI. EADV Congress, Abstract FC01.01


April 2019

What's New in Psoriasis

What's new in Psoriasis

Even having completed a fellowship in psoriasis, there are some psoriasis patients for whom treatment is not simple or easy. This month, I'll discuss recent updates on special populations of patients with moderate to severe psoriasis and their treatment with biologic TNF inhibitor therapies (stronger than topical therapy, but risks including infection and cancer given suppression of the immune system, also difficult to obtain insurance authorization given retail costs of about $30-$40,000 a year).

Pregnancy: While the most common management is limited usage of topical steroids along with potential phototherapy (the patient stands in a special booth that emits light called nbUVB which decreases skin inflammation), certolizumab pegol (Cimzia) seems to be the preferred biologic agent if one is to be used. in 2018 the FDA updated the label of a TNF inhibitor biologic medication called certolizumab pegol (Cimzia) to state "two studies...demonstrated that placental transfer of certolizumab pegol was negligible in most infants at birth, and low in other infants at birth." Certolizumab is also the medication recommended by Drs. Kaushik and Lebwohl as "the most preferred agent because of its minimal transplacental transfer" due to its pegylated structure. However, the FDA label still states "Limited data from the ongoing pregnancy registry on use of CIMZIA in pregnant women are not sufficient to inform a risk of major birth defects or other adverse pregnancy outcome." There is also the caveat that "all pregnancies have a background risk," estimated as 2-4% risk of major birth defects and 15-20% of miscarriage that patients may attribute to the medication even if it were not medication induced.

Pediatric population: Etanercept (Enbrel) is the only biologic approved in 2016 by the FDA for use in children > 4 years of age with psoriasis. That being said, I would prefer to avoid it if possible. A combination of topical steroids and/or phototherapy would be safer as "malignancies, some fatal, have been reported among children, adolescents, and young adults who received treatment with TNF-blocking agents (initiation of therapy at ≤ 18 years of age), including Enbrel. Approximately half the cases were lymphomas, including Hodgkin's and non-Hodgkin's lymphoma. The other cases represented a variety of different malignancies and included rare malignancies usually associated with immunosuppression and malignancies that are not usually observed in children and adolescents. The malignancies occurred after a median of 30 months of therapy (range 1 to 84 months). Most of the patients were receiving concomitant immunosuppressants."

Chronic infections:

Hepatitis B: When being screened for therapy with TNF inhibitor biologics, they should have Hepatitis testing including HbsAg (indicates patient is infectious) & anti-HbcAg (present for life once a patient is infected). If HbsAg is positive, there seems to be a 39% risk of Hepatitis B reactivation vs. 5% risk if only anti-HbcAg positive. Antiviral prophylaxis (patients will have to see their Hepatologist / Gastroenterologist for this, dermatology does not prescribe it) reduced the overall risk of Hepatitis B reactivation from 62% to 23%. Overall, biologics should likely be avoided in HbsAg positive patients but can be considered otherwise.

Hepatitis C: Screening for therapy with TNF inhibitors should include HCV RNA levels & "prior to treatment with TNF-α inhibitors, patients with HCV should be referred to a hepatologist." In a study, 3 of 97 patients had viral reactivation with a conclusion of "minimal risk." If therapy is begun, liver function should be tested every 3 months with controversy for whether to also test for HCV viral load at the same time. Unfortunately, the summary is "a definitive statement regarding the safety of anti-TNF-α therapies in the setting of chronic HCV infection cannot be made" but "appears to be safe in the short term, but there are insufficient data to assess their long-term safety." Etanercept (Enbrel) has been the most frequently used agent for patients with chronic Hepatitis C.

Tuberculosis: About 4.2% of the US population has latent tuberculosis. This is screened by performing a TB skin test or interferon gamma release assay blood test. If positive, a chest radiograph is usually performed. If that is positive, that is worrisome for active tuberculosis and is an absolute contraindication to biologic therapy. If the chest radiograph is negative, it still suggests latent TB and patients "should receive isoniazid prophylaxis for 1 to 2 months before biologic initiation can also be considered acceptable."

If you have psoriasis or another skin condition, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
-Kaushik SB, et al. Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections. J Am Acad Dermatol 2019

-Lesney MS. Chronic infections cause unique problems in psoriasis. Dermatology News 2019

-Cimzia Product Label https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/125160s283lbl.pdf Last accessed 4/7/19

-Enbrel (etanercept) Product Label https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/103795s5552lbl.pdf Last accessed 4/7/19

-Pompili, et al. Tumor necrosis factor-α inhibitors and chronic hepatitis C: A comprehensive literature review. World J Gasteroenterol 2013


March 2019

What's New in Seborrheic dermatitis & Psoriasis

What's new in Dandruff

Having completed a fellowship in hair, I see more patients with hair issues than most dermatologists. Dermatologists like myself are best at treating hair diseases involving inflammation, especially alopecia areata along with other non-scarring and scarring conditiPatients understandably do not like having dandruff on their own scalp or that of their children. The two most common conditions causing this are seborrheic dermatitis and psoriasis. While steroid medication is usually considered first line, some patients prefer to avoid steorids, esp parents coming in with affected infants and children.

A prescription nonsteroidal spray (Loyon™) has been receiving increasing attention for helping both conditions by containing moisturizing dicaprylyl carbonate & dimethicones. These are gentle keratolytics (remove scale). It does not contain steroids or salicylic acid. The first published study in 2017 enrolled 20 infants & children (aged 3 to 36 months) with seborrheic dermatitis and 80% improved to very mild or mild scaling intensity after 8 days. The prescription was applied to the affected scalp and washed away with baby shampoo after at least 3 hours. This was repeated daily as necessary, up to 3 applications. "It does not achieve its effect by pharmacological or immunological means, but by a physical mode of action with the absence of systemic effects." Three side effects related to the prescription were noted, two of itching and one of sweat accumulation, with all resolving within 5 days of stopping treatment. There were no safety concerns. It was "well tolerated, safe and effective in facilitating the removal of scaling in infants and children with cradle cap."

The second published study was of 40 adult patients with psoriasis treated daily for 7 days with Loyon™. These patients also applied the spray for at least 3 hours but, likely due to the fact psoriasis is usually thicker than seborrheic dermatitis, were encouraged to leave it on overnight before shampooing. There was improvement in at least one severity grade in 73.1% of patients, with an average improvement of 37% in their scaling after 7 days of treatment. This was a decent (but not great) result given that psoriasis typically has much thicker scaling than seborrheic dermatitis and the medication has no known systemic side effects. The results do indicate that patients would usually need steroid medication as well if they wish more improvement. Loyon™ was summarized as a "safe, well-tolerated, practicable, and efficient keratolytic."

Drawbacks are that it is only FDA approved as a "device", not a "medication." Device approval is far less rigorous than medication approval. The manufacturer obtained FDA 510(k) clearance March 2017 as their study showed "comparable safety and efficacy to a similar device that is already on the market." In addition, insurance coverage is always a concern for newer branded prescriptions. There is no generic currently.

If you have scalp scaling (dandruff), consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
-Hengge UR. Topical, Non-Medicated LOYON in Facilitating

-the Removal of Scaling in Infants and Children with Cradle Cap: a Proof-of-Concept Pilot Study. Dermatol Ther 2014

-Hengge UR, et al. Single-center, noninterventional clinical trial to assess the safety, efficacy, and tolerability of a dimeticone-based medical device in facilitating the removal of scales after topical application in patients with psoriasis corporis or psoriasis capitis. Psoriasis (Auckl) 2017

-Loyon 510(k) Premarket Notification https://www.accessdata.fda.gov/cdrh_docs/pdf16/K162217.pdf Last accessed 2/18/19

-Dotinga R. Persistence, collaboration are the keys to treating stubborn conditions. Dermatology News 2019


February 2019

What's New in Alopecia areata

What's new in Alopecia

Having completed a fellowship in hair, I see more patients with hair issues than most dermatologists. Dermatologists like myself are best at treating hair diseases involving inflammation, especially alopecia areata along with other non-scarring and scarring conditions. Unfortunately, we are not as able to treat androgenetic/age-related thinning and do not have great treatments for hair shedding without an internal cause. The first line treatment for alopecia areata patients is usually injections of steroids (intralesional triamcinolone). This usually works quite well and most adults and children above age 12 tolerate this relatively well. However, children under 12 and some adults are not very receptive toward the injections. For those, topical steroids are often used, but often do not provide much success.

There is increasing evidence that topical anthralin, a medicine that was derived from a tree in Brazil "devoid of any systemic side effects" (Sehgal et al), is a useful add-on second line therapy. A recent review of 37 patients under age 18 in the Cleveland Clinic alopecia areata database found 32% experienced complete scalp hair regrowth and 68% experienced at least 50% scalp regrowth with the addition of anthralin treatment. The study authors' conclusion was anthralin "offers potential for significant scalp regrowth with minimal systemic side effects." However, the medication was slow acting, with mean time to regrowth of 3.4 months and patients on average not having maximal response until 15 months. Relapses were relatively common, affecting 64% of patients. A first-line therapy such as steroid injections or topical steroid was needed in conjunction with the anthralin. Last, most dermatologists agree anthralin needs to cause a mild-moderate rash (dermatitis) to achieve hair regrowth. This rash prompted 4 patients to stop their treatment. In addition, achieving the mild-moderate rash likely requires frequent follow-up visits initially to make sure the rash isn't too mild or too severe. Too severe of a rash may require breaks in treatment and/or increasing the strength of topical steroids.

If you have hair loss, especially if it's patchy or scarring, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Wu SZ, et al. Treatment of pediatric alopecia areata with anthralin: A retrospective study of 37 patients. Pediatr Dermatol 2018

-  Pivovarov JD. Anthralin shows promise as a second-line agent for alopecia. Dermatology News 2019

-  Sehgal VN, et al. Anthralin/dithranol in dermatology. Int J Dermatol 2014


January 2019

What's New in Eczema (atopic dermatitis)

What's new in eczema

For my patients with sensitive skin (ie, eczema, atopic dermatitis), I often discuss over-the-counter gentle skin care products before I discuss the prescriptions I will be writing. The reasoning is that while moisturization and usage of sensitive skin care products can take time and, unfortunately, cost more money than no moisturization and usage of harsh products, they essentially have almost no side effects. Usage of the proper over the counter products can oftentimes decrease the amount and/or length of prescription medication usage.

The most important part of skin care is moisturization. Two studies totaling about 200 neonates in the United States, United Kingdom, and Japan showed a 30-50% decreased risk of developing atopic dermatitis (evaluated approximately at months 6-8) compared to controls by simply applying whole body moisturizer at least once daily. While this cannot be definitively extrapolated to adults (and there will probably never be clear data for adults as an entity sponsoring a non-pharmaceutical clinical trial for decades is unlikely), it implies simple moisturization not only helps out short term, but also helps prevents long term skin issues.

If you have sensitive skin or another skin condition, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Simpson EL, et al. Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol 2014

-  Horimukai K, et al. Application of moisturizer to neonates prevents development of atopic dermatitis. J Allergy Clin Immunol 2014

-  Lio PA. Advances in atopic dermatitis raise bar for treatment. Dermatology Times 2018


December 2018

What's New in Psoriasis

What's new in autoimmune

The first line therapy for many skin conditions, especially psoriasis, are corticosteroid ("steroid") creams and ointments. Patients often ask how long they can use a mediation for. The FDA label for many steroid creams vary between 2 weeks, 4 weeks, and rarely longer. One of the strongest steroid creams for psoriasis is clobetasol cream. However, the official FDA product insert states "treatment beyond 2 consecutive weeks is not recommended" for most patients and even those with moderate to severe psoriasis are advised "can be used up to 4 consecutive weeks." There are no FDA guidelines on how long of a break should occur prior to restarting the medication. Having been a Psoriasis Fellow at UCSF, I would say from experience a patient with moderate to severe psoriasis with active plaques often flares if they take any break, much less a long-term break. I have seen many patients take substantial breaks due to their concern for steroid cream related side effects. Unfortunately, they often flared into severe disease and sometimes required either time-intensive treatments (phototherapy twice weekly) or higher risk systemic medications (oral or injectable).

An improvement is a new steroid that is now FDA approved for 8 weeks called halobetasol lotion 0.01%. Unfortunately, as a new medication it is only available as brand name Bryhali lotion. There were 2 clinical trials, totaling 430 subjects. There was no permanent hypothalamic-pituitary-adrenal axis ("hormone") suppression. There were about 1-2% of patients having an upper respiratory infection, application site rash, or elevated sugars. Drawbacks are that it is likely weaker than the generic halobetasol 0.05% cream, with only about 40% of patients experiencing treatment success, defined as "clear" or "almost clear" skin. To my knowledge, the strength (corticosteroid category) has not yet been reported, but it will likely be a class II (2nd strongest) or less medication versus the commonly used class I (strongest) steroid creams that are often used for psoriasis. Also, to my knowledge, the price has not yet been released. I wouldn't be surprised for it to cost insurance companies hundreds of dollars to cover. This would likely result in a high chance of insurance rejection.

Nevertheless, the information is useful in at least having FDA backing for 8 weeks of steroid cream safety for at least one product. Data has been lacking as steroid cream clinical trials are not common. Many of these medications have either been grandfathered in before today's more intensive testing, not had the funding for a long clinical trial, or the manufacturers did not wish to spend the money if the FDA did not require longer testing. It is quite possible that there are other steroid creams that are safe and effective for 8 weeks or longer, but the hard data is unfortunately not available.

Thus, we are practically left with physician experience to guide how to use the steroid creams and ointments. Given that psoriasis is often life long, many patients require steroid creams for months or years. Breaks are dependent on how a patient does, how careful they are to correctly apply the medication only on the rashes and not normal skin, and whether any side effects are seen. I do recommend periodic follow-up visits for evaluation for side effects. Systemic side effects have been extremely rare in adults. However, there can be skin side effects such as skin thinning, especially in patients who do not regularly see their doctor.

If you have psoriasis or other skin condition, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
Green LJ, et al. Safety and Efficacy of a Once-Daily Halobetasol Propionate 0.01% Lotion in the Treatment of Moderate-to-Severe Plaque Psoriasis: Results of Two Phase 3 Randomized Controlled Trials. J Drugs Dermatol 2018

-  Package insert: Clobetasol cream. https://www.accessdata.fda.gov/drugsatfda_docs/anda/2001/75733_Clobetasol%20Propionate_Prntlbl.pdf Accessed 12/9/18

-  Package insert: Bryhali (halobetasol propionate) lotion. https://www.bauschhealth.com/Portals/25/Pdf/PI/Bryhali-PI.pdf Accessed 12/9/18

November 2018

What’s New in Toenail fungus (onychomycosis)

What's new in autoimmune

Many patients come in for their toenail fungus, which manifests as yellow thickened toenails with "debris” underneath. The most effective treatment is taking an oral tablet called terbinafine (Lamisil) for 3 months. However, it does have risks including liver toxicity and taste loss.

For very motivated (in terms of seeking treatment within 1 year of the fungus developing, willingness to treat every day for 48 weeks, and be willing to pay likely high medication copays), the two newer solutions, either efinaconazole (Jublia) or tavaborole (Kerydin) seem to be reasonable alternatives. That being said, the majority of patients I see would likely not fulfill all 3 criteria, as most wait until they’ve had the condition for years, do not wish to do the somewhat time-intensive (it takes time to use the applicator to treat each affected toenail with several strokes to cover the nail, the lateral nailfold, the proximal nailfold, and the distal nailfold) treatment literally every day for 48 weeks, and often face large medication copays from their insurance company as there are not yet (and likely not for decades) generic equivalents for these branded medications.

In the past, I haven’t been that excited about these two medications due to the efficacy for those who’ve had the fungus more than a year still only being 16 to 17% even in those who do the daily applications for 48 weeks and pay the large copays (as a side note, patients often ask how much the copay will be. The doctor does not know, although can guess if it’ll usually be "low” or "high.” The pharmacy is the only one who can tell the patient the specific amount as they’re the ones charging the insurance company & dispensing the medication).

The patients I am somewhat excited to treat are those who say "I didn’t have any fungus a year ago” as a clinical trial showed for those with toenail fungus less than a year, the efficacy for efinaconazole solution once daily for 48 weeks is 43%. This starts to get in the range that it is a reasonable alternative to the oral terbinafine tablets. However, again, this still involves a time commitment and potentially high copays. It also still means there’s a 57% chance the fungus will not be cured (although potentially still improved somewhat).

The other additional work for patients that has been shown to increase their chances for toenail fungus cure is to also treat any coexisting foot fungus (tinea pedis). This would be another cream or gel, usually twice daily.

If you have toenail fungus, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
Jancin B. Best bets for topical toenail fungus therapy. Dermatology News 2018

Markinson B, et al. Efinaconazole Topical Solution, 10% Efficacy in Patients with Onychomycosis and Coexisting Tinea Pedis. J Am Podiatr Med Assoc 2015

-  Rich P. Efinaconazole topical solution, 10%: the benefits of treating onychomycosis early. J Drugs Dermatol 2015

For archives, click here.


October 2018

What’s New in Contact Dermatitis

What's new in autoimmune

Contact dermatitis comes in two types. Irritant contact dermatitis is when someone is exposed for a "significant duration or in significant concentration”, ie frequent hand washers esp. in chefs and teachers or in those who are elderly and have experienced significant skin thinning esp of the hands and thus have a shorter duration of tolerance as when they were younger. Allergic contact dermatitis occurs when the immune system recognizes a compound as foreign, ie poison ivy. Once this occurs, it is generally considered incurable. However, complete remission of the rashes can occur with "assiduous avoidance.”

An increasingly recognized allergen that causes allergic contact dermatitis esp in sensitive individuals diagnosed with atopic dermatitis or eczema is carmine, a red dye obtained from an insect known as cochineal. A study of 67 patients, half with atopic dermatitis (ie, sensitive skin) and half controls, found 41% of atopic dermatitis were carmine sensitive and 15% of controls. I consider this a high rate of allergic sensitivity.

Factories kill the insect then extract the dye using solutions. The dye was brought into the public consciousness with internet discussions of it being used in a national coffee chain’s "strawberries and cream” drink (which has been reformulated to no longer use carmine).

The possible reason it has uncommonly been reported as a known allergen in patient case reports may simply be due to the high difficulty in diagnosing carmine allergy. To diagnose this allergy would require A) A high index of suspicion. A visit to go over carmine allergy, depending on the patient and doctor, would not be surprising to take the entire time slot. Given there are a multitude of potential allergens to discuss, it is unlikely to be a high yield discussion point, esp in the first or second visit. B) A motivated patient. It would probably require many ongoing hours to obtain and read the ingredients label of every pink/red product they touch. Common products containing carmine include: cosmetics, shampoos, red applesauce, lollipops, popsicles, yogurt, wines and liquors, food coloring, frozen meat or fish, soft drink beverages, canned soups, pills/ointments/syrups, and canned fruits. Companies are required by the FDA to list carmine as an ingredient. C) A patient willing to print out and keep with them a list of the multitude of carmine synonyms including: Cochineal, Cochineal extract, Crimson lake, Carmine lake, Cl 75470, Natural red 4, B Rose liquid, CCRIS1204, EINECS 215-724-4, FEMA No. 2242, FEMA No. 2330, E120 D) A patient willing to travel to an academic allergy center for confirmatory testing. To my knowledge, there is not a widely available test for carmine allergy available to private dermatologists or most private allergists.

Unfortunately, simply reading the above is likely quite boring to the average person, much less putting it into practice. To be practical, I usually go over a list of recommended cosmetic products (in my clinic, I usually do not see ingestion/food allergies, I more commonly see cosmetic allergies) that do not contain carmine or, as much as possible, other common allergens. I usually recommend an "elimination” of their old products. This is, of course, in addition to discussing prescription medication options/recommendations. Then, after their rash clears up, some patients re-introduce their old products one at a time if they wish to resume them. More practically, many patients simply continue using the gentle skin care products I recommend.

If you have a rash or sensitive skin, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
-  Rundle CW, et al. Allergen focus: Carmine update. The Dermatologist 2018 https://www.the-dermatologist.com/article/carmine-update

-  Catli GC, et al. Is Patch Testing with Food Additives Useful in Children with Atopic Eczema? Pediatr Dermatol 2015

For archives, click here.


September 2018

What’s New in Autoimmune and Autoinflammatory Disorders

What's new in autoimmune

One of the most common medications used for autoimmune (the body attacking specific portions of itself, mediated by the adaptive immune system) and autoinflammatory (the body with generalized inflammation, mediated by the innate immune system) diseases is a medication called hydroxychloroquine (brand name Plaquenil). One of its potential side effects is permanent retinopathy (impairment or loss of vision). Retinopathy screening and the dosage decision have been a core part of prescribing the medication. Recommendations on screening from the American Academy of Ophthalmology have been updated. The guidelines have largely been updated based on a relatively recent analysis of case-control data in a 3.4 million integrated health organization member database. The new guidelines may result in your dermatologist adjusting to the recommended hydroxychloroquine dosage (less than or equal to 5 mg/kg real body weight) and duration of usage (ideally less than 10 years).

In the past, retinopathy risk was considered rare at 0.5 to 2% prevalence of longterm users. However, with modern visual testing techniques and data on long-term patients now available, the risk is now thought to be roughly 3 times higher than previously reported. The new consensus is there is a 2% prevalence if the medication is used 10 years but almost 20% prevalence after 20 years. The risk is higher if a patient has kidney issues or is on tamoxifen.

Interestingly, the data showed the average patient only ingested 80% of the prescribed amount, making some patients in the newly recommended dosing even if they were prescribed a higher dosage based on previous guidelines and other factors.

Patients may suffer some confusion in taking the recommended dosage, esp. those who are on multiple oral medications already. Unfortunately, the dosage cannot be adjusted by prescribing a different tablet size (hydroxychloroquine only comes as 200 mg tablets). To obtain their ideal dosage based on body weight, patients will have to skip tablets on certain days of the week and/or split tablets.

The American Academy of Ophthalmology still considers retinopathy "low risk” with hydroxychloroquine at a "daily use of 5.0 mg/kg of real body weight or less…for up to 10 years of use.”

If you have a dermatologic autoimmune disease or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options. Charles Chiang, MD, FAAD Board Certified Dermatologist

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Hsu S. What’s hot? Dermatology World 2018
- Marmor MF, et al. Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision). Ophthalmology 2016
- Melles RB, et al. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol 2014
- Ciccarelli F, et al. An update on autoinflammatory diseases. Curr Med Chem 2014


August 2018

What's New in Hyperhidrosis

What's new in hyperhidrosis

Hyperhidrosis (excessive sweating) is a common disease affecting about 5% of the United States population. A new product to treat this, glycopyrronium wipes (brand name Qbrexza) has been FDA approved in 2018. I will likely prescribe it once it is available in pharmacies. The company reports it to be available starting October 2018; however, in my experience this may practically mean early 2019.

The clinical trials involved about 700 patients. About 60% of treated patients had significant improvement versus 30% of the placebo group. Overall it was well tolerated. Only 4% of patients discontinued the mediation. The most common side effects were dry mouth and dilated pupils (mydriasis). Other side effects included urinary retention/hesitancy, blurred vision. There were 2 patients with serious side effects. One had "moderate unilateral mydriasis [considered treatment-related]” which I assume resolved after stopping the wipes, but information on the final outcome was not provided in the study publication. The other patient had "dehydration [considered treatment-unrelated].” A caveat is that the clinical trial was only 4 weeks in duration.

Current treatment for hyperhidrosis is currently so-so. In medical dermatology, treatment usually begins with over-the-counter antiperspirants then prescription antiperspirants then oral pills (e.g. glycopyrrolate). In my experience, oral glycopyrrolate has almost always been successful in its purpose of decreasing sweating. However, there are numerous potential side effects. About one quarter of patients have to discontinue the medication due to side effects. This is obviously higher than the reported rate for the wipes. It is what is called an anticholinergic medication so its side effects include: dry mouth, blurred vision (mydriasis), dry eyes, constipation, urinary retention, dizziness when standing quickly, confusion, slowed mental processes, and abnormal heart rhythms.

If you have hyperhidrosis or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

 

Charles Chiang, MD, FAAD

Board Certified Dermatologist

References:

-          Glaser DA, et al. Topical Glycopyrronium Tosylate for the Treatment of Primary Axillary Hyperhidrosis: Results from the ATMOS-1 and ATMOS-2 Phase 3 Randomized Controlled Trials. J Am Acad Dermatol 2018

-          Moodie T. Anticholinergic medication https://www.dermnetnz.org/topics/anticholinergic-medications/

 

July 2018

What's New in Ocular rosacea

What's new in ocular rosacea

Rosacea is a common disease that causes inflammation of the skin and blood vessels of the face. There seem to be multiple factors, with the most obvious being photodamage over time. Other components include skin mites, generalized immune system inflammation, and skin irritation.

One of the most troublesome manifestations is eye involvement, ie ocular rosacea. This is seen in 58 to 72% of rosacea patients. This can result in gritty sensations in the eyes, "blurred vision, tearing, pain, and problems with glare.”

Treatment usually involves both dermatology and ophthalmology. For ocular rosacea, dermatology can mostly offer oral antibiotic pills to decrease inflammation over the entire face, including the eyes. Dermatology can also treat nearby inflamed skin, esp the nose and cheek regions.

Ophthalmology is usually in charge of medicated eye drops, partially because many common eye drops include corticosteroids that can increase intraocular pressures. Only ophthalmologists and eye clinics can screen for glaucoma development.

Patients almost always request information on non prescription options when possible. There is one study that showed that omega 3 fatty acids (dosage used was 500 mg capsules, each containing 325 mg EPA & 175 mg DHA, twice daily for 3 months) seem to "benefit the quality of the tear film.” Specifically, a study of 264 patients with dry eyes (not all patients had rosacea, but all had eye issues) found 66% of the treated group and 33% of the placebo group had improvement in eye symptoms. In addition, there was a significant increase in tear production, measured by Schirmer’s test & significant increase in tear retention, measured by tear breakup time.

No side effects were reported.

If you have rosacea or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Dotinga R. Ocular rosacea remains a stubborn foe. Dermatology News 2017
-  Wladis EJ, et al. Current and Emerging Therapies for Ocular Rosacea. US Ophthalmic Review 2013
-  Bhargava R, et al. A randomized controlled trial of omega-3 fatty acids in dry eye syndrome. Int J Opthalmol 2013

June 2018

What's New in Eczema (atopic dermatitis)

What's new in dermatitis

In the March update, I discussed the association between eczema = atopic dermatitis = sensitive skin with autoimmune and autoinflammatory conditions. In this month’s update, I am adding further systemic associations. Specifically, the Liberty AD-AWARE survey study of 1028 patients found a significantly increased association with severity of atopic dermatitis with obesity, coronary heart disease, stroke, anxiety, depression, sleep disorders, and ADHD. This is in addition to the long-known associations of hay fever, asthma, food allergies (Note: Parents often hope that the food allergies cause the sensitive skin. This is, unfortunately, rarely the case. Most dermatologists view food allergies not as the cause of the sensitive skin, but rather that the sensitive skin increases the risk of developing food allergies). It even found that severe atopic dermatitis increased the risk of poor education, poor career, unemployment, and poor salary.

These results have been corroborated in other studies. One found coronary artery plaques by cardiac CT angiography more often in severe atopic dermatitis patients compared to matched controls (48% vs 21%), even more so than severe psoriasis (38%). Another found a higher rate of ADHD in children (14% increased risk compared to controls) and adults (61% increased risk) with atopic dermatitis. The risk was higher in patients with severe atopic dermatitis.

Potential etiologies include altered brain development due to inflammation, genetic risks, and simply living with chronic itching and poor sleep. In theory, improving the skin may decrease the risks of depression and quality of life.

If you have sensitive skin or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Jancin B. Survey shines new light on weighty comorbidity burden. Dermatology News 2017
-  Hjuler KF, et al. Increased Prevalence of Coronary Artery Disease in Severe Psoriasis and Severe Atopic Dermatitis. Am J Med 2015
-  Riis JL, et al. Hospital-diagnosed atopic dermatitis and long-term risk of myocardial infarction: a population-based follow-up study. BMJ Open 2016
-  Strom MA, et al. Association between atopic dermatitis and attention deficit hyperactivity disorder in U.S. children and adults. BJD 2016

 

May 2018

What's New in Contact dermatitis

What's new in dermatitis

I’m seeing an increasing number of patients with rashes behind their ears. As a dermatologist, my first thought is either a contact dermatitis (irritation or allergy) due to shampoo or conditioner versus seborrheic dermatitis ("dandruff”). The rest of the physical exam can usually point toward one of these diagnoses.

For patients I diagnose with a contact dermatitis, the chemical is often the official 2017 "Allergen of the Year” (voted yearly by the American Contact Dermatitis Society) of alkyl glucosides (ie, anything on the ingredients label that has the word "glucoside”). It is in many shampoos, conditioners, and cleansers. While overall allergy rates are about 2%, this is of course much higher in patients who see the doctor and have a rash behind the ears. Unfortunately, there is currently no widely available test to confirm the allergy as the most common test performed by allergists called the T.R.U.E. test does not include this compound. The allergen can be specially ordered and tested for, but this is uncommonly done by private allergists. I do not do this test and usually simply recommend avoidance and re-evaluation as the practical test.

The most common rash occurs behind the ears where the shampoo or conditioner drips from the thicker scalp skin to the thinner behind the ear skin. Dermatologists can treat the rash but the main potential cure is stopping the irritating shampoos and conditioners. Unfortunately, this is hard to do. The gentlest over the counter shampoo I recommend has tar which some people do not like the smell of. Regarding conditioners, due to the way they work, I do not know one that is reliably gentle.

If you have sensitive skin or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Boyd, et al. Update on Alkyl Gluocsides. The Dermatologist 2017
- Sasseville D. Alkyl Glucosides: 2017 "Allergen of the Year.” Dermatitis 2017


April 2018

What's New in Eczema (atopic dermatitis)

What's new in Eczema

Patients often ask about natural treatments for their or their child’s eczema (atopic dermatitis). A recommendation I often make is adding colloidal oatmeal (usually pre-packed, ie Aveeno oatmeal bath packets, or self-ground 1 cup of steel-cut oat in a coffee or spice grinder) to the bathtub. Studies often recommend soaking for 15-20 minutes twice weekly (which is fine. I usually recommend being a bit more aggressive and performing a bath with oatmeal daily to every other day for at least 5 min). Studies have shown benefit in improving skin dryness, scaling, roughness, and itch intensity. Colliodal oatmeal includes omega 3 and 6 fatty acids, polar lipids, and beta-glucans which coat the skin and decrease water loss. In addition, oatmeal has antimicrobial properties, which is helpful as patients with atopic dermatitis have decreased antimicrobial peptides which makes them more prone towards infections in general.

If you have sensitive skin or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Rupani, R. Oatmeal soothes, relieves, and inhibits viruses. Dermatology Times 2016
- Reynertson KA, et al. Anti-inflammatory activities of colloidal oatmeal (Avena sativa) contribute to the effectiveness of oats in treatment of itch associated with dry, irritated skin. J Drugs Dermatol 2015
- Aries MF, Vaissiere C, Pinelli E, Pipy B, Charveron M. Avena Rhealba inhibits A23187-stimulated arachidonic acid mobilization, eicosanoid release, and cPLA2 expression in human keratinocytes: Potential in cutaneous inflammatory disorders. Biol Pharm Bull 2005


March 2018

What's New in Eczema (atopic dermatitis)

What's new in Eczema

Eczema (atopic dermatitis) is quite common, affecting about 15% of the pediatric population and 10% of adults. Many pediatric patients are told that they will outgrow their sensitive skin. However, given that the prevalence for adults is only 1/3 less than that for the pediatric population, it likely often remains or recurs in the future. The drawback of the data is that the studies didn’t follow the same patients so some patients may have developed adult eczema without having had a diagnosis as a child. However, even in those cases, oftentimes the adult had some sensitive skin as a child that wasn’t severe enough to cause his parents to seek medical attention.

Awareness of having eczema / atopic dermatitis / sensitive skin is important as there is increasing data that it increases the risk of many autoimmune and autoinflammatory conditions. It has been linked toward inflammatory bowel disease, rheumatoid arthritis, alopecia areata, vitiligo, chronic urticaria, celiac disease, systemic lupus erythematosus, rheumatoid arthritis, among other conditions. In my practice, the most common link I see if between eczema and chronic hives (urticaria), of which the hives treatment is oftentimes long-term, without easy solutions, and frustrating for both the patient and the doctor. Theories for the many disease associations vary between autoreactive cells immune cells (ie, their immune system becomes inflamed by their own tissue, cells, and proteins) in patients with sensitive skin and possible predisposition toward environmental triggers due to the compromised skin barrier. In theory, improving control of the sensitive skin with gentle skin care and potential prescription medication (usually topical steorids) may decrease the risk of developing the associated conditions by decreasing the susceptibility to environmental triggers and avoiding inflaming the immune system.

If you have sensitive skin or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Andersen YM, et al. Autoimmune diseases in adults with atopic dermatitis. J Am Acad Dermatol 2017
- Magen E, et al. Association of alopecia areata with atopic dermatitis and chronic spontaneous urticaria. Allergy Asthma Proc 2018
- Anderson K, et al. 2017: Year in Review. The Dermatologist 2017
- Silverberg JI, et al. Adult eczema prevalence and associations with asthma and other health and demographic factors: a US population-based study. J Allergy Clinc Immunol 2013

February 2018

What's New in Warts

What's new in Warts

Warts are a common reason to see the dermatologist. They are an infection of the HPV virus that can affect any skin or mucous membrane. Treatment can be difficult. The most common treatment is liquid nitrogen and usually requires multiple treatments. This is obviously frustrating for the patient and doctor.

Thus, there has been increasing interest in zinc, as an oral supplement, to potentially enhance immunity against the HPV virus and either speed treatment or decrease the risk of relapse. To my knowledge, two non-genital wart studies have been reported. One study of 31 patients showed about have had their warts resolve after two months of zinc supplementation. Nausea and itching were reported side effects. No serious side effects were reported. A second study of 32 patients showed 78% of the zinc group cleared after 2 months versus 13% of the placebo group. Both studies used a zinc dosage of 10 mg/kg/d up to a maximum of 600 mg/day. Drawbacks include the first study lacking a control group and the second group being reported as a "letter to the editor” rather than a more detailed "original article.” In addition, the patient numbers were low. There was a separate genital wart study of 228 patients which reported which found no significant difference in treatment efficacy but did show a significant decreased relapse rate with zinc supplementation. This study used a zinc sulfate dosage of 400 mg daily for 8 weeks. The fact that the larger 228 patient study didn’t show a difference in treatment efficacy may indicate the smaller 31-32 patient studies were underpowered in terms of patients.

While the data on zinc supplementation efficacy and safety isn’t strong enough for me to suggest it for every wart patient, it seems to be potentially useful supplement for a limited time period for patients with refractory warts.

If you have wart(s) or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Lio P. Unconventional treatments for warts and mollsucum. Dermatology Times 2015
- Mun JH, Kim SH, Jung DS, Ko HC, Kim BS, Kwon KS, Kim MB. Oral zinc sulfate treatment for viral warts: an open-label study. J Dermatol. 2011 Jun;38(6):541–5
- Akhavan S, Mohammadi SR, Modarres Gillani M, Mousavi AS, Shirazi M. Efficacy of combination therapy of oral zinc sulfate with imiquimod, podophyllin or cryotherapy in the treatment of vulvar warts. J Obstet Gynaecol Res. 2014 Oct;40(10):2110-3
- Yaghoobi R, Sadighha A, Baktash D. Evaluation of oral zinc sulfate effect on recalcitrant multiple viral warts: a randomized placebo-controlled clinical trial. J Am Acad Dermatol. 77 2009 Apr;60(4):706–8.

January 2018

What's New in Acne

What's new in Acne

Acne is a very common reason to bring patients to the dermatology office. Many of the cases I see are of the nodulocystic subtype where there are cysts producing scarring on the face. Oftentimes, standard therapy (antibiotic pills and/or topical agents) don’t provide sufficient benefit. Thus, many patients consider what is generally considered the strongest medication for acne, isotretinoin, commonly known as Accutane. Other than the risk for birth defects for births taking place during or within 1 month of the end of therapy, the most common concern is a FDA warning from 1998 that it may be associated with an increased risk of depression, suicidal ideation, and suicide. Partially due to the FDA warning and listing of this potential side effect in the FDA mandated Accutane handout, I do generally have patients with a current or recent history of depression and especially suicidal ideation see their psychiatrist, psychologist, or primary care doctor for Accutane clearance. That being said, a recent systemic review and meta-analysis by Huang and Cheng has been published that states "Isotretinoin treatment for acne does not appear to be associated with an increased risk for depression. Moreover, the treatment of acne appears to ameliorate depressive symptoms.” This is after analyzing 31 studies from 1984 to 2016. In addition, Strahan in 2006 and Marqueling in 2007 "concluded that the current literature does not support a causative association between isotretinoin and depression.”

There is a study in psychiatry from Bremner in 2012 that disagrees with the other 3 studies’ conclusion, instead stating "The literature reviewed is consistent with an association between isotretinoin administration, depression and suicide in some individuals.” However, the data analysis by Bremner seems to be less rigorous than that of Huang and Cheng.

It does seem to be true that depression is more common in patients with severe acne, which may affect studies or case reports that do not take this into account.

If you have acne or other skin issues, please make an appointment for dermatology consultation at (626) 251-1500 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Huang YC, Cheng YC. Isotretinoin treatment for acne and risk of depression: A systematic review and meta-analysis. J Am Acad Dermatol 2017
- Bremner JD, et al. Retinoic Acid and Affective Disorders: The Evidence for an Association. J Clin Psychiatry 2012
- Strahan JE, Raimer S. Isotretinoin and the controversy of psychiatric adverse effects. Int J Dermatol. 2006
- Marqueling AL, Zane LT. Depression and suicidal behavior in acne patients treated with isotretinoin: a systematic review. Semin Cutan Med Surg 2007
- Halvorsen JA, et al. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study. J Invest Dermatol 2011
- Anderson K, et al. 2017: Year in review. Acne and Rosacea. The Dermatologist 2017

 

December 2017

What's New in Bed Bugs

What's new in Bed Bugs

Bug bites are a relatively common diagnosis in dermatology. The issue is that while the general diagnosis of "bug bites” has a fairly straightforward physical appearance, the answer to "what bug is it?” is much more difficult. The visit usually begins with identifying the general signs of bug bites, especially the classic "breakfast lunch dinner” pattern where there are pink bumps in a row as a bug feeds, crawls, feeds, crawls, and feeds some more. Then, ideally a sign of the specific bug can be seen.

One observation that has been helpfully reported by Dr. Quach is a case series of 6 pediatric patients where they had a positive "eyelid sign” where there is a bug bite visible on the eyelid. This has been reported to a good clue for bed bug bites in the United States as the main alternative bug that bites the eyelid is the bug causing Chagas disease. Since Chagas disease primarily in rural Latin America, it is usually not a practical concern in the United States.

The other helpful note in Dr. Quach’s report is that 5 of the 6 pediatric patients were the only ones with bug bites (ie, for the majority of the reported patients, no other family members were affected). I frequently advise my bug bite sufferers that often only one person in the family is sensitive to or attracts the bugs.

Last, it was reported that bed bug extermination cleared all patients’ symptoms. Unfortunately, the consensus by most medical professionals is that home remedies are not very helpful and usually a professional exterminator is necessary for eradication.

If you have eczema, itchy skin, or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Dotinga R. ‘Eyelid Sign’ provides a clue that bed bugs are the cause. Dermatology News 2017
- Centers for Disease Control and Prevention. Parasites - American Trypanosomiasis (also known as Chagas Disease). https://www.cdc.gov/parasites/chagas/gen_info/detailed.html Last accessed 12/18/17
- Quach KA, et al. The eyelid sign: a clue to bed bug bites. Pediatr Dermatol 2014

 

November 2017

What's New in Eczema (atopic dermatitis)

What's new in Eczema (atopic dermatitis)

There have been helpful pediatric (less than age 18) studies of patients with eczema (atopic dermatitis), ie sensitive skin. The parents of pediatric patients often ask what non-prescription products can improve their child’s itching. While I almost always review gentle skin care products, studies have shown that oral melatonin can be helpful with a "really safe” safety profile. This is because patients with itchy skin often have difficulty falling asleep. This may result in additional time scratching while in bed, less healing time while asleep, and potential increased itching during the daytime due to being less well rested.

A recent study showed that the worse the skin was doing, the worse the sleep disturbances. Studies have varied in showing whether patients with sensitive skin have decreased or increased melatonin. However, a study of 72 pediatric patients with atopic dermatitis by Chang et al showed that increased melatonin levels are correlated with improved sleep efficiency. Then a follow-up randomized clinical trial of 73 pediatric patients (age ranging from 1.8 to 17 yrs, median 7 yrs) also by Chang et al found that melatonin 3 mg/day improved their atopic dermatitis by about 20% (as defined by a scoring system called SCORAD) and the onset of sleep occurred about 20 minutes faster. No adverse events were reported.

Melatonin has traditionally been used to manage insomnia and jet lag. It seems to have "immunomodulatory, anti-inflammatory, and antioxidative effects, which might improve the skin inflammation.”

Safety-wise, melatonin is overall considered quite safe. A British Medical Journal publication stating "17 randomised [sic] controlled trials with 651 participants showed no evidence of adverse effects of melatonin with short term use (three months or less).” The study by Chang et al above used a 4 week timeframe which I consider reasonable given the evidence we have so far. There is no evidence I am aware of to guide how often this 4 week timeframe can be repeated and would be up to the treating physician’s experience and intuition. Studies of melatonin have included both pediatric and adult studies. However, the youngest patient treated in the study above was 1.8 years of age.

If you have eczema, itchy skin, or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Kronemyer B. Impact of childhood AD. Dermatology Times 2017
- Chang YS, et al. Melatonin Supplementation for Children With Atopic Dermatitis and Sleep Disturbance: A Randomized Clinical Trial. JAMA Pediatr 2016
- Chang YS, et al. Atopic dermatitis, melatonin, and sleep disturbance. Pediatrics 2014
- Marseglia L, et al. Melatonin and atopy: role in atopic dermatitis and asthma. Int J Mol Sci 2014
- Rossignol DA, et al. Melatonin in autism spectrum disorders: a systematic review and meta-analysis. Dev Med Child Neurol 2011
- Buscemi N, et al. Efficacy and safety of exogenous melatonin for secondary sleep disorders and sleep disorders accompanying sleep restriction: meta-analysis. BMJ 2006

 

October 2017

What's New in Rosacea

What's new in Rosacea

Past columns have discussed new medications becoming available for rosacea. However, first-line treatment is always avoidance of triggers. While sunlight is considered by most as the most important trigger (ie, sunscreen, sun-protective clothing, and sun avoidance as practical), alcohol is clearly a trigger as well. Unfortunately, some of my adult patients tell me it is just not practical to completely abstain from alcohol due to social reasons. Sometimes I am asked what alcohol is the "best.” A recent study of 4945 rosacea patients finally gives a good answer to that question. These patients submitted surveys every 4 years for 14 years of their amount and type of alcohol intake. My summary of the data would be that overall, white wine seemed to place patients at highest risk for rosacea then hard liquor then regular beer then red wine then light beer. In addition, the risk was dose dependent, e.g. drinking at least 5 four-ounce glasses of white wine per week led to about a 50% higher risk of rosacea compared to someone who never drank while drinking 1-3 glasses per month led to a 14% higher risk of rosacea. Unfortunately for my patients, that means even infrequent social drinking still increases their risk for rosacea.

Limitations of the study were not evaluating the mechanism for alcohol to increase the risk for rosacea. Also, while it makes sense that alcohol that increases the risk of rosacea would also flare rosacea once someone has it, a much smaller 353 rosacea patient study by the National Rosacea Society reported red wine being worse than white wine in flaring rosacea. That being said, I favor the data for 4945 patients over 353 patients.

For those who ask why this matters, rosacea has been associated with an increased risk of gastrointestinal issues. A study in Taiwan showed it’s associated with almost double the risk for a condition called inflammatory bowel disease. A study in Denmark showed that those with rosacea had a higher risk of death for those who developed gastrointestinal disease, esp. liver disease. However, it is unclear whether it is the rosacea itself or the increased incidence of alcohol intake in those with rosacea that causes this.

Overall my summary is that if social drinking is an important part of my patient’s life then light beer is the best and ideally less is better. For my patients who tell me light beer isn’t acceptable, red wine would be my next recommendation. Of course, drink responsibly.

If you have rosacea or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options. Treatment is available although is most efficacious for the acne portion of rosacea. Treatment for the redness portion is more difficult and may involve high copay creams and/or cosmetic laser (ie, Magan Medical Clinic’s Medical Aesthetics Laser Center).

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Li S, et al. Alcohol intake and risk of rosacea in US women. J Am Acad Dermatol 2017
- Wu CY, et al. Risk of inflammatory bowel disease in patients with rosacea: Results from a nationwide cohort study in Taiwan. J Am Acad Dermatol 2017
- Egeberg A, et al. Nationwide Assessment of Cause-Specific Mortality in Patients with Rosacea: A Cohort Study in Denmark. Am J Clin Dermatol 2016
- Red Wine Named Top Alcohol Trigger https://www.rosacea.org/rr/2010/fall/article_4.php Last accessed 10/15/17

 

September 2017

What's New in Vitiligo

What's new in Vitiligo

Progress in vitiligo (an autoimmune disease where pigment on the skin is completely lost in areas) treatment has been slow. The practical recent development is evidence suggestive that an oral antibiotic called minocycline may improve vitiligo with its anti-inflammatory effects. A 2014 study of 50 patients found it was not significantly different in effectiveness when compared to oral steroids, which most would consider as having many more side effects. Both treatments showed improvement in a score called VASI (Vitiligo Area Scoring Index). That being said, efficacy was mild (which is true of most vitiligo treatments), with repigmentation being partial in the majority of case. More than 75% repigmentation was achieved in only 12% of minocycline-treated patients. No serious side effects were reported. In general, for minocycline side effects, serious side effects are usually allergic reactions (which are possible with any medication) and possibly an increased risk of autoimmune disease, esp. systemic lupus erythematosus.

In addition, a clinical trial of bimatoprost 0.03% solution (Latisse, normally used to cosmetically "grow lashes longer, fuller, and darker”) showed a mild improvement of ~25-50% but only in 20% of patients. When combined with topical steroids, its efficacy increased to being mildly effective (25-50% improvement) in about 46% of patients. However, as a cosmetic product (ie, not covered by insurance) that costs about $200 for a 5-mL dropper bottle, it is impractical for the majority of my vitiligo patients who would likely need to pay $1000’s per month out of pocket for a sufficient amount to provide possibly mild improvement, with a large chance of no improvement.

If you have vitiligo or skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Grimes PE. Bimatoprost 0.03% Solution for the Treatment of Nonfacial Vitiligo. J Drugs Dermatol 2016
- Dillon AB, et al. Advances in Vitiligo: An Update on Medical and Surgical Treatments. J Clin Aesthet Dermatol 2017
- Singh A, et al. Randomized controlled study to evaluate the effectiveness of dexamethasone oral minipulse therapy versus oral minocycline in patients with active vitiligo vulgaris. IJDVL 2014
- Vitiligo: The bench has reached the bedside https://aadmeetingnews.org/2017-summer-meeting-dailies/vitiligo-the-bench-has-reached-the-bedside/ Last accessed 9/10/17

 

August 2017

What's New in Acne

What's new in Acne

Many patients ask about the relationship between acne and their diet. Historically, the most evidence-based exacerbators of acne were:

  1. Diary: There is consensus that low fat & skim milk worsen acne. Full fat milk also likely worsens acne, but there is some research disagreement on this.
  2. High glycemic index diet: High glycemic index foods worsen acne. A link is below from the American Diabetes Association regarding different foods and their glycemic index. Since it is a complicated topic, many doctors simplify this into telling patients to avoid sugars.

Now, chocolate is being added to the list. Patients have long asked about the relationship between chocolate and acne. However, the answer has long been that we just didn’t have enough data to answer that question. Now, decent studies indicate that yes, chocolate is bad for acne. Dr. Delost published a single-blind randomized crossover study of 54 college students who were randomly selected to receive an equivalent glycemic load of either milk chocolate or jellybeans. Forty-eight hours later, the group eating chocolate had a significant increase from roughly 4 acne lesions to roughly 8 acne lesions. The group eating jellybeans had no significant change. The effects disappeared after 4 weeks. The groups were swapped with similar findings repeated. A separate study found that dark chocolate also worsened acne.

The theory behind chocolate exacerbating acne is that research has shown that chocolate consumption "primed human blood mononuclear cells to release more proinflammatory cytokines, interleukin-1β, and TNFα, upon stimulation with Propionibacterium acnes. Because overinflammation is an important contributor to acne pathogenesis and the antiinflammatory dose effect of antibiotics has been demonstrated to be most effective in treating acne, it is plausible that altered cytokine profiles can contribute to worsening acne.”

If you have acne or skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- LaRosa CL, et al. Consumption of dairy in teenagers with and without acne. J Am Acad Dermatol 2016
- Danby FW. Nutrition and acne. Clin Dermatol 2010
- American Diabetes Association http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/glycemic-index-and-diabetes.html?referrer=https://www.google.com/ Last accessed 8/21/17
- Delost GR, et al. The impact of chocolate consumption on acne vulgaris in college students: A randomized crossover study. J Am Acad Dermatol 2016
- Caperton C, et al. Double-blind, Placebo-controlled Study Assessing the Effect of Chocolate Consumption in Subjects with a History of Acne Vulgaris. J Clin Aesthet Dermatol 2014
- Cerman AA, et al. Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris. J Am Acad Dermatol 2016
- Vongraviopap S, et al. Dark chocolate exacerbates acne. Int J Dermatol 2016

 

July 2017

What's New in Warts (condyloma)

What's new in Warts (condyloma)

I am seeing an increasing number of warts, including genital warts. This seems to be borne out in studies showing an increasing prevalence of the causative HPV virus in the United States. A CDC government was recently published of 2013-2014 data which showed any genital HPV was present in 42.5% of adults aged 18-59 (45.2% in men, 39.9% in women) vs 2003-2004 data showing any genital HPV being present in 26.8% of females aged 14-59. Note that while the age ranges were slightly different, it would only be part of the reason for the large percentage increase. The same data showed 2013-2014 HPV at high risk for progression to cancer present in 22.7% of adults (25.1% of men, 20.4% of women) vs. 2003-2004 high risk HPV in 15.2% of females aged 14-59.

The government stated that the actual number may be even higher than in the study, as the government did not include several high risk groups (those using illegal injection drugs, homeless, or incarcerated) in their study.

This is of concern because genital warts are an infection caused by the HPV virus. Beyond social stigma and its infectious risk, they also have potential to become cancer in both women and men. The good thing is that parents can discuss vaccination with the Gardasil 4 or 9 vaccine (Gardasil 9 protects against more strains of the virus than Gardasil 4) with their primary care doctor. The FDA indication is for both men and women ages 9 through 26 for the prevention of genital and anal cancer. While it is preferred to be vaccinated prior to sexual activity, there is likely some benefit to being vaccinated even after being sexually active as, per the CDC, "few sexually active young women are infected with all HPV types prevented by the vaccines, so most young women could still get protection by getting vaccinated.”

Note that many insurance companies do not cover this vaccination even if FDA indicated. This is especially true if the patient is already sexually active as theoretically the vaccine is not as effective. Many patients have to pay the full cost out of pocket. It is an expensive vaccination, several hundred dollars for each of 3 vaccinations. To my knowledge, insurance companies are not mandated to cover this vaccination, which is unfortunate.

If you have warts or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options. There are a few caveats for genital warts. Dermatology can treat external genital warts. However, most treatments (ie, freezing) leave scars. Warts inside the vagina should be treated by Ob/Gyn. Dermatology does not have the ability to provide vaccinations. Please see your primary care doctor for vaccination requests and questions.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- McQuillan G, et al. Prevalence of HPV in Adults Aged 18–69: United States, 2011–2014. NCHS Data Brief 2017 https://www.cdc.gov/nchs/data/databriefs/db280.pdf Last accessed 7/16/17
- Dunne EF, et al. Prevalence of HPV Infection Among Females in the United States. JAMA 2007
- HPV Vaccine Information For Young Women. https://www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm Last accessed 7/16/17

 

June 2017

What's New in Rosacea

What's new in Rosacea

There is a new topical therapy for rosacea called Rhofade (oxymetazoline) cream. While the FDA approved it in January, it has only been available at pharmacies recently. It is best used for the redness of rosacea (there are plenty of other medications for the acne-like bumps that are treated separately). It is a cream applied once daily that works by constricting blood vessels (technically called an alpha adrenergic agonist). It seems to be an improvement over a similar product called Mirvaso as it seems to cause less rebound (when a medication constricting the blood vessels wears off, there is potential that blood will rush into the area faster than before, causing increased redness and burning sensations. I’ve had some patients experience that with Mirvaso. Anecdotally, it seems much rarer with Rhofade).

I am not aware of the full clinical trial data being published. That being said, the FDA product insert summarizes that 489 study subjects were treated over 4 weeks. A separate up to 1 year clinical trial enrolled 440 subjects. Efficacy was good. However, the redness rarely completely resolved. Adverse reactions were quite low with 3% or fewer subjects experiencing rashes, flares, itching, redness, and discomfort.

As with most new products, it is only available as a brand name. No generic is available. Thus, the usual caveats that the copay may be high, it might be completely rejected by insurance, or I may recommend using a specialty pharmacy that is experienced in brand name medication insurance paperwork for a higher success rate. I have zero financial ties with any of these specialty pharmacies.

If you have rosacea or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Waldorf HA, et al. Getting the red out: Expert tips Practical Dermatology 2017
- Prescribing information. Rhofade (oxymetazoline). https://www.allergan.com/assets/pdf/rhofade_pi.pdf Last accessed 5/29/17

 

May 2017

What's New in Molluscum

What's new in Molluscum

Imiqiumod (Aldara) cream is a medication I used to prescribe for molluscum, a viral skin infection commonly seen in children (sometimes in adults). As I advised parents and patients, it sometimes worked, but not strongly so and not consistently. I also advised that direct destruction (freezing with liquid nitrogen or scraping off, ie curettage) was more effective. However, some chose the cream to potentially minimize scarring and discomfort. That being said, I now no longer give the option of the cream as the data for a placebo controlled trial with 3 times/week application has become more widely known. Specifically, while 24-26% of patients treated resolved after 18 weeks, 26-28% of placebo patients also resolved in the same timeframe. Thus, it doesn’t work any better than placebo.

A potential limitation could be that 3 times/week application was insufficient as I sometimes increase up to 7 times/week usage if a patient tolerates 3 times/week usage. (I always warn to decrease or stop the medication if issues, esp. excessive irritation) That being said, with the data being so strong against any benefit with 3 times/week usage, I no longer offer the cream even with more frequent usage as an option.

Unfortunately, it is only recently that this data has become known. The full data from these large (702 patients, 470 receiving imiquimod), industry-sponsored clinical trials has still not been published in a medical journal despite being conducted in 2006. This is despite, as pointed out by dermatologist Dr. Katz, that the company was rewarded with 6 additional months of marketing exclusivity in exchange for conducting the trials.

Thus, if a high degree of efficacy is desired, we are left with primarily destructive treatments. Specifically, freezing with liquid nitrogen of scraping off, ie curettage. The downsides are scarring and discomfort, esp for young children. Some physicians use topical cantharidin to cause blistering of the molluscum to avoid in-office pain although there is some controversy on its effectiveness. I sometimes prescribe topical steroids to minimize itching to prevent molluscum spread.

If you or your child has molluscum or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Farhangian ME, et al. Treatment of Molluscum Contagiosum with Imiquimod in the United States: A Retrospective Cross-Sectional Study Pediatr Dermatol 2016
- Levy ML. Managing Molluscum with Imiquimod: Ignoring the Evidence Pediatr Dermatol 2016
- Katz KA, Swetman GL. Imiquimod, molluscum, and the need for a better "Best Pharmaceuticals for Children” Pediatrics 2013
- Katz KA. Imiquimod is not an effective drug for molluscum contagiosum Lancet Infect Dis 2014
- DailyMed. Aldara (imiquimod) cream for topical use. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0c3aed27-7b3f-442e-9f60-f2f5c672c85d#S8.4 Last accessed 4/30/17
- Osier E, et al. The utility of cantharidin for the treatment of molluscum contagiosum Pediatr Dermatol 2015

 

April 2017

What's New in Eczema (atopic dermatitis)

What's new in Eczema (atopic dermatitis)

Last month we discussed a promising new topical for eczema & atopic dermatitis (sensitive itchy skin). This month, I’d like to mention a new systemic therapy called dupilumab, which was just approved this year. It’s currently only available as a brand name called Dupixent. It is a human monoclonal antibody that blocks molecules that affect inflammation called IL-4 and IL-13 in the bloodstream.

It is FDA indicated for adult moderate to severe atopic dermatitis not adequately controlled by topical (applied directly so skin) medications. For my pediatric patients (ie, less than age 18), this medication is not currently indicated.

The two published phase 3 trials totaled 671 patients. The average participant age was 38. About 37% of those receiving the medication became almost clear or clear after 16 weeks. About 10% of the placebo group reached the same goal. This is good improvement, although not amazing.

Common side effects included:

  • Injection site reactions: (ie, redness and irritation where the needle was injected)
    • 10% in treated, ~5% in placebo
  • Conjunctivitis:
    • ~10% in treated, 2-5% in placebo
  • Keratitis: (eye issue)
    • 1-4% in treated, 0 in placebo
  • Herpes
    • Oral: 3-4% in treated, 2% in placebo
    • Non-oral: 1-2% in treated, ~1% in placebo

Cons include the side effect of it being a brand name is its cost of roughly $37,000/year. Many insurance plans may block this medication outright or make it extremely difficult to obtain. Also the patient does have to be okay with needles as he or she will have to self inject roughly every 2 weeks. The published studies only lasted for 16 weeks. The FDA product insert mentions a 52 week study but I have not yet seen it published (since the 16 week data was only published online Dec 2016, the 52 week data likely won’t be published until at least September 2017).

If you have eczema or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Simpson EL, et al. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. New Engl J Med 2016
- Vorhees AV. Does dupilumab pass the test for atopic dermatitis? Dermatology World https://www.aad.org/dw/monthly/2017/january/does-dupilumab-pass-the-test-for-atopic-dermatitis?utm_source=AAD%20Newsletters Last accessed 4/2/17
- Thomas K. Severe Eczema Drug Is Approved by F.D.A.; Price Tag Is $37,000 a Year. NY Times https://www.nytimes.com/2017/03/28/health/drug-prices-fda-eczema-skin-disease.html?_r=0 Last accessed 4/2/17

 

March 2017

What's New in Eczema (atopic dermatitis)

What's new in Eczema (atopic dermatitis)

Many patients (and for children, their parents) prefer to avoid topical steroids when possible for their itchy skin. While dermatologists agree that topical steroids are the mainstay first line treatment, I always try to accommodate patient preferences as possible. Unfortunately, there are only a few non-steroidal options. The mainstays have been tacrolimus ointment (brand name Protopic) and Elidel (no generic available) which are called calcineurin inhibitors. Their cons are that they are far weaker than steroids, can cause a burning sensation on application, are rarely covered by insurance, are very expensive out of pocket, and have a black box warning about causing lymphoma & skin cancer (which are not side effects of topical steroids).

That being said, it’s always good to have more options. There is now a new non-steroidal ointment approved by the FDA and available as a prescription. Specifically, Eucrisa ointment (the generic crisaborole will not be available for many years) uses a new mechanism of being a phosphodiesterase 4 inhibitor, which decreases molecules involved in inflammation. Two placebo-controlled clinical trials have been published. In total, 1527 patients averaging age 12 and at least age 2 were enrolled for the 28 day trial. Efficacy was achieved, although mild to moderate from my standpoint, as expected from a non-steroid medication. Essentially, 32% significantly improved with the medication versus 22% with just the placebo ointment vehicle. Very simplified, that means very roughly 10% more improvement from the medication versus routinely moisturizing with an ointment. Another benefit was less skin infections were seen (which is also a benefit of steroidal medications) by healing the cracks through which bacteria penetrate.

Safety is the main question when using these non-steroidal medications as it is unlikely they will ever be more effective than steroids. Unfortunately, it was only a 28 day trial. Thus, safety cannot be guaranteed. I have not heard that the trial will be continued for a longer time, so we’ll be dependent on anecdotal reports of safety (or side effects) over time to have a better idea. So far, no serious adverse events were reported. It had less burning on application (only 4.4%, which was 3% more than the vehicle alone) than other non-steroidal mediations (tacrolimus, Elidel). Safety is theorized to be promising as crisaborole is reported to have "low systemic absorption and is quickly metabolized to its inactive metabolites.”

The other question is insurance coverage and cost. One tube currently retails for about $600. Thus, it is not practical to pay out of pocket unless insurance covers it. I’ve written a few prescriptions so far (it has only been recently released). I do not have a good answer for this question yet, but it’s worth trying to prescribe for the right patient.

If you have eczema or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Paller AS, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol 2016
- Elias P. An Appropriate Response to the Black-Box Warning: Corrective, Barrier Repair Therapy in Atopic Dermatitis. Clin Med Dermatol 2009

 

February 2017

What's New in Acne

What's new in Acne

Spironolactone is a medication I sometimes use for healthy females who are practicing effective birth control with moderate to severe acne that has failed standard first line therapy (usually topicals and/or oral antibiotics). This medication is used in other specialties for its diuretic properties (it makes you pee more, thus lowering blood pressure). However, for acne, it has antiandrogen properties.

Limitations include that it is not FDA approved for acne. It may cause birth defects, by blocking testosterone esp for a male fetus. Thus, concurrent 100% adherence to birth control pills possibly in conjunction with condom usage or an IUD is preferred (I do not prescribe these, patients will need to see their primary care doctor or Ob/Gyn). If not, strict adherence to effective birth control measures is mandatory, ie. 100% adherence to condoms for the complete duration of all intercourse. If birth control pills or an IUD is not used, monthly laboratory pregnancy testing is likely mandatory. Laboratory pregnancy testing is primarily used both because it usually detects pregnancy sooner and more reliably than OTC methods, but also for medicolegal reasons. While no one wishes to take any risk to a baby, the risk "occurs approximately six weeks post-conception, and if inadvertent administration is discontinued at an early state, the potential risk to the male fetus is negligible.” Thus, a monthly pregnancy test will help decrease the risk a male fetus is exposed too long to the medication.

There is potential for cancer, specifically estrogen-dependent malignancies such as breast cancer. The package insert has a warning that tumors were found in rats given ~25-250 times the usual human dose (on a body weight basis). Thus, patients with a family history of breast cancer or worry about the risk of breast cancer may wish to avoid this medication. That being said, in a 8 year follow-up study, there were zero cases of breast cancer out of 91 patients (although 4 patients underwent biopsies with benign outcomes).

Common side effects include increased urination, irregular periods, and breast tenderness.

In addition, it can elevate potassium levels (hyperkalemia) which is a potentially serious adverse effect. This can lead to heart issues, muscle cramps, and/or weakness. Traditionally, potassium levels are checked at baseline, after 1 month of medication, and with any increase in dosage. This is despite this side effect being rare. However, a recent chart review by Dr. Plovanich found no practical potassium elevation in 974 healthy young women taking spironolactone. Healthy was defined as no heart issues, no kidney issues, and no medications with potential for interaction. Young was defined as 18 to 45 years, but on average 27 years. The rate of elevated potassium values was the same as the general population rate (0.72% in treated vs 0.76 in the untreated population). Of the 13 elevated values, 6 were normal on re-testing and no action was taken by the clinician in the remaining 7 (indicating it was not clinically significant). Thus, the conclusion was "routine potassium monitoring is unnecessary for healthy young women taking spironolactone for acne.”

For my summary, I’d say spironolactone is acne medication to be considered for healthy females who accept the risks. I’ve never been a huge fan of the medication, but some of my patients find it quite helpful. It is not the strongest medication as isotretinoin (Accutane) is clearly more effective with longer lasting results, but some patients prefer not to take isotretinoin for various reasons. Many patients dislike the frequent laboratory testing for spironolactone and overall the evidence would make me willing to decrease or not perform laboratory testing for patients who understand that many physicians would still recommend laboratory testing (partially due to the FDA recommendation for laboratory testing), are on a birth control pill (ideally with condom usage as well) or a IUD, and that they accept the risk of side effects.

If you have acne or other skin issues, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Plovanich M, et al. Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne. JAMA Dermatol 2015
- Shaw JC, et al. Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg 2002
- Kim GK, et al. Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris. J Clin Aesthet Dermatol 2012

 

January 2017

What's New in Sarcoid

What's new in Scaroid

Sarcoid is a disease in which the body becomes inflamed, resulting in damage especially to the lungs and lymph nodes. This also results in scar-like rashes on the skin. A manifestation that traditionally hasn’t been taught or appreciated is that there is also commonly (~40% of patients) nerve damage as well, resulting in pain and uncomfortable sensations. These symptoms are commonly mistaken for fibromyalgia syndrome.

Unfortunately, a recent study reports that mainstay treatments (corticosteroids, methotrexate) are not very effective in treating the nerve damage. This is partly because nerves are known to heal much more slowly than other parts of the body (they regenerate only 1 inch/month after injury). Thus, once any nerve is damaged by the disease, it may take years of remission before it can be healed. A limited 3 person case series did report that a treatment called intravenous immunoglobulin may be helpful. However, at approximately $40,000 (I could only find a published 2006 cost of $25,000 but anecdotally costs seem to have roughly doubled in the past 10 years) for 3 months of medication for what has been reported as permanent treatment with no end, the hassle for the patient of visiting an infusion center every 2-3 weeks, the risks of immunosuppression, and the unlikelihood of insurance covering indefinite $160,000/yr experimental therapy, it is not currently a practical option.

While I hope more practical treatments may be available in the future, the main takeaway for me is for the numerous patients I see in clinic with itching, esp. when out of proportion to the rash (ie, very itchy patient with clinically mild or no rash), it is not simply a skin disease. There is also likely a common endpoint of nerve damage. The causes likely vary (sun damage which has been theorized to damage superficial nerves, age-related degeneration, diabetes, hypertension, poor circulation, damage from scratching, scar tissue, etc) and it is often impossible to find the exact cause. Even though there are treatments to attempt, patients and doctors are often frustrated that there is no one medication that is guaranteed to work. Step therapy is usually needed (ie, start with relatively safe medication and potentially work up to stronger medications with more side effects if first-line treatment fails).

If you have unusual lesions on your skin, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Jancin B. Small fiber neuropathy common, vexing in sarcoidosis. Dermatology News 2016
- Mackinnon SE, et al. Nerve injury & recovery. http://nerve.wustl.edu/NerveInjury.pdf Last accessed 1/15/17
- Jordan SC, et al. Intravenous gammaglobulin (IVIG): a novel approach to improve transplant rates and outcomes in highly HLA-sensitized patients. Am J Transplant 2006

 

December 2016

What's New in Eczema (atopic dermatitis) & Food allergy

What's new in Melanoma

One factor that can worsen eczema (atopic dermatitis, "sensitive skin”) is food allergy. It is known that patients with eczema have a higher risk of food allergy. A recent study showed that this may be due to a bacteria called Staphylococcus aureus ("staph”). This bacteria colonizes ~50% of patients with eczema, weakening the skin barrier and promoting food allergens to penetrate the skin, triggering a cascade leading to food allergy. This is in addition to some patients who are genetically missing a protein called filaggrin that also have a more permeable skin barrier. It is theorized that treating the S. aureus colonization would help decrease the risk for food allergy. From the dermatologist point of view, this can entail a combination of mupirocin (Bactroban) ointment to the nostrils, a common location of S. aureus colonization, bleach baths (http://eczemacenter.org/Bleach%20Baths.pdf), and/or oral antibiotics.

Researchers used a database of 718 patients. They found that those with a history of S. aureus culture (either MRSA or MSSA) and highly elevated IgE levels for specific foods (peanut, egg white, cow’s milk). They found the patients had a higher IgE level with a history of a MRSA culture than a MSSA culture than no positive S. aureus culture. Peanut skin prick test results were similar. They theorized that S. aureus leads to skin barrier dysfunction (it produces multiple virulence factors, e.g. superantigens, proteases, etc) and inflames the immune system to prime the immune system for food allergy (increased Th2 mediated responses, decreased regulatory T-cell function).

Several caveats:

#1) It could simply be the severe eczema itself leads to both higher risk for S. aureus and food allergy. The study is suggestive, but doesn’t prove causality.

#2) The evidence points towards the eczema preceding the food allergy, not vice versa. This suggests eczema causes food allergy. Thus, even if any food allergies are cured, it is unlikely the eczema will be cured. That being said, reducing the food allergy portion of their itching and rashes can be helpful.

#3) Testing for food allergy is somewhat controversial. Practically, the best test for food allergy is simply observing that your child or yourself has a reaction after eating the food then simply avoiding that food. Indeed, American Academy of Dermatology guidelines state "broad panel allergy testing independent of a history of a reaction to foods is not recommended.” The National Institute of Allergy and Infectious Diseases guidelines suggest consideration of limited food allergy testing (cow’s milk, eggs, wheat, soy, and peanut) if a child <5 years of age has moderate to severe AD and (1) persistent disease in spite of optimized management and topical therapy or (2) a reliable history of an immediate allergic reaction after ingestion of a specific food. The problem with testing is what to do with the results. They are good at ruling out food allergy (>95% negative predictive rate) but almost like flipping a coin if positive (40-60% positive predictive value and specificity). Thus, positive tests are theoretically supposed to be followed by a double-blind, placebo-controlled oral food challenge. This entails one person putting the possible food allergen (ie, peanuts) in 1 cup & a placebo (ie, sugar cubes) in a 2nd cup. Then, a different person is supposed to feed 1 of the cups, wait 48 hours (as there are both immediate and delayed allergic reactions), then assess if any reaction happened within that 48 hours. Then, the 2nd cup should be given, another 48 hours used up, then again an assessment performed. Then, only if a patient had a positive lab test and a positive oral food challenge should they be considered to be allergic to that food. Then, they simply have to avoid that food. This is almost always not practical due to this requiring 4 days of testing per food item and, if the patient is truly allergic to the food item, the risk for anaphylaxis (do not try this at home without consulting with your doctor). As a practical basis, I recommend consulting your allergist if you wish to consider allergy testing.

If you or your child has eczema, itchy skin, or have other skin questions, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Jones AL, et al. Food allergy is associated with Staphylococcus aureus colonization in children with atopic dermatitis. J Allergy Clin Immunol 2016
- Franki L. Food allergy development linked to S. aureus colonization in children with AD. Dermatology News 2016
- Tsakok T, et al. Does atopic dermatitis cause food allergy? A systematic review. J Allergy Clin Immunol 2016
- Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol 2014

 

November 2016

What's New in Melanoma

What's new in Melanoma

I am seeing increasing numbers of melanoma in my practice, with two cases in one day recently. One relatively simple agent that may improve survival is vitamin D. A recent prospective cohort study of 1,042 melanoma patients by Fang et al found that those with higher vitamin D values had significantly higher "overall survival, melanoma-specific survival, and disease-free survival.” Those with < 16 ng/ml, the approximate value used to mark Vitamin D deficiency, "were 1.62 times more likely to experience recurrence and were 1.76 times more likely to die as a result of melanoma.”

That being said, the study does not prove cause and effect. I would also emphasize I would not recommend increasing sun exposure to increase vitamin D levels. The consensus is oral supplementation is much preferred over increasing sunlight exposure. In addition, vitamin D is not risk free and can lead to excessive calcium levels ("particularly in high dosages of >5000 IU daily”)

While further data and guidelines would be ideal, those who have been diagnosed with melanoma or are at high risk for melanoma may wish to consider vitamin D blood level testing and/or supplementation.

If you have bumps on your body worrisome for skin cancer, especially melanoma, or have other skin questions, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Fang S, et al. Association of Vitamin D Levels With Outcome in Patients With Melanoma After Adjustment For C-Reactive Protein. J Clin Oncol 2016
- Sondak, et al. Vitamin D and Melanoma: What Do We Tell Our Patients? J Clin Oncol 2016
- Newton-Bishop JA, et al. 25-Hydroxyvitamin D2/D3 levels and factors associated with systemic inflammation and melanoma survival in the Leeds melanoma cohort. Int J Cancer 2015
- Khan QJ, et al. How I treat vitamin d deficiency. J Oncol Pract 2010

 

October 2016

What's New in Alopecia areata

What's new in Alopecia areata

Alopecia areata is a relatively common disease affecting 2% of the population. It is characterized by bare patches lacking hair on the scalp. It appears quickly and many patients report it occurs "overnight.” The most effective treatment for patchy disease involving less than half the scalp is a series of steroid injections into the affected areas. This is usually repeated every 4 to 6 weeks until full regrowth is achieved.

However, there has been no good therapy for those who have more than half their scalp involved. In addition, anywhere the body has hair can also be affected, e.g. beard, mustache, armpits. It is just not practical to inject all of these areas at once. Oral steroids work temporarily but have side effects, esp. when used long-term. Also, once the oral steroids are stopped, the disease tends to return.

Thus, patients commonly ask me if there are any new medications available for extensive alopecia areata. The main answer I’m aware of are that there have been increasing case reports and limited studies that a class of medications called "JAK inhibitors” (named for the inflammatory enzyme the mediations block) seem to improve patients with extensive alopecia areata, esp tofacitinib. The medication is currently indicated for rheumatoid arthritis. One recent speaker Dr. Sidharthan reported that 7 of 12 patients in a single-arm clinical trial achieved more than 50% regrowth with tofacitinib after 6 months of treatment. Of those 12 patients, 7 had moderate to severe alopecia areata and 5 had complete scalp hair loss (alopecia totalis or alopecia universalis). However, the investigator had to push the dosage beyond what is currently being used for rheumatoid arthritis (5 mg twice daily) to twice the dosage (10 mg twice daily) for 6 of the 7 patients.

Side effects for tofacitinib include serious infections, cancer, stomach or intestinal perforation, and blood or liver issues. This is of course not to be taken lightly. In the clinical trial, there were no serious adverse events but there was a decreased platelet count (the cells that form clots) that resolved after discontinuing the medication, an increased white blood cell count (the cells that fight infection) that resolved after discontinuing the medication, liver inflammation that may have been due to patient-reported alcohol usage, self-limiting diarrhea, and blood in urine. While these weren’t considered serious, it is still a fairly high rate of side effects which is not surprising given that the investigator used twice the normal medication dosing.

Other limitations include that I am not aware of any double-blind placebo controlled trials, which is considered the gold standard in determining if a medication works. This is particularly important in alopecia areata where there is a high, fairly random, remission rate. That being said, 7 of 12 patients experiencing › 50% regrowth within months is suggestive of a true benefit. Also, I am not aware of any long term follow-up studies in reporting the average duration of the benefit, whether days, weeks, months, or years. Oral steroids have a fairly high remission rate, but also a high rate of relapse. As always with today’s medical system, cost is also a concern with tofacitinib retailing for about $3000/month for rheumatoid arthritis dosing and $6000/month for the dosages used in the above reported clinical trial. Thus, insurance companies may not cover it.

In summary, I’m not excited about tofacitinib, but it is an option to consider for patients with extensive alopecia areata who are willing to take on the risks and understand the effect may not be long-lasting.

If you have alopecia areata or have other skin questions, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options. You can also sign up for the National Alopecia Areata Foundation newsletter at https://naaf.org

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Karon A. JAK inhibitor improves alopecia, with caveats. Dermatology News 2016
- Gupta AK, et al. Efficacy of tofacitinib in treatment of alopecia universalis in two patients. J Eur Acad Dermatol Venereol 2016
- Xing L, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med 2014
- WHAT IS XELJANZ? Safety & Side Effects http://ra.xeljanz.com/about-xeljanz/safety-and-side-effects Last accessed 10/16/16
- Alopecia areata. http://nahrs.org/PatientInformation(FAQs)/AlopeciaAreata(FAQ).aspx Last accessed 10/16/16

 

September 2016

What's New in Nonmelanoma skin cancer

What's new in Nonmelanoma skin cancer

Similar to how patient see their primary care doctor for both treatment and prevention of diabetes and high cholesterol, patients see dermatology for both skin cancer treatment and prevention as well. One target are the precancerous lesions called actinic keratosis (scaling pink bumps on the skin). Published risk estimates vary, but has been summarized to be about 8% risk per individual scaling bump of progression to skin cancer. The highest risk is for squamous cell skin cancer, a type that can metastasize if left alone too long. The most common treatment of actinic keratoses is focal application of liquid nitrogen to treat individual lesions. Sometimes, physicians utilize creams, esp. 5-fluorouracil for 2-4 weeks. The creams & solutions do have risks, esp. excessive long-lasting skin irritation, infection, and insurance issues. Practically, I tell patients they may look very red and raw for 1-2 months and the medication can cost hundreds of dollars. Usually patients prefer focal liquid nitrogen application.

That being said, a study has been published that if the 5-fluoruracil is used in conjunction with a medication called calcipotriene, it seems to be effective with just twice daily x 4 days application. The theory is that calcipotriene, which is synthetic vitamin D usually used for psoriasis, induces a protein called thymic stromal lymphopoietin which suppresses skin cancers. It seemed to be tolerated well. However, the major practical concern is cost. Beyond the cost of the chemotherapy 5-fluorouracil, now patients will also have to pay for the calcipotriene that seems to be hundreds of dollars even with insurance. Unfortunately, I would not be surprised if the total cost for the two medications is close to a thousand dollars, even with insurance. Hopefully that will change in the future although it seems insurance is moving the other way (toward higher and higher medication copays for patients). It also appears the "inventors” are patenting this combination, which is quite dismaying from my standpoint, so that may increase costs further in the future. This may cause focal liquid nitrogen to still be the standard of care for many more decades.

If you have sun damage or rashes worrisome for skin cancer, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Karon A. Adding calcipotriene to 5-FU dramatically reduced AKs. Dermatology News 2016
- Seckin D, et al. Can topical calcipotriol be a treatment alternative in actinic keratoses? A preliminary report. J Drugs Dermatol 2009
- Glogau RG. The risk of progression to invasive disease. J Am Acad Dermatol 2000
- 5-Fluorouracil+Calcipotriol Topical Preparation for the Treatment of Actinic Keratosis. https://otm.wustl.edu/technologies/5-fluorouracilcalcipotriol-topical-preparation-for-the-treatment-of-actinic-keratosis/ Last accessed 9/18/16

 

August 2016

What's New in MRSA colonization

What's new in MRSA Colonization

I have been seeing an increasing number of infections, including MRSA bacteria, in my patients. This has been especially true among my teenage and college patients who play sports. Recently, a solid study corroborated what I see and showed that 8-13% of athletes are colonized with MRSA. The colonization is especially in the nostrils, but also groin (inguinal) and armpits (axillary) areas. The sports with the highest risk were wrestling (22%), football (8%), and basketball (8%). I also see high rates among patients who use mats (martial arts, gymnastics, yoga) and frequent public gym usage. The reason this is a concern is that MRSA colonization increases the risk of MRSA infection elsewhere on the body by at least 7-fold. This includes boils (furuncles), superficial skin infections (impetigo), and deep skin infections (cellulitis).

Practically speaking, if a patient has repeated infections, I oftentimes recommend treating the colonization as well. Nasal colonization is usually treated with a prescription antibiotic ointment. Studies sometimes use oral antibiotics to increase efficacy for the nose while treating the rest of the body. When possible, I prefer to avoid oral antibiotics especially when there is not an active MRSA infection and sometimes recommend what’s called a bleach bath that I explain during the appointment (please do NOT pour undiluted bleach onto the skin!). When patients perform the decolonization, I usually never see them with an active skin infection again.

If you have a skin infection or any other skin question, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Karanika S, et al. Colonization With Methicillin-resistant Staphylococcus aureus and Risk for Infection Among Asymptomatic Athletes: A Systematic Review and Metaanalysis.. Clin Infect Dis 2016
- Willingham V. Asymptomatic MRSA colonization prevalent in athletes. Dermatology News 2016
- Bleach baths. http://www.eczemacenter.org/Bleach%20Baths.pdf Last accessed 8/21/16
- Stenehjem E, et al. MRSA nasal colonization burden and risk of MRSA infection. Am J Infect Control 2013

 

July 2016

What's New in Rosacea

What's new in Rosacea

In the September 2014 update, I had discussed how ivermectin cream (brand name Soolantra) had been shown effective for papulopustular rosacea (ie, acne with pustules, not just flat redness). Now research has shown that it also induces a longer remission rate if the patient became clear or almost clear, specifically 115 days (~3.9 months) with ivermectin cream vs 85 days (~2.8 months) with the commonly used metronidazole cream.

As rosacea tends to be a chronic condition, allowing patients to have longer breaks without needing to apply medication is quite helpful.

Unfortunately, it is getting harder and harder to get medications covered through insurance. In my experience, it seems that Soolantra is sometimes covered for patients younger than 65 and worth trying to prescribe but almost never covered for patients age 65 or older (Ie, with Medicare). Even the commonly prescribed metronidazole cream is having more and more rejections nowadays. There are alternatives, of course, but not as ideal.

If you have rosacea, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Hilton L. Ivermectin 1% cream extends rosacea remission. Dermatology Times 2016
- Taieb A, et al. Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-week extension of the ATTRACT randomized study. J Eur Acad Dermatol Venereol 2016
- Taieb A, et al. Superiority of ivermectin 1% cream over metronidazole 0·75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol 2015

 

June 2016

What's New in Pediatric Psoriasis

What's new in Pediatric Psoriasis

Psoriasis is a skin disease of pink raised rashes covered with "silvery scale.” While it is most common in adults (about 2.6% of the population), 1 in 3 patients have their first outbreak before age 20 and 20,000 children are diagnosed with psoriasis each year.

First line treatment is usually topical therapy. However, there are definitely teenagers with such widespread psoriasis that systemic therapies are considered. The most studied systemic biologic for pediatric psoriasis is currently etanercept. Recently, a 5 year clinical extension trial of 182 pediatric patients treated with etanercept has been published. This is in addition to the initial trial lasting 48 weeks. Of course, the medication was efficacious with most achieving at least 75% improvement in their psoriasis.

That being said, most parents are reasonably concerned primarily with the safety data. In the original clinical trial for 48 weeks of 211 patients, there were 4 serious adverse events (3 infections, 1 ovarian cyst that was removed). There were no long term side effects after these were treated. In the 5 year extension trial, there was only one serious side effect reported to be due to the medication, a single case of skin infection (cellulitis). Otherwise, there were no other serious infections or cancers thought to be due to the medication. However, there were 7 other serious adverse events that occurred, but were thought by the study investigators not due to the medication. Some I would agree sound completely unrelated (a patient with a bone birth defects had more bone issues, a patient with a bladder birth defect had intestinal issues after a surgery), some sound unlikely (anxiety), some sound possible without further information (an abortion, infectious mononucleosis, a thyroid cyst). The most common side effect was an upper respiratory infection (ie, cold, flu, etc). The overall conclusion was "etanercept in pediatric patients was generally well tolerated.”

It is always good to have options, and I’m glad that there is a relatively safe option if a patient’s psoriasis is severe enough. That being said, topical steroids are the usual first line therapy for most patients. For pediatric patients with widespread psoriasis, I usually first suggest considering phototherapy (ie, standing in a medical upright light booth using a wavelength called narrow band UVB. high rate of improvement but needs regular visits to maintain the benefit) before biologics such as etanercept.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Paller AS, et al. Long-term safety and efficacy of etanercept in children and adolescents with plaque psoriasis. J Am Acad Dermatol 2016
-  Paller AS, et al. Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med 2008
-  Jancin B. Pediatric psoriasis: Biologics safe, effective long term. Dermatology News 2016
About psoriasis and psoriatic arthritis in children. Accessed: June 5, 2016

 

May 2016

What's New in Eczema

What's new in Eczema

Parents often ask me for recommendations on special diets for their babies with "sensitive skin,” i.e. atopic dermatitis/eczema. Specifically, I’ve been asked whether they should consider hydrolyzed formula. Hydrolyzed means that the milk proteins have been broken down into smaller pieces. These formulas are advertised as "might be a good choice” for "skin rashes.”

However, a recent review (meta-analysis) of 37 clinical trials "found no consistent evidence to support a protective role for partially or extensively hydrolysed formula [for reducing risk of allergic or autoimmune disease].” In addition, researchers "found evidence of publication bias, methodological biases, and conflict of interest in those studies reporting allergic outcomes.”

In addition, the FDA’s conclusion summarized in Pediatrics was "there is little to very little credible evidence for a qualified health claim about W-PHF [whey protein partially hydrolyzed infant formula] and a reduced risk of AD [atopic dermatitis]”

Overall, it seems the guidelines that do recommend the consideration of hydrolyzed formula base this on "little evidence.” While parents often hope that changing the baby’s diet will improve matters, from a skin standpoint, it seems that special formulas are not the solution. If you or your child has eczema, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Boyle RJ, et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ 2016
-  Chung CS, et al. FDA’s Health Claim Review: Whey-protein Partially Hydrolyzed Infant Formula and Atopic Dermatitis. Pediatrics 2012
How Hydrolyzed Formulas Can Help Your Baby. Accessed: May 8, 2016

 

April 2016

What's New in Psoriasis

What's new in Psoriasis

I usually post updates on new disease treatments. This month is unusual for instead discussing a new birth defect risk for etanercept (Enbrel), an injectable biologic medication used to treat moderate to severe psoriasis. Specifically, it may double the risk of major congenital defects. The FDA currently rates its safety in pregnancy as "B”, which is as safe a rating as I have seen in dermatology, other than folic acid (which is the only "A” I am aware of in dermatology). This means that the FDA believes animal studies show no risk of adverse effects but there are no adequate studies in pregnant women. However, a study of 370 women exposed to etanercept while pregnant has recently been reported to show a doubled risk of major congenital defects. This includes spine defects (spina bifida), heart defects (atrial septal defects), cleft palate, genital defects (hypospadias), extra finger or toe (polydactyly), and skull defects (craniosynostosis). Its main alternative adalimumab (Humira) hasn’t had full results yet reported but verbally "hasn’t found much to worry about.” Thus, with this new update, I may steer women with moderate-severe psoriasis who wish a systemic treatment to adalimumab (Humira) or another alternative if they may possibly become pregnant.

Currently, the doubled risk seems to have only been reported verbally by the Organization of Teratology Information Specialists (OTIS) at a rheumatology conference (annual meeting of the American College of Rheumatology) and in a publication reporting on the conference. OTIS’s own website on Enbrel hasn’t yet been updated with the information. Caveats were provided including "not meeting the criteria for causality” (not fitting normal teratogen pattern of also seeing reduced birth weights and spontaneous abortions) and "no biological plausibility” (since etanercept doesn’t seem to cross the placenta during the most vulnerable period for the fetus). However, I feel a doubled risk is large enough that the association is still something to consider.

If you have psoriasis, please make an appointment for dermatology consultation at (626) 331-6411 to discuss your options.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Otto, A. Etanercept doubles risk of major malformations. Dermatology News 2016
-  Etanercept (Enbrel®) and Pregnancy. http://mothertobaby.org/fact-sheets/etanercept-enbrel-pregnancy/ Last updated 12/20/15

 

March 2016

What’s New in Eczema

What's new in Eczema

Many adults see me for itchy skin. One common reason is that the skin becomes naturally drier with age due to sun damage and the skin secreting less natural moisturizing factor. As discussed in my October 2015 update, many patients wish to use supplements in addition to medical treatment for their skin diseases. While there is rarely solid evidence to support supplements for the skin, dry skin is a case where it is reasonably supported by medical science. One supplement I sometimes recommend is nicotinamide 500 mg twice daily (synonym for niacinamide). A substudy of a phase 3 trial has reported transepidermal water loss (TEWL, the rate of water evaporation from the skin) is reduced about 6% with no increase in side effects reported compared to placebo. The research subjects were adults with a history of skin cancer so the results may not be well generalizable to children. Thus, this supplement is more supported for the many adults I see with dry, itchy skin and less supported for children with dry skin.

As in my last update, this supplement is not to be confused with niacin (nicotinic acid), which has side effects many patients consider intolerable (flushing, headache, etc).

As with most supplements, the evidence isn’t strong. The research is also currently only reported as an oral presentation. However, the main study it is part of is solid and published in the New England Journal of Medicine.

If you have severely dry or itchy skin, please make an appointment for dermatology consultation at (626) 331-6411

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Jancin B. Oral nicotinamide reduces transepidermal water loss. Dermatology News 2016
-  Chen AC, et al. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med 2015


 

February 2016

What’s New in Infantile Hemangiomas

What's new in Infantile Hemangiomas

As discussed in my July 2014 update, infantile hemangiomas are benign blood vessel tumors that typically grow rapidly then gradually involute. They can leave fibrofatty scars and sometimes "specific anatomic curves of the lips, nose, and philtrum do not necessarily return to normal contours after becoming distorted.” Treatment has shifted from steroids to a blood pressure medication called propranolol to there now being promising data on using a medication called itraconazole. This is a good trend as the newer medications seem to be both safer and more efficacious than the previous medications used. The previous propranolol could require a cardiovascular and pulmonary exam, in addition to bloodwork monitoring. Thankfully, itraconazole only needs routine bloodwork. It has been shown in laboratory research to inhibit growth and migration of proliferating human hemangioma epithelial cells, similar to the older propranolol but efficacious at a 10-fold lower dosage concentration.

Oral itraconazole led to a 71% success rate (80-100% improvement & both parents and physicians indicated satisfaction with the results). Treatment averaged 8.8 weeks, and the medication was dosed at 5 mg/kg/day. Patients were monitored for liver issues and all liver results were normal. One third of patients had mild diarrhea not requiring discontinuation of medication.

The major caveat is that this is a single medical center with 17 treated patients. More data is obviously better, but for a relatively safe medication, this is likely enough data to consider the option.

If your child has a worrisome hemangioma or other concern, I look forward to seeing him/her. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

-  Ran Y, et al. Successful treatment of oral itraconazole for infantile hemangiomas: a case series. J Dermatol 2015
-  Jancin B. Infantile hemangiomas: Case series supports therapy. Dermatology News 2016
-  Freiden IJ. Infantile Hemangiomas: Past, Present, and Future. Dermatology Focus 2014

 



January 2016

What’s New in Melanoma

What's new in melanoma

Every year, there seems to be a new study demonstrating another medical benefit of coffee. Pertaining to dermatology, caffeinated coffee has now been shown to decrease the risk of melanoma. This is important given that melanoma is the 5th most common cancer in the United States and has a risk of mortality. It was a well-designed study where about 500,000 cancer-free participants agreed to answer medical questionnaires for ~10 years. About 1% of the participants (4778) developed melanoma in this time frame. Overall, those who drank at least 4 cups of caffeinated coffee a day had a 20% lower risk of malignant melanoma. Unfortunately, there was no statistical benefit to decaffeinated coffee

This is biologically plausible as coffee contains numerous chemicals. One of these is 5-O-caffeoylquinic acid which has been shown to decrease ultraviolet-induced carcinogenesis in mice. Coffee also seems to protect against Parkinson’s disease, type 2 diabetes, liver disease, and depression.

If you have a changing mole that needs evaluation or biopsy, please make an appointment for dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Loftfield E, et al. Coffee drinking and cutaneous melanoma risk in the NIH-AARP diet and health study. J Natl Cancer Inst 2015
- Hensrud, D. Is coffee good or bad for me?



December 2015

What’s New in Vitiligo

What's new in vitiligo

There has been interest in past columns dealing with "natural” ways of treating various skin diseases. For vitiligo, there are two studies demonstrating the effectiveness of Ginkgo biloba. Only one was a randomized clinical trial (testing 40 mg 3 times a day). However, relatively recently a second trial (testing 60 mg 2 times a day) was published also showing effectiveness. Even though it was an "open label” trial (when patients and investigators know they’re using the tested medication, there is a tendency to over-report any disease improvement), it makes me more open to recommending Gingko biloba 60 mg 2 times per day, 10 minutes before a meal, esp. if patients fail standard therapy (ie, both steroid and non-steroidal creams, phototherapy).

Side effects are low with Ginkgo biloba. The main issue is an increased bleeding risk. Most likely it should be stopped at least 3 weeks prior to many surgeries and some dental procedures.

For those who don’t know, vitiligo is an autoimmune disease where the body attacks normal pigment producing cells (melanocytes). There may be other factors as well. The end result is white patches that can appear anywhere on the skin, which can be emotionally distressing to patients.

If you have vitiligo or have any other questions, please make an appointment for dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Brunk D. Top 10 treatments for vitiligo. Dermatology News 2015
- Parsad D, et al. Effectiveness of oral Ginkgo biloba in treating limited, slowly spreading vitiligo. Clin Exp Dermatol 2003
- Szczurko O, et al. Ginkgo biloba for the treatment of vitilgo vulgaris: an open label pilot clinical trial. BMC Complement Altern Med 2011
- Whitton ME, et al. Interventions for vitiligo. Cochrane Database Syst Rev 2015
- Drugs and Supplements: Ginkgo (Ginkgo biloba) http://www.mayoclinic.org/drugs-supplements/ginkgo/safety/hrb-20059541 2015



 

November 2015

What’s New in Dermatitis herpetiformis

What's new in Dermatitis Herpetiformis

Most people have heard of celiac disease, an autoimmune disease where the ingestion of gluten (a protein found in certain foods, esp. the "big 3” of wheat, barley, & rye) causes the body to become inflamed. In dermatology, we see patients where the inflammation in the bowel spreads to the skin as well. This leads to the disease called dermatitis herpetiformis (which confusingly enough, has nothing to do with herpes). It results in intense itching, esp. on the elbows, knees, and buttocks. It is usually seen in middle age patients or older, almost never in children. Usually, a biopsy is performed to confirm the diagnosis.

Thankfully, a medication called dapsone usually works well for the itching and the rash. However, it does have side effects. It also doesn’t protect against the disease’s internal effects, including lymphoma (~30% increased risk in those with DH, esp. in the gastrointestinal tract and nearby lymph nodes. Different sources report widely different risks, however) and osteoporosis (seen in 50% of DH patients vs. 30% of control patients).

Thus, the theoretical treatment is a gluten-free diet. By avoiding gluten, the disease goes into remission, with the itch and rash disappearing and protection against lymphoma occurring. However, my patients hate the thought of giving up gluten, esp. bread. In the past, I’ve tried to do my own diet discussions, but with the increasing usefulness of the internet nowadays, most motivated patients find the Celiac Disease Foundation’s website to be most helpful:

Many stores have gluten-free sections nowadays. However, some patients may like an online store specializing in gluten-free products: (no relationship, financial or otherwise)

If you have dermatitis herpetiformis or have any other questions, please make an appointment for dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Lorinczy K, et al. Does dermatitis herpetiformis result in bone loss as coeliac disease does? A cross sectional study. Rev Esp Enferm Dig 2013
- Vinícius MC, et al. Dermatitis herpetiformis: pathophysiology, clinical presentation, diagnosis and treatment. An Bras Dermatol 2014
- Sigurgeirsson B, et al. Risk of lymphoma in patients with dermatitis herpetiformis. BMJ 1994



October 2015

What’s New in Nonmelanoma Skin Cancer

What's new in Nonmelanoma Skin Cancer

Patients frequently tell me they wish to use supplements in addition to medical treatment for their skin diseases. For patients at high risk for nonmelanoma skin cancer (one definition used by a recent study was having 2 or more nonmelanoma skin cancers in the past 5 years), nicotinamide 500 mg twice daily (synonym for niacinamide) has been shown to reduce their risk to develop another nonmelanoma skin cancer by ~25%. Two quick notes. This supplement is not to be confused with niacin (nicotinic acid), which has side effects many patients consider intolerable (flushing, headache, etc). Also, the investigator Dr. Damian does not recommend it currently for the general population, only for those who have a history of nonmelanoma skin cancer.

Two main things are holding me back from strongly recommending this to my patients. One, the research is currently only published in abstract (summarized) form and I am awaiting the full data to be published. Two, the effect was seen after subjects took the supplement twice daily for a year. Practically speaking, it’s difficult for most people to be consistent about taking a twice daily medication for so long. Third, while not studied, it is likely that the benefit would be lost once subjects stopped taking the supplement. As difficult as it is to take a pill twice daily, taking a pills indefinitely would be even tougher.

If you have a lesion worrisome for skin cancer or have any other questions, please make an appointment for dermatology consultation at (626) 331-6411

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Martin AJ, et al. Oral nicotinamide to reduce actinic cancer: A phase 3 double-blind randomized controlled trial. J Clin Oncol 33, 2015 (suppl; abstr 9000)
- London S. Nicotinamide cuts nonmelanoma skin cancers. Dermatology News 2015
- Surjana D, et al. Nicotinamide enhances repair of ultraviolet radiation-induced DNA damage in human keratinocytes and ex vivo skin. Carcinogenesis 2013

September 2015

What’s New in Rosacea

What's new in Rosacea

In past posts, I’ve discussed that many skin diseases (especially psoriasis and atopic dermatitis) are independent risk factors for internal disease. Now, rosacea is also having increased literature that links it to dyslipidemia (high cholesterol), coronary artery disease (heart disease), hypertension (high blood pressure). There seems to be a roughly 20-40% increased risk of these. In addition, the worse the rosacea, the higher the association. The reason for this is unclear. Possibly, like psoriasis, rosacea may be partially be linked to the circulation of inflammatory molecules in the bloodstream. Since the treatment of psoriasis has been linked to a decrease in these comorbidities, hopefully treatment of rosacea may also provide some benefit. However, this is currently only a hope.

If you wish help in improving your rosacea or have any other skin concerns, please make an appointment for dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Rainer BM, et al. Rosacea is associated with chronic systemic diseases in a skin severity-dependent manner: Results of a case-control study. J Am Acad Dermatol 2015
- Hua TC, et al. Cardiovascular comorbidities in patients with rosacea: A nationwide case-control study from Taiwan. J Am Acad Dermatol 2015
- Moon MA. Rosacea linked to dyslipidemia, hypertension, CAD. Dermatology News 2015

August 2015

What’s New in Eczema (atopic dermatitis)

Eczema (atopic dermatitis) - Dr. Chiang | Magan Clinic

Many skin diseases are ignored and dismissed by both patients and providers because it’s "just the skin.” However, research has shown an increasing understanding that simply having some skin diseases increases the risk of internal side effects. The evidence has been strongest for psoriasis which has been linked to metabolic syndrome including diabetes, high blood pressure, elevated cholesterol, and obesity. It also increases the risk of coronary artery disease. Thus, patients are at elevated risk for heart disease and stroke. Thankfully, treatment of moderate to severe psoriasis may decrease these risks.

More recently, studies have shown that children with eczema (atopic dermatitis) are also at risk for internal side effects, especially elevated blood pressure and obesity. In addition, there is an elevated risk of mental health issues including depression, anxiety, conduct disorder, and autism that increases with the severity of skin disease. In addition, female teenagers may have an increased risk of suicidal behavior.

If you wish help in improving your skin disease or have any other skin concerns, please make an appointment for dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Silverberg JI, et al. Central Obesity and High Blood Pressure in Pediatric Patients With Atopic Dermatitis. JAMA Dermatol 2015
- Yaghmaie P, et al. Mental health comorbidity in patients with atopic dermatitis. J Allergy Clinic Immunol 2013
- Noh HM, et al. The relationship between suicidal behaviors and atopic dermatitis in Korean adolescents. J Health Psychol 2015
- Ahlehoff O, et al. Cardiovascular outcomes and systemic anti-inflammatory drugs in patients with severe psoriasis: 5-year follow-up of a Danish nationwide cohort. J Eur Acad Dermatol Venereol 2015
- Gisondi P, et al. Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case-control study. Br J Dermatol 2007
- Sommer DM, et al. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res 2006

July 2015

What’s New in Wound Healing

Chronic wounds are painful, increase the risk of infection, and can be socially debilitating. Common locations are leg ulcers, most commonly due to venous (blood vessel) deterioration from obesity, lack of physical activity, smoking, work that requires long periods of standing, past deep venous clots, and past infection. Another common location is the buttock, which is a frequent location for pressure sores.

There has been increased interest in using topical solutions, specifically a beta blocker called timolol to improve wound healing. Specifically, Dr. Kirsner, a wound care expert, has published several cases where applying roughly 1 drop every 2 cm along the wound edge dramatically reduced the wound size. The average improvement was 78.2% after 7 weeks of treatment. While this was not complete resolution nor was it quick, it was a clear improvement. Prior studies have showed that beta blockers block catecholamines which may play a role in chronic wounds.

This is of course in addition to the many other treatments needed to improve healing including keeping the area clean, reducing swelling, treating any infection that may be present, stopping any smoking, losing weight if needed, and treating any diabetes or high blood pressure that exists. Note that a general dermatology office does not have all the tools necessary for curing the most severe chronic wounds such as skin grafts (either from the patient or human skin cultures) and advanced dressing materials (foams, hydrocolloids, hydrogels). Another caveat is that, in my experience, insurance almost never covers home wound care supplies which can be quite expensive. Even the timolol solution may not be covered. Last, for wounds that your primary care doctor thinks is not doing well, a wound care center may be appropriate for many patients, especially the most severe.

For most wounds, primary care is the first appointment to make. However, if your wound needs additional evaluation, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Jesitus J. Wound healing – Diverse tools and technique advances. Dermatology Times 2015
- Braund LR, et al. Topical timolol for recalcitrant wounds. JAMA Dermatol 2013
- Mohammadi AA, et al. Efficacy of propranolol in wound healing for hospitalized burn patients. J Burn Care Res 2009
- Tang JC, et al. For topical timolol for a refractory wound. Dermatol Surg 2012

 

June 2015

What’s New in Hives (urticaria)

Hives (urticaria)

Hives causes a high degree of itching where patients frequently cannot obtain a decent night’s sleep. It is relatively common in both children and adults. Treatment is complicated since identifying the trigger is often difficult and patients frequently cannot tolerate the stronger prescriptions available due sleepiness (sedation). The largest improvement is obtained with systemic steroids (either administered as an injection or as pills), but this is not a good long term solution. Thus, patients often ask how long they will be afflicted with the condition. Before, I didn’t have good data with which to answer this question but recently a study was performed which provided an answer at least for children. A study of 92 children found that hives resolved after a median duration of 4.3 years. Of course, some resolved sooner (18.5% at 1 year) and some resolved later (67.7% at 5 years). Unfortunately, most of the parents of my patients come in hoping the hives will resolve after a few days and are not excited to hear the average of ~4 years.

While I hope one day for a cure for hives (or at least a highly effective treatment with few/no side effects), at least this gives some of my patients (and parents of those patients) some answers. If you or your child suffers from hives, or have other questions, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Chansakulporn S, et al. The natural history of chronic urticaria in childhood: a prospective study. J Am Acad Dermatol 2014

May 2015

What’s New in Cold Sores (herpes simplex)

Cold Sores (herpes simplex)

Cold sores (ie, herpes simplex, usually type 1) are common, painful, and socially embarrassing. Thankfully, treatment of recurrent cold sores on the lip has become shorter. Rather than the older traditional ~1 week of treatment, it has become accepted that one day of treatment is effective. However, this is true only if treatment is begun as soon as possible. If the HSV-1 virus is allowed to increase in number by delaying treatment even after symptoms are noticed (burning, tingling) or the rash (blisters, sores) is noticed, then the peak viral replication phase may have passed (the first eight hours after symptoms are noticed) and treatment may not be as effective.

In addition, it has become more accepted that valacyclovir is preferred over traditional acyclovir due to greater absorption into the bloodstream.

While I hope that some day there will be a cure for this vexing condition, improvements on our treatment is always appreciated. If you suffer from cold sores, or have other questions, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Schlesinger TE. Advances in short-term therapy for herpes labialis. Practical Dermatology 2014
- Spruance SL, et al. High-dose, short-duration, early valacyclovir therapy for episodic treatment of cold sores: results of two randomized, placebo-controlled, multicenter studies. Antimicrob Agents Chemother 2003

April 2015

What’s New in Psoriasis

psoriasis

Psoriasis is a frustrating and relatively common disease. For moderate to severe patients, the FDA recently approved a new injectable medication called Cosentyx (secukinumab). It appears to be the strongest injectable medication for psoriasis yet. The results of two phase 3 trials have been released and encompass ~2000 patients. The medication is available as two dosages, 300 mg and 150 mg. The standard measurement of efficacy has traditionally been 75% reduction in psoriasis (termed PASI75). The 300 mg dosage had a ~80% rate of patients reaching this, while the 150 mg dosage had a ~70% rate of the same. Even better, the efficacy of recent injectable medications has bolstered the usage of a more difficult to reach measure of efficacy of "clear or almost clear.” This is practically the point that my patients become happy with the results. The 300 mg dosage had ~65% of patients reaching "clear or almost clear” vs. ~50% with the 150 mg dosage.

For side effects, I am most concerned about the potential risk for major adverse cardiac events, e.g. heart attacks and strokes, which were seen in a prior interleukin 12 & 23 inhibitor that has not yet met FDA approval. This medication also blocks an interleukin, specifically interleukin-17A. I have not had success obtaining detailed information on the risks of cardiac events from the manufacturer and in the published studies. So far, I have only been able to find information from one poster hosted by the Canadian Dermatology Association that states there were 2 heart attacks & 2 strokes in the treated groups and apparently none in the placebo groups. Until more safety data is released, the risk of heart attack and stroke in patients treated with this medication does seem increased to me. On the other hand, published data seems to indicate that the older but weaker injectables (primarily Enbrel & Humira) may instead decrease the risk of heart attack and stroke. Of note, while Enbrel & Humira are weaker, most of my patients using these are either satisfied or happy with their results

Injectable medications for psoriasis usually charge insurance companies thousands of dollars a month so there is often difficulty obtaining these medications even in patients meeting the generally accepted threshold of having at least 10% of their body surface area affected by psoriasis. Cosentyx as a new medication is likely to have similar hurdles.

Overall, I am glad to have a new option for my moderate to severe psoriasis patients. For now, it seems to be the strongest injectable available but it has some questions about safety and insurance coverage. Overall, it is a reasonable option to consider for some patients and especially my most severe.

If you have psoriasis, of whatever severity, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Langley, et al. Secukinumab in plaque psoriasis--results of two phase 3 trials. N Engl J Med 2014
- Elewskin, et al. Secukinumab in Subjects With Moderate-to-Severe Plaque Psoriasis: Results From the Efficacy of Response And Safety of 2 Fixed secUkinumab REgimens in psoriasis (ERASURE), a Pivotal Phase 3 Study. http://www.dermatology.ca/wp-content/uploads/2012/06/2014_P15_01.pdf

 

 

March 2015

What’s New in Eczema (atopic dermatitis)

eczema

Eczema has been increasingly associated to cardiac risk factors. The first is obesity. As the prevalence of eczema has been increasing in the past few decades (up to 20% of children and 10% of adults), a research review concluded it may be related to the increasing prevalence of obesity worldwide. This would make sense as eczema is partially a disease of a dysfunctional immune system, overactive in some ways, underactive in other ways. Obesity does result in a chronic low-grade inflammation that would theoretically worsen eczema. Overall, the, the analysis did indeed find a modest association between being overweight/obese and an increased prevalence and severity of eczema. As a side note, I am often asked if there is any diet that would improve eczema. I am not aware of one, but healthy weight loss should help.

In addition, separate studies found that eczema increased the odds of hypertension and prediabetes. This may be intrinsic to eczema itself. It may also be partially due to increased rates of alcohol usage and smoking along with decreased exercise activity found in population studies of patients with eczema. These poor health habits may be secondary to the increased stress of having itchy skin and visible rashes along with poorer heat tolerance (ie, poor sweating).

If you or your child has eczema, of whatever severity, I look forward to seeing you. Hopefully optimal management of the eczema will decrease the risks of obesity, hypertension, and prediabetes. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Zhang, et al. Association of atopic dermatitis with being overweight and obese: A systematic review and metaanalysis. J Am Acad Dermatol 2015
- Silverberg, et al. Eczema and cardiovascular risk factors in 2 US adult population studies. J Allergy Clin Immunol 2015

 

 

February 2015

What’s New in Psoriasis

eczema

Similar to last month’s column for eczema, one of the most common questions I am asked is how to control psoriasis other than using medications. I usually answer that medications, especially topical steroids, are the mainstay of therapy for limited psoriasis. We consider systemic options (phototherapy, injections, pills) for more severe psoriasis. However, a recent study indicates oral curcumin, an ingredient in Indian curry spice mixes and specifically a component of tumeric, may be helpful as additional treatment for patients already on topical steroids. The study was of 60 patients in Italy, randomly assigned to 3 grams per day of curcumin versus placebo. Patients who took curcumin had 4 times the chance of reaching 75% improvement in their psoriasis. In addition to clinical improvement, patients had decreased inflammation on blood testing (patients who took curcumin had about half the level of IL-22, a marker of inflammation, after 12 weeks of treatment). Only one side effect (nausea) was seen in the treated patients. Interestingly, there were two side effects in the placebo group. Overall, curcumin is considered well tolerated up to 12 grams per day, far above the recommend psoriasis dosage of 3 grams per day.

I do wish to specifically state I do not recommend patients simply stop their psoriasis treatment, especially their topical steroids, and simply take curcumin. This was a relatively small study only verbally presented and, even with both curcumin and topical steroids, only half of the patients reached 75% reduction in psoriasis (PASI75), which is approximately where my patients need to reach before they feel happy about their improvement. Also, most over-the-counter preparations are 500 mg, which means patients have to take 6 capsules a day, which is quite a lot. Also, the formulation used is, to my knowledge, not available in the United States and used "nanopartical liposomes.” Last, in the United States, we pretty much have no guarantee what’s in our supplements (see NYTimes where 4 out of 5 of the supplements sold by national retailers that were tested by the New York State attorney general’s office did not contain any of the herbs on the labels). Unfortunately, I do not know any better than my patients which over-the-counter supplements are genuine or not.

If you have psoriasis, of whatever severity, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- O’Connor A. New York Attorney General Targets Supplements at Major Retailers. New York Times 2015
- Jancin B. Oral curcumin shown effective in psoriasis. Dermatology News 2014
- Nguyen TA, Friedman AJ. Curcumin: a novel treatment for skin-related disorders. J Drugs Dermatol 2013

 

 

January 2015

What’s New in Eczema (atopic dermatitis)

eczema

Eczema (atopic dermatitis) is frustrating for both patients and parents. One of the most common questions I am asked is how to control the eczema other than using medications. I usually answer that medications, especially topical steroids, are the mainstay of therapy. However, a recent study indicates vitamin D can be helpful for some patients. The study was of 107 children, ages 2 to 17, in Mongolia. These children had a history of worsening eczema in the winter. Supplementation with 1,000 IU daily of vitamin D significantly improved their skin when compared to placebo. No adverse effects were seen. Unfortunately, the children were not tested to see if they were truly vitamin D deficient and if there was more benefit in those who might have had low vitamin D levels. While it was not a perfect study, it does show that vitamin D supplementation for children with eczema that worsens in the winter could be helpful.

Part of the reason vitamin D could be helpful is that it increases the body’s production of antimicrobial peptides. This could reduce skin infections which patients with eczema are more prone towards, which could in turn reduce the itching the bacteria can cause.

If you have eczema, of whatever severity, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Camargo CA, et al. Randomized trial of vitamin D supplementation for winter-related atopic dermatitis in children. J Allergy Clin Immunol 2014
- Oh JW. The clinical impact of vitamin D in children with atopic dermatitis. Allergy Asthma Immunol Res 2013

 

 

December 2014

What’s New in Psoriasis

Psoriasis

Psoriasis is characterized by red scaly plaques, especially on the elbows and knees. However, it can affect anywhere on the body, including the private areas. This is part of the reason psoriasis patients suffer from a "very large negative effect” on their lives. This was seen in a 2011 study of the injectable medication Stelara when patients answered a standardized questionnaire (Dermatology Life Quality Index). The study was important in finding a 22.6% rate of impaired sexual function, seen more in females than males. Importantly, this rate decreased to 2.7% after 3 months of treatment. A more recent study of the yet-to-be-approved systemic medication ixekizumab (an easier to say brand name will be used once the medication is approved) found an even higher 32% rate of self-reported psoriasis-related sexual difficulties, decreasing to 7% after 4 months of treatment.

Overall, the takeaway message isn’t that a specific medication would be useful in assisting psoriasis patients who suffer from sexual dysfunction. However, it does seem that the better the psoriasis is controlled, whether by topicals (ie, creams/ointments), phototherapy (using the medical phototherapy booth we have in our office), or systemics (pills or injections), the better the quality of life for patients, including the private areas of their lives.

If you have psoriasis, of whatever severity, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Jancin B. Ixekizumab linked to decrease in psoriasis-related sexual difficulties. Skin & Allergy News 2014
- Guenther L, et al. Impact of ustekinumab on health-related quality of life and sexual difficulties associated with psoriasis: results from two phase III clinical trials. JEADV 2011

 

 

November 2014

What’s New in Eczema (atopic dermatitis)

I see expectant mothers who have suffered with sensitive skin (ie, eczema / atopic dermatitis) their entire lives. I am often asked how to decrease the chance their child will have to go through the same hassles they have (using only products designed for sensitive skin, applying medications during flares, and breaking out when simply applying fragrance during a night out). The most recent analysis found the most effective way to reduce the risk of passing on sensitive skin was to breast feed the child for at least the first four months of life, thereby reducing the risk by up to 33%. While this isn’t complete protection, this does add to the numerous other proven benefits of breast feeding and makes breast feeding even more highly recommended. This benefit was seen even when breast feeding was supplemented with formula. It only applies to children at high risk for atopic dermatitis (ie, having a first-degree relative with it). If a supplemental formula is used, it seems to be helpful to use one based on a hydrolyzed formula rather than intact cow’s milk.

The analysis also looked at antigen avoidance, ie avoiding certain foods such as cow’s milk, eggs, peanuts, fish, and chocolate, as some mothers do during pregnancy. If done during pregnancy, there was no protective effect and there was a tendency toward preterm birth. If done while breastfeeding, large trials did not show any benefit. Only one small trial showed a non-significant reduction in eczema severity. Overall, antigen avoidance does not seem practically useful in reducing eczema risk.

I hope you found this month’s column useful. If you have eczema, I look forward to seeing you. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Blattner CM, et al. A practice gap in pediatric dermatology: does breast-feeding prevent the development of infantile atopic dermatitis? J Am Acad Dermatol 2014
- Kramer MS, et al. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2012

 

 

October 2014

What’s New in Acne

Acne can be severe. In the March 2014 update, I discussed isotretinoin (commonly known as Accutane) and how it is considered the most effective medication for acne, especially cystic scarring acne. The reason it is not usually prescribed for mild to moderate acne is for potential side effects. The main side effect is potential birth defects if a baby is conceived while on the medication. Thus, for females, there is a need for either complete abstinence or two forms of birth control while on the medication. Other than this, I have viewed the potential side effect of inflammatory bowel disease (ie, ulcerative colitis) as the most worrisome side effect. However, a study published in 2014 by Rashtak et al. actually found the opposite, a decreased risk of inflammatory bowel disease in patients treated with isotretinoin. A separate study in 2013 by Alhusayen et al. did find a possible increased risk. However, it also found this risk in acne patients treated with topical creams/gels. Thus, Alhusayen’s study suggested an association between inflammatory bowel disease and acne itself. Overall, while I do view inflammatory bowel disease as a risk of Accutane, the practical increased risk is debatable.

Another interesting update is a trend toward longer treatment durations with isotretinoin. While the traditional treatment duration of approximately 6 months is highly effective and what I most often use, a 2013 study found that approximately doubling the duration of therapy increased the long term benefits of isotretinoin without any increase in adverse side effects other than skin rashes. Practically, I usually treat for 6 months and increase the duration further for patients that want the best chance at a long term remission or have cysts that still develop.

If you have acne, I look forward to seeing you to discuss your options, whether creams or pills. I am happy to find a regimen that suits your preferences. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Rashtak S, et al. Isotretinoin Exposure and Risk of Inflammatory Bowel Disease. JAMA Dermatol 2014
- Alhusayen RO, et al. Isotretinoin use and the risk of inflammatory bowel disease: a population-based cohort study. J Invest Dermatol 2013
- Blasiak RC, et al. High-Dose Isotretinoin Treatment and the Rate of Retrial, Relapse, and Adverse Effects in Patients With Acne Vulgaris. JAMA Dermatol 2013
- Jesitus J. Expert shares tips on isotretinoin dosing at AAD 2014. Dermatology Times 2014

 

 

September 2014

What’s New in Rosacea

Rosacea can sometimes be quite severe. Most patients improve with creams and sometimes oral antibiotics (especially patients with eye irritation). However, I see some patients that fail standard treatment. Rosacea is multifactorial (ie, each patient has a likely different reason to have rosacea) but there has been recent appreciation of the role that skin mites (Demodex folliculoum) may play in the disease, especially in those that fail standard treatment. There are different ways to treat these mites. The antibiotics dermatologists prescribe have some efficacy against them (antibiotics have anti-inflammatory and anti-mite effects in addition to their traditional anti-bacterial effects). To target the mites, I currently use a pill called ivermectin and have had success in some severe patients who failed standard treatment. However, in general, it is preferred to use a cream to avoid systemic side effects. Ivermectin 1% cream has completed phase 3 trials with ~40% of patients becoming clear or almost clear after 12 weeks of treatment. In addition, the creams were tolerated well with only 2.5% of patients having significant irritation. It is a greatly appreciated addition to our armamentarium although likely will not be available until 2015. There is a 0.5% lotion available that is approved for head lice, but is unlikely to be as effective as the upcoming 1% cream.

If you have rosacea, I look forward to seeing you to discuss your options. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Stein L, et al. Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol 2014
- Holmes AD. Potential role of microorganisms in the pathogenesis of rosacea. J Am Acad Dermatol 2013

 

 

August 2014

What’s New in Eczema (atopic dermatitis)

The mainstay of therapy for moderate to severe eczema (atopic dermatitis) are topical steroids. They are effective and, when properly utilized and supervised, provide benefits that usually outweigh rare risks. However, there is a patient perception that some doctors call "steroid phobia”, when even some of the most severe patients that scratch daily, have open sores, and suffer from severe social and professional issues avoid the most effective treatment medicine has to offer. As someone who suffered from severe eczema until adulthood because my mother refused to accept the treatments recommended when I saw a dermatologist, it also saddens me when I see a parent decline topical steroids for a severely affected child I think will only worsen with time.

For patients and parents who choose not to use topical steroids, I currently discuss gentle over-the-counter products, avoiding harsh cosmetics, and prescribe medications called Protopic (tacrolimus) ointment and Elidel (pimecrolimus) cream. Although these medications are not topical steroids, they have different potential side effects and are clinically much weaker. They are also often not covered by insurance due to their cost (there are no generic versions).

Thankfully, there has been progress made in alternative therapies, esp. a class of medications called phosphodiesterase-4 inhibitors that have an anti-inflammatory effect. An oral version called Apremilast (Otezla) has been approved for psoriatic arthritis and has showed promise in trials for adult eczema and psoriasis. So far, side effects have been mild to moderate primarily consisting of gastrointestinal issues (nausea, vomiting, diarrhea) and headaches. No significant blood test abnormalities have been so far reported. While there is interest in the oral formulation, I am even more interested in an ointment called AN2728 (once FDA approved, medications are given more patient friendly names). So far it has completed a phase II trial in which 86 adolescents with eczema averaged a 71% improvement after 1 month. A phase III trial is in place and the medication should ideally be widely available next year.

If you or your child has severely itchy skin, I look forward to seeing him/her. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Jancin B. New, nonsteroidal atopic dermatitis therapies in pipeline. Skin & Allergy News 2014
- Samrao A, et al. A pilot study of an oral phosphodiesterase inhibitor (apremilast) for atopic dermatitis in adults. Arch Dermatol 2012
- Moustafa F, Feldman SR. A review of phosphodiesterase-inhibition and the potential role for phosphodiesterase 4-inhibitors in clinical dermatology. Dermatology Online J 2014

 

July 2014

What’s New in Infantile Hemangiomas

Infantile hemangiomas are the most common tumors of infancy. They are benign blood vessel (technically a progenitor cell with neural crest and pericyte origin) tumors that typically grow rapidly then gradually involute. Involute is the term used rather than "disappear” because some can leave a fibrofatty scar. Overall, 92% involute by age 4, which was shown by two recent studies and is different than the classical teaching which was 90% involute by age 9.

IMost hemangiomas are simply followed by the primary care doctor. However, treatment is considered for those at risk for disfigurement. The concern for fibrofatty residue is more likely with hemangiomas that are larger, have a superficial component, have steep borders, or have thick infiltrative dermal involvement. Those located on the central face may have significant disfigurement as the "specific anatomic curves of the lips, nose, and philtrum do not necessarily return to normal contours after becoming distorted” (quoted from Dr. Frieden, UCSF Pediatric Dermatology, expert in hemangioma treatment).

Treatment, if used, is most often topical medication for non-ulcerated hemangiomas with a 92% efficacy and 56% regression rate, i.e. treatment helps the majority of the time but does not necessarily always eliminate the hemangioma. This is deemed at least as good as laser by Dr. Frieden. Injectable and oral (Hemangeol, propranolol) medications are also options. However, oral medications have a higher rate of side effects especially hypoglycemia (low blood sugar) and pre-treatment clearance with a cardiovascular and pulmonary exam would be needed from either the primary care doctor or cardiologist. If your child has a worrisome hemangioma, I look forward to seeing him/her. Please make an appointment for a dermatology consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Freiden IJ. Infantile Hemangiomas: Past, Present, and Future. Dermatology Focus 2014
- Couto RA, et al. Infantile hemangioma: clinical assessment of the involuting phase and implications for management. Plast Reconstr Surg 2012
- Chakkittakandiyil A, et al. Timolol maleate 0.5% or 0.1% gel-forming solution for infantile hemangiomas: a retrospective, multicenter, cohort study. Pediatr Dermatol 2012
- Drolet BA, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics 2013

 

June 2014

What’s New in Hyperpigmentation (melasma / lentigines)

Many patients seek dermatologist care for excess pigmentation, especially on the face. After evaluating for medical reasons (pregnancy, hormonal therapy, skin cancer, medications), I often recommend over-the-counter and/or prescription creams. Thankfully, more options are becoming available beyond hydroquinone, which has long been considered the mainstay of therapy.

In addition, sun protection is key when lightening the skin. Many of my patients cannot tolerate standard chemical sunscreens (which is partly why they have excess pigment in the first place!). Now, gentle and elegant sunscreen is available. Sun protection also has the benefit of decreasing one’s risk for skin cancer.

If you suffer from bothersome dark spots, I look forward to seeing you. Please make an appointment for a medical dermatology consultation at (626) 331-6411. If cosmetic peels or lasers are desired, consider also making an appointment with Magan’s Medical Aesthetics Laser Center.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Jesitus J. Experts advise multifaceted strategy for hyperpigmentation. Dermatology Times 2014
- Alexis AF, Blackcloud P. Natural ingredients for darker skin types: growing options for hyperpigmentation. J Drugs Dermatol 2013

 

May 2014

What’s New in Eczema (atopic dermatitis)

Recent studies have shown that contact allergy (ie, sensitivity to non-gentle skin care products) worsens eczema (atopic dermatitis) and have clarified specific categories that are most worrisome. Formaldehyde releasers are the most important allergens in my practice and an increased rate of reactions was found in patients with eczema. Thus, I recommend avoiding skincare products with ingredients such as quaternium-15, imidazolidinyl urea, DMDM hydantoin, and 2-bromo-2-nitropropane-1,3-diol. These ingredients are common, even in products claiming to be designed for sensitive skin. Only this year did Johnson & Johnson finally stop using formaldehyde releasers in their baby shampoo. Practically speaking, most patients opt to use gentle products I recommend although some do take the time to read through (long!) ingredient labels.

Another category found to be more common was flowers, specifically the sunflower/daisy family (scientific name is asteraceae = compositae). Thus, playing in a backyard filled with flowers is unfortunately not the best idea for children with eczema.

If you are interested in a visit for eczema for yourself or your child, I look forward to seeing you to both discuss gentle skin care products and treatment options. Please make an appointment for a consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:
- Shaughnessy CN, et al. Cutaneous delayed-type hypersensitivity in patients with atopic dermatitis: reactivity to topical preservatives.
J Am Acad Dermatol 2014.
- Thomas K. The ‘No More Tears’ Shampoo, Now With No Formaldehyde. NY Times 2014
- Gittler JK, et al. Atopic dermatitis results in intrinsic barrier and immune abnormalities: implications for contact dermatitis. J Allergy Clin Immunol. 2013.
-  Fonacier LS, et al. The role of contact allergy in atopic dermatitis. Immunol Allergy Clin North Am 2010.

April 2014

What’s New in Rashes in Pregnancy (PUPPP, acne, rosacea)

Pregnancy is a time of joy, hope, and bliss. Well, maybe not all the time…and definitely not when a rash develops. Historically, many physician and patients have decided to forego medication that could help the numerous itchy rashes that can develop (including PUPPP, pruritic urticarial papules and plaques of pregnancy, pictured above). Recently, a study was completed comparing thousands of pregnant women who decided to utilize corticosteroid medication to those who did not. There was no association found between topical corticosteroid usage and the birth outcomes analyzed (orofacial cleft, low birth weight, preterm delivery, fetal death, low Apgar score, or mode of delivery) as long as the amount of potent/superpotent topical corticosteroid usage was less than 300 grams (~5 large tubes) during the entire pregnancy.

Thus, I wanted to let our pregnant patients know that they do not have to suffer for the sake of their baby. This also applies to acne and rosacea as there are multiple medications that have not demonstrated a risk to the fetus in studies performed either in pregnant women or laboratory animals.

If you or your significant other is pregnant and has itching, acne, or rosacea, I look forward to seeing you. Please make an appointment for a consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Chi CC, et al. Pregnancy outcomes after maternal exposure to topical corticosteroids: a UK population-based cohort study. JAMA Dermatol 2013

 


March 2014

What’s New in Acne

I wanted to discuss isotretinoin, commonly known as Accutane, even though it is not a new medication and has been FDA approved since 1982. This is due to the recent efforts to improve access to this medication that sometimes is the only medication able to control severe acne. Namely, Promius Pharma began a program in 2013 called "The Promius Promise” for patients with a high co-pay or for whom insurance does not cover the medication at all. Patients simply call 1-888-959-7600 to obtain assistance.

The program does add an extra step and, so far, my HMO and PPO patients have not required it. Reassuringly, I have not yet had an Accutane rejection. However, when I one day encounter a patient’s insurance denying my prescription, I appreciate the program being available.

This is because acne can be a physically and emotionally scarring disease. Accutane is indicated for nodulocystic acne unresponsive to conventional therapy including oral antibiotics. It often has great results (see a patient posting his before/after pictures at http://www.youtube.com/watch?v=NIo85lGuxow#t=10m0s). Studies have demonstrated 85 to 97% improvement. My experience has been similar. However, I do tell patients complete clearance is not a guarantee.

If you have severe acne and wish a patient-doctor discussion of Accutane or simply have your first pimple developing, I look forward to seeing you. Please make an appointment for a consultation at (626) 331-6411.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- http://www.zenatane.com/toolkit/Promius-Promise-Enrollment-Form.php

- Layton et al. Isotretinoin for acne vulgaris--10 years later: a safe and successful treatment. Br J Dermatol 1993

- Peck et al. Isotretinoin versus placebo in the treatment of cystic acne. A randomized double-blind study. J Am Acad Dermatol 1982


February 2014

What’s New in Hives (urticaria)

Hives (urticaria) consists of an itchy pink or pale raised rash. The individual wheals usually resolve within 24 hours, but the overall rash can last much longer. When a patient presents to the physician, numerous causes are considered (a long list including infections, mechanical, sweating, stress, allergic, drugs, autoimmune, and water…yes some people develop hives by simply touching water of any temperature). However, 1/3 to ½ of cases are idiopathic, i.e. no specific cause can be found.

Unfortunately, many patients fail or cannot tolerate standard treatment with antihistamines. For these patients, a 2013 New England Journal study demonstrated that a medication traditionally used in asthma, omalizumab (Xolair), was effective. It binds IgE after it is injected subcutaneously, similar to an insulin injection, once monthly. The lead investigator has stated "This is a safe drug. This is a drug that doesn’t have any differences in its safety profile compared to placebo.” While I wouldn’t completely agree with him that there are no side effects, the study data does demonstrate an encouraging side effect profile. I do note that this medication does not cure the hives. It simply improves it until, as occurs in some patients, the patient’s own immune system undergoes spontaneous remission. The lead investigator has "had patients on omalizumab for 5-6 years now.”

Please make an appointment for a consultation at (626) 331-6411 if you are interested in discussing your options for anything ranging from simple, first-time hives to frustrating, long-term hives that may need consideration of omalizumab. I look forward to seeing you.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Maurer M, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med 2013 Mar.

- Jancin B. Two new trials bolster omalizumab for urticaria. Skin and Allergy News 2013 Dec.


January 2014

What’s New in Nail fungus (onychomycosis)

Nail fungus (onychomycoisis) is common, affecting ~4% of the population. It presents as yellow, thickened nails. It can cause itching and rashes on the feet. In addition, in diabetic and immunocompromised patients, it can promote severe infections. Traditionally, oral antifungal pills have been needed to treat the infection. However, they do have risks, including liver inflammation for which 0.2% of patients discontinued the medication in the clinical trials.

While pills are still the most effective, topical treatments have improved and a new solution provides improvement for the majority of patients. It would be a good option for patients that do not wish to risk the side effect of the pill. It is applied on the weekdays for several months.

Please make an appointment for a consultation at (626) 331-6411 if you are interested in discussing your options. I look forward to seeing you.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Sigurgeirsson B, et al. The prevalence of onychomycosis in the global population

- A literature study. J Eur Acad Dermatol Venereol 2013 Nov

- Nasir A, et al. Clinical evaluation of safety and efficacy of a new topical treatment for onychomycosis. J Drugs Dermatol 2011

- http://www.pharma.us.novartis.com/product/pi/pdf/Lamisil_tablets.pdf


December 2013

What’s New in Melanoma screening & skin examinations

(Example of a melanoma evolving and demonstrating an increase in size, pigment, and inflammation)

While there have been new (and expensive) medications developed to treat advanced melanoma, it is far more effective to diagnose and treat melanoma early. Thus, it has been gratifying to see increasing research demonstrate that skin examinations using the dermatoscope ("the dermatologist stethoscope” that I carry on my hip) is an improvement over naked eye analysis, both in detecting melanoma and reducing unnecessary biopsies. Thus, I use it for any lesion for which there is doubt whether to biopsy or not. It is a specialized device consisting of a magnifying lens, LED lighting, and a polarizing filter to reduce glare. The United States has lagged Europe in adopting this, so ideally patients should see a dermatologist that utilizes it.

If you are interested in a skin examination (you must have at least one specific mole/bump/rash to evaluate for insurance to cover the visit), I look forward to your visit.

Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Marghoob et al. Current Status of dermoscopy in the diagnosis of dermatologic disease. J Am Acad Dermatol 2013 Nov

- Argenziano et al. Dermoscopy – The ultimate tool for melanoma diagnosis. Semin Cutan Med Surg 2009


November 2013

What’s New in Atopic dermatitis (eczema)

Research has increasingly shown a bacterial component to atopic dermatitis, the itchy sensitive skin that ~15-20% of the population (especially children) is affected by at some point in their lives. Indeed, 76-100% of atopic patients are colonized with the bacteria S. Aureus, while only 2-25% of non-atopics are. The bacteria increase skin inflammation and trigger the itching that begins the vicious itch/scratch/itch cycle. Clinical trials have demonstrated that treating the bacterial colonization improves atopic dermatitis. If you are interested in discussing methods to decrease the bacterial colonization of your child and help reduce the scratching, I look forward to seeing you for a consultation.


Charles Chiang, MD, FAAD
Board Certified Dermatologist

References:

- Ryan et al. Novel sodium hypochlorite cleanser shows clinical response and excellent acceptability in the treatment of atopic dermatitis. Pediatr Dermatol 2013.

- Huang et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009.

 


October 2013

What’s New in Rosacea

Dermatology has been successful in treating the pustules and papules (pink bumps) of rosacea. However, we never had an effective topical therapy for the redness (erythematotelangiectatic rosacea) until this year. In August, the FDA approved Mirvaso (brimonidine) topical gel. The clinical trial results were encouraging and I have high hopes for this medication. We have samples and I have not yet had insurance issues with this medication. If you are interested, come on by for a consultation.

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