Sports Dermatology - Skin Infection in Athletes
Brian Burke Adams MD, MPH, FAAD
Assoc Prof, Dir VA, Dept Derm, U Cincinnat...
hair in a normal or abnormal pattern. This may be genetic (inherited), or due to medications,
hormones, malnutrition, tumo...
Temporary skin dyspigmentation (lightening or darkening), especially in patients with tans or
intrinsically darker skin, m...
light device for home-use hair removal. Dermatol Surg 2009; 35. Alster TS, Bryan H, Williams
CM. Long-pulsed Nd:YAG laser-...
fair skinned individuals. The negative consequences of increased melanin include a higher
incidence of pigmentary disorder...
skin structure and function? Rawlings AV. Int J Cosmet Sci. 2006 Apr;28(2):79-93. Racial
(ethnic) differences in skin prop...
using standard therapy that includes sun protection, smoking cessation, topical corticosteroids or
topical immunomodulator...
depletion. J Invest Dermatol 2008; 128: 2745-7. Parker SRS, et al: Mortality of bullous
pemphigoid: An evaluation of 223 p...
diagnosis of eccrine poroma. Clinically, eccrine poroma may exhibit polymorphic features that
can make the diagnosis diffi...
morphologic based scheme is used rather than etiologic based one, as it is the most practical
method to generate a relevan...
fearful skin tumor. Typical cases of melanoma, together with soborrhoeic-keratosis-like
melanoma, as well as other melanom...
surgeons will have to deal with a wound that requires an unusual closure method to provide a
cosmetically appropriate resu...
significant difference in survival or disease-free interval. In addition, the German Melanoma
Group reported that women wh...
melanoma. Br J Cancer. 2004;90:770-2. 8. Francken AB, Accortt NA, Shaw HM, et al. Follow-
up schedule after treatment for ...
the ability to assess patients’ actual use of their medication. Studies of psoriasis have showed
quite variable adherence ...
Resident Jeopardy
Amit Garg MD, FAAD
Asst Prof, Dept Derm, Boston U Sch of Med, Boston, MA
Friday, March 06, 2009, 9:00 AM...
chemical alopecia or weathering; traction alopecia; seborrheic dermatitis and tinea capitis.
Common permanent forms of hai...
for transcription of E6 and E7, as the virus integrates into the chromosome of the host cell o
High risk HPV E6 strongly b...
types: avian, mammalian related to MuPyV, and mammalian related to simian virus 40 (SV40) o
SV40 subgroup contains all hum...
alterations in the honey-comb fibrous strands connecting the skin to underlying fascia and an
excess of adipose tissue wit...
patient and physician to determine which laser is best. This lecture will compare a variety of
fractionated CO2 Lasers in ...
effective for small seborrheic keratoses and verruca vulgaris. (1,2) • Spray is preferred for many
keratotic lesions that ...
salicylic acid treatment fro plantar verrucae. 1 Foot and Ankle Surg 200 1;40:4. 3. Damstra R1
,van Vloten W A. Cryotherap...
physician extenders in many dermatology practices. Speakers will relate how physician
extenders are educated, trained, and...
Physician Assistant-Scope of Practice PAs should be permitted to provide any legal medical
service that is delegated to th...
insurance, AAPA dues, SDPA dues, NCCPA certification, DEA registration, and 401K or other
retirement match Dermatology Dis...
the dimers can translocate to the nucleus, an inhibitory protein (IkBα) must be removed. The
removal of IkBα is catalyzed ...
configuration, thus exposing multiple hidden sites for phosphorylation reactions in wound
healing. After the wound is heal...
audience response format. Each case is then discussed by the presenter who comments on the
correct response and why each i...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
Sports Dermatology - Skin Infection in Athletes Brian Burke ...
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  1. 1. Sports Dermatology - Skin Infection in Athletes Brian Burke Adams MD, MPH, FAAD Assoc Prof, Dir VA, Dept Derm, U Cincinnati, Cincinnati, OH Sunday, March 08, 2009, 12:15 PM Room 2010 - West Brian B. Adams, M.D., M.P.H. Associate Professor, University of Cincinnati, School of Medicine Department of Dermatology Chief of Dermatology, Veterans Administration Medical Center Cincinnati, Ohio “Sports-Related Skin Infections” Focus Session Full Abstract Most dermatologists will encounter athletes with sports-related dermatoses in their practices. Most types of skin problems that occur in athletes are infections. Gram positive bacteria can infect athletes and cause impetigo, folliculitis, and furunculosis. Wrestlers may be particularly at risk for developing impetigo. A great deal of attention has been paid to MRSA (methicillin resistant staphylococcus) in athletes. Epidemics have occurred all over the country. Rapid diagnosis and therapy are crucial. The gram negative organism Pseudomonas may infect individuals in hot tubs causing hot tub folliculitis. Herpes simplex virus (known as herpes gladiatorum) may infect wrestlers and those playing rugby. Quite contagious, this infection must be quickly detected and treated to prevent transmission among team members. Tinea corporis (ringworm) may occur in epidemics on wrestling teams (known as tinea corporis gladiatorum), thereby disrupting practices and competitions. Prevention, as well as early detection and treatment are essential. Other fungal related conditions affecting the athlete include tinea cruris and tinea pedis. Finally, individuals playing sand volleyball may rarely become infested with cutaneous larvae migrans, a small burrowing worm. Knowledge of cutaneous conditions in the context of specific sporting events permits the dermatologist to treat these patients most effectively. Lasers Tina S. Alster MD, FAAD Dir, Washington Inst Derm Laser Surg, Clin Prof,Georgetown U, Washington, DC Friday, March 06, 2009, 9:00 AM Room 303 Laser and Light-Based Hair Removal Including Home-Use Devices Course C003: Lasers Friday, March 6, 2009 Tina S. Alster, MD Washington Institute of Dermatologic Laser Surgery Washington, DC BACKGROUND Unwanted facial and body hair is a common problem, generating a high level of interest for treatment innovations. A wide range of modalities for the management of unwanted hair have been advocated over the years with varying degrees of clinical success. Most recently, lasers and light sources have been used to address this problem with improved clinical success rates in properly selected patients. Excessive hair growth is classified as either hypertrichosis or hirsuitism. Hypertrichosis is the excessive growth of body
  2. 2. hair in a normal or abnormal pattern. This may be genetic (inherited), or due to medications, hormones, malnutrition, tumors, or metabolic problems. Hirsuitism is excessive growth of hair in women, but in a male pattern such as the beard, mustache, or lower abdomen and may be due to hormone problems, medications, tumors, or heredity. Several factors relating to hair removal treatment are of concern to patients, including clinical efficacy, safety, expense, convenience, associated pain, and other short-and long-term side effects. There are many ways to remove unwanted hair, but most of these methods are temporary. Methods include shaving, epilation (plucking, electronic tweezers, radiofrequency tweezers, or waxing), depilatories (creams), electrolysis (inserting a needle into each hair follicle one at a time followed by an electric spark to burn out the follicle), and lasers. A topical cream called eflornithine can be applied to slow hair growth on the face in women, but must be used on an ongoing basis. LASER AND LIGHT- BASED HAIR REMOVAL Laser surgery permits satisfactory treatment of large areas of unwanted excess hair with less discomfort and fewer complications than other treatment methods. Lasers and intense pulsed light (IPL) devices send specific intense beams of light through the skin that are absorbed by the melanin (dark) pigment present in the hair follicle shafts. Since hair cycles as it grows, repeated treatments are necessary to destroy the hair follicles. The ruby, alexandrite, diode, and intense pulsed light systems were the first lasers FDA-approved for hair reduction. These devices work best on light skinned, dark haired individuals because the light from these lasers are not significantly absorbed by dark pigments in the surrounding skin. Systems with longer wavelengths, such as the Nd:YAG lasers, have the ability to treat darker skin types. Preoperative assessment of patients for laser-assisted hair removal should include a determination of each patient’s skin type (eg, intrinsic tanning/burning potential), hair color, location and thickness of hair, prior hair removal methods used, presence of medical conditions (eg, ovarian or thyroid disease, medication use, inflammatory skin diseases), and the presence of cosmetic tattoos/moles in the treatment area (certain titanium or iron oxide containing tattoos may darken with laser light exposure). Realistic patient expectations should be discussed including the need for multiple treatment sessions, the potential for maintenance treatments, and the possibility of variable responses to treatment. Patients are advised to avoid tanning or sunless tanners and to use a broad-spectrum sunscreen for up to six weeks prior to treatment. No plucking, waxing, or electrolysis should be performed, but the sites should be shaved one to two days prior to laser treatment. A prophylactic oral antiviral medication may be started the day prior to treatment if there is a history of herpes simplex infections in the treatment area. On the day of treatment, the areas to be treated should be clean and free of make-up. A topical anesthetic cream may be applied , but most lasers have an epidermal cooling device in the form of a cool gel, refrigerant spray, or water cooled contact piece that lessens the discomfort from the laser light and also protects the epidermis from excessive heating and potential pigmentary alteration. In general, three or more treatments are required to achieve permanent hair growth reduction. Darker hair responds best to the laser. Lighter colored hair (white, gray or red) are least responsive, but topical medications (eg, PDT) can be used in an effort to increase the receptiveness of light hairs to the laser. The laser pulses produce a minor amount of discomfort (like oil splattering or warm pinpricks on the skin). Swelling and redness around the hair follicles appear within a few minutes for which a mild topical corticosteroid cream can be applied. Patients are instructed to avoid sun exposure to the treatment sites and to use a broad-spectrum sunscreen with SPF 30 post-treatment. Side effects of hair removal laser treatments include pain, perifollicular edema and erythema lasting one to three days. Blistering, herpes simplex outbreaks, and bacterial infections can also occur.
  3. 3. Temporary skin dyspigmentation (lightening or darkening), especially in patients with tans or intrinsically darker skin, may be seen. Permanent pigmentary change or scarring is very rare. Loss of freckles or lightening of moles in the treatment area may occur, as can darkening or lightening of tattoos. The percentage of hairs removed per session varies in different body locations, with thinner skinned areas (eg, axillae and inguinal regions) generally showing better response than thick skinned areas (eg, back and chin). Approximately 10-25% reduction in hair growth can be expected with each treatment. Treatments are repeated every 4-8 weeks. The hair that re-grows tends to be lighter and finer in texture. TREATMENT TRENDS The preference for at-home treatments has long been prevalent among consumers looking for high quality products, but at more affordable prices and with the added convenience of being able to obtain professional-like results in the privacy of a home setting. Home care of this nature has heretofore been limited to the multi-billion dollar markets of cosmetic, skin care and hair products. In the last decade; however, the introduction of self-administered treatments including microdermabrasion and mechanical epilation as well as other low tech aesthetic procedures demonstrated that consumers were willing to spend more money and take greater personal control of procedures which have traditionally been considered to be the sole domain of professionals. These introductory devices were limited in their clinical efficacy and were typically of such low impact that FDA approval was unnecessary. In recent years, there has been a growing trend to transition high-end aesthetic medical technologies to the home-use market. This trend is being led by companies in the laser and light products industry that are seeking ways to expand their market beyond their traditional physician base. These companies have found their physician markets to be limited, characterized by increased competition, rising saturation and deflated prices. In order to survive and grow, the laser manufacturers have realized that a new customer must be reached. Improvements in laser and light technology over the last decade and a growing shift in demand for aesthetic medicine from the wealthy to middle- class consumer have created the first genuine opportunity for laser manufacturers to begin offering home-use devices with the clinical efficacy commonly reserved for the professional provider. The area of most interest is hair removal, which is currently the most popular skin treatment worldwide with a market of $9 billion. Even with the availability of numerous effective treatments (including shaving, waxing, depilatories, electrolysis, and laser), the vast majority of the population, either because of economic or convenience factors, do not pursue professional (in-office) laser or light-based treatment which has been considered to be the gold standard of hair removal. In 2008, Home Skinovations and Spectragenics launched FDA- approved products that are compact, portable, and clinically efficacious to address the gap between the demand for light-based hair removal and actual application in a home setting. These at-home devices were initially available for sale only with a physician prescription in order to build device credibility and to reassure consumers of their effectiveness and safety. Most units were sold to patients who desired maintenance following professional treatment and/or for physicians to reach consumers who would not otherwise seek professional services in the first place. SUMMARY The presence of excessive hair can be a source of distress that often leads to such psychological problems as anxiety, depression, and reduced quality of life. The use of lasers and light sources permit expedient treatment of larger areas of skin with minimal discomfort. In addition, the selectivity and, therefore, effectiveness of these methods are less operator- dependent than other modes of therapy. Their noninvasive, needle-free nature greatly reduces the risk of disease transmission and scarring and has even provided the first opportunity for safe at- home treatment. REFERENCES Alster TS, Tanzi EL. The effect of a novel, low-energy, pulsed
  4. 4. light device for home-use hair removal. Dermatol Surg 2009; 35. Alster TS, Bryan H, Williams CM. Long-pulsed Nd:YAG laser-assisted hair removal in pigmented skin: a clinical and histologic evaluation. Arch Dermatol 2001; 137: 885-9. Anderson RR, Parrish JA. Selective photothermolysis: precise microssurgery by selective absorption of pulsed radiation. Science 1983; 220: 524-27. Grossman MC. Laser-assisted hair removal. In Alster TS, Apfelberg DB (eds). Cosmetic Laser Surgery. New York: John Wiley & Sons, Inc, 1998, pp. 211-25. Handrick C, Alster TS. Comparison of long-pulsed diode and long-pulsed alexandrite lasers for hair removal: a long-term clinical and histologic study. Dermatol Surg 2001; 27: 622-6. Nanni CA, Alster TS. A practical review of laser-assisted hair removal using the Q-switched Nd:YAG, long-pulsed ruby, and long-pulsed alexandrite lasers. Dermatol Surg 1998; 24: 1399-405. Tanzi EL, Alster TS. Long-pulsed 1064-nm Nd:YAG laser-assisted hair removal in all skin types. Dermatol Surg 2004; 30(1): 13-7. Wanitphakdeedecha R, Alster TS. Physical means of treating unwanted hair. Dermatologic Therapy 2008; 21: 392-401. Clinical Pearls for Common Clinical Problems in Ethnic Skin Sonia Badreshia-Bansal MD, FAAD Sunday, March 08, 2009, 7:00 AM Room 3009 - West There is a paucity of scientific data on the epidemiology, clinical diagnoses, and treatment of dermatologic disease in skin of color. Changing US demographics indicate that dermatologists will treat an increasing number of ethnic skinned patients. Common diagnoses such as acne, dyschromias, contact dermatitis, and photoaging found in ethnic skin can be difficult to evaluate, diagnose, and treat. A major issue in treatment of inflammatory skin conditions is the need to treat and prevent postinflammatory hyperpigmentation (PIH), which is common in this population. In addition, cultural practices can also have a significant impact with incidence of disease and clinical presentations. As the importance of ethnic markets continues to grow, dermatologists and cosmetic surgeons will require more expertise in the treatment of ethnic skin to adequately address their unique concerns. Scientific research and technologies related to key skin concerns for patients of color have led to recent developments in skin care and treatment. People who are skin of color constitute a wide range of ethnic groups including Africans, African Americans, Indians, Arabs, Pakistanis, Hispanics, Chinese, Japanese, and Native Americans. Ethnic skin comprises the majority of the world's population, with Asians comprising more than half of the total population of the earth. It is predicted that people with pigmented skin will comprise a majority of the domestic and international population during the 21st century. Ethnic differences in skin properties may explain racial disparities seen in dermatologic disorders and provide insight into differences in the management of these disorders. There is not a wealth of data on differences found in ethnic skin. The studies that exist are flawed or have very small patient populations with few definitive conclusions that can be made. The most obvious ethnic skin difference relates to skin color which is dominated by the presence of melanin. The advantages include the vital photoprotection which influences the slow rate of skin aging changes between the different racial groups and lower incidence of skin cancer compared with
  5. 5. fair skinned individuals. The negative consequences of increased melanin include a higher incidence of pigmentary disorders and dyschromias. In addition, new research is elucidating similarities and differences in skin of color and white skin with regard to skin barrier, sensitivity, and architecture. There may be differences in stratum corneum architecture and resulting barrier function, sebum excretion, pore size, dermal quality, and somatosensory activity. However, more well designed research needs to be performed for more conclusive evidence. A common issue facing ethnic skinned patients includes acne vulgaris. Although the pathophysiology is similar, acne can display histological and clinical differences in people with skin of color compared with Caucasians. Acne lesions without obvious clinical sign of inflammation tend to show a higher degree of inflammation histologically, which may account for the common and psychologically devastating resulting post inflammatory hyperpigmentation (PIH). Additionally, the response to therapeutic agents may vary in people with skin of color. Early and aggressive treatment is important to avoid ongoing acne and its sequale, especially PIH and keloids which are common to ethnic skin. However, balancing this treatment regimen with skin irritability, skin type, cosmetic choice, seasonal variation, and compliance is critical to avoid further complications. Pigmentary disorders are one of the most common and challenging skin issues facing ethnic skinned patients and the leading cause for dermatologic visits. Specifically, PIH and melasma are distressing conditions afflicting this unique subset of the population. The number of agents available for the treatment of PIH is limited and minimally effective. Products for skin of color should be carefully selected because of the higher incidence to develop additional pigmentary abnormalities in response to skin irritation or trauma. Dermatologists need to familiarize themselves with cosmeceutical skin lightening agents and corrective camouflage formulations. Increasing general patient interest in natural ingredients has been addressed by the formulation of relatively gentle and efficacious products containing soy, licorice, vitamins, among others. Sun protection is critical and underused in the ethnic population to address the issues of PIH, photoaging, and skin cancers. Several botanical products are useful in augmenting photoprotection with conventional sunscreens. In addition to more effective therapeutic agents, development of enhanced camouflaging techniques are also necessary. Combination agents with sunscreen will often be the most effective treatment available. Skin cancer most commonly affects Caucasians and rarely affects skin of color. Although skin cancer is rare in these groups, the diagnosis may be associated with increased morbidity and mortality compared with their white counterparts. These findings may be a result of a lower index of suspicion by the clinician and atypical presentations such as the palmoplantar skin and mucosal surfaces with the acral lentiginous melanoma being the most common histologic subtype. Therefore, diagnosis is often delayed resulting in an advanced presentation and a worse prognosis. More comprehensive medical training, expanded public educational campaigns, and increased awareness among patients of all skin types to perform self skin checks are essential. The ethnic market has become an important component to the success of the cosmetics industry. The long-term cosmetic concerns of the individuals that comprise this market should be comprehensively evaluated. Esthetic considerations for ethnic skin presently include laser treatments, Botulinum, chemical peels, and cosmetic fillers. The response to cosmetic treatment modalities also differs in patients of darker skin pigmentation, and this needs to be recognized by the cosmetic and laser surgeon. There are some basic differences regarding treatment protocols, patient expectations, and side effects when compared to their Caucasian counterparts. Badreshia S, Taylor S. The Structure and Function of Skin of Color. In: Dermatology for Skin of Color. Editors Taylor and Kelly. McGraw-Hill, New York, New York. 2007. In press. Ethnic skin types: are there differences in
  6. 6. skin structure and function? Rawlings AV. Int J Cosmet Sci. 2006 Apr;28(2):79-93. Racial (ethnic) differences in skin properties: the objective data. Wesley NO, Maibach HI. Am J Clin Dermatol. 2003;4(12):843-60. Acne on pigmented skin. Poli F. Int J Dermatol. 2007 Oct;46 Suppl 1:39-41. Insight into skin lightening cosmeceuticals for women of color. Badreshia-Bansal S, Draelos ZD. J Drugs Dermatol. 2007 Jan;6(1):32-9. Skin cancer in individuals of African, Asian, Latin-American, and American-Indian descent: differences in incidence, clinical presentation, and survival compared to Caucasians. Byrd-Miles K, Toombs EL, Peck GL. J Drugs Dermatol. 2007 Jan;6(1):10-6. Avoiding Complications and Maximizing Results in Cutaneous Laser Surgery Eric F. Bernstein MD, FAAD Clinical Associate Professor, Department of Dermatology, University of Pennsylvania Sunday, March 08, 2009, 7:00 AM Room 3003 - West Lasers, light sources and other forms of electromagnetic radiation have been used to treat a variety of cutaneous conditions. They have enabled the removal of hair, surface pigment, tattoos, unwanted blood vessels, celluliate or fat and allowed treatment of conditions including acne, psoriasis and a long list of others. The rapid pace of technological advancement has resulted in a myriad of devices being available for treating a broad range of dermatologic conditions using the full range of the electromagnetic spectrum. This makes understanding these devices and using them safely increasingly difficult. A decade ago there were only a handful of devices on the market. Now there are literally hundreds of lasers and light sources available for treating a host of dermatologic conditions. This being said, there are some general principles physics and biology that once understood result in a few common practices that are essential for using lasers safely. In addition, simple office procedures can further limit the risks of laser surgery. Finally, there are tips for the safe use of individual devices that can help one to avoid complications and maximize results from each device or class of devices on the market. After taking this course, participants should come away with key tips for avoiding complications with the devices they use in their practice while maximizing results. They should also gain a better understanding of the types of devices on the market, to enable selection of the ones that best fit their practice. Advanced Medical Dermatology Jeffrey Phillip Callen MD, FAAD Prof Med (Derm), Div Derm, Scho Med, U Louisville, Louisville, KY Tuesday, March 10, 2009, 12:00 PM Room 3020 - West Most patients with cutaneous lesions of lupus erythematosus are managed without difficulty
  7. 7. using standard therapy that includes sun protection, smoking cessation, topical corticosteroids or topical immunomodulators, and antimalarials. However, roughly a quarter of patients will have disease that is difficult to control with these measures. Such patients should be carefully assessed for exacerbating factors, and then might be treated with one of the following therapies – thalidomide, azathioprine, methotrexate, mycophenolate mofetil, or efalizumab. Dermatomyositis may present with skin lesions only, or patients may have had muscle disease which after treatment is quiescent but their skin disease remains active. The skin manifestations have a significant impact on the quality of life and often are more difficult to manage than lesions in patients with lupus erythematosus. In addition, patients with cutaneous DM may have more frequent reactions to antimalarials and seem to respond only modestly to these agents. Lastly, some patients might have a malignancy which if recognized might result in a control of their skin lesions. Patients with recalcitrant skin lesions might be treated with methotrexate, mycophenolate mofetil, intravenous immune globulin or rituximab. Other adjunctive therapies are less well studied. Journal Watching Jeffrey Phillip Callen MD, FAAD Prof Med (Derm), Div Derm, Scho Med, U Louisville, Louisville, KY Sunday, March 08, 2009, 3:00 PM Room 310 Each month I review journals within and external to dermatology for articles with medical implications. The journals that I tend to select articles from include the following: Archives of Dermatology, Archives of Internal Medicine, JAMA, New England Journal of Medicine, British Journal of Dermatology, Arthritis and Rheumatism, Medicine (Baltimore), Journal of Rheumatology, Annals of Internal Medicine and a smattering of articles in Nature journals including the Journal of Investigative Dermatology. In this session, we will discuss some of the highlights from the literature, which I think are of general and of practical importance to the dermatologist in practice. The following are articles that might be discussed: Hirsch LJ, et al: Cross-sensitivity of skin rashes with antiepileptic drug use. Neurology 2008; 71: 1527-34. Alvestad S, et al: Cross-reactivity pattern of rash from current aromatic antiepileptic drugs. Epilepsy Res 2008; 80: 194-200 Prey S, Paul C: Effect of folic and folinic acid supplementation on methotrexate-associated safety and efficacy in inflammatory disease: a systematic review. Br J Dermatol 2008 (epub ahead of print) Fahri D, et al: Significance of erythema nodosum and pyoderma gangrenosum in inflammatory bowel diseases: A cohort study of 2402 patients. Medicine (Baltimore) 2008; 87: 281-93. Ferri C, et al: Safety of anti-tumor necrosis factor-a therapy in patients with rheumatoid arthritis and chronic hepatitis C virus infection. J Rheumatol 2008; 35: 1944-9 Stagaki E, et al: The Treatment of Lupus Pernio: The Results of 116 Treatment Courses in 54 patients. Chest 2008; published online October 23, 2008 DOI 10.1378/chest.08- 1347 Mouquet H, et al: B-cell depletion immunotherapy in pemphigus: effects on cellular and humoral immune responses. J Invest Dermatol 2008; 128: 2859-69 Emming et al: Rituximab exerts a dual effect in pemphigus vulgaris. J Invest Dermatol 2008; 128: 2850-8. Zambruno G, Borradori L: Rituximab immunotherapy in pemphigus: Therapeutic effects beyond B-cell
  8. 8. depletion. J Invest Dermatol 2008; 128: 2745-7. Parker SRS, et al: Mortality of bullous pemphigoid: An evaluation of 223 patients and comparison with mortality in the general population in the United States. J Am Acad Dermatol 2008; 59: 582-8. Firooz A, et al: Role of thiopurine methyltransferase activity in the safety and efficacy of azathioprine in the treatment of pemphigus vulgaris. Arch Dermatol 2008; 144: 1143-7. Carrier M, et al: Systematic Review: The Trousseau Syndrome Revisited: Should We Screen Extensively for Cancer in Patients with Venous Thromboembolism? Ann Intern Med 2008; 149: 323-333. Ornstein DL: A nickel’s worth of cancer. Ann Intern Med 2008; 149: 350-2. Taylor WJ, et al: Drug use and toxicity in psoriatic disease: Focus on methotrexate. J Rheumatol 2008; 35: 1454-7. Weger W, et al: Occurrence of subacute cutaneous lupus erythematosus after treatment with fluorouracil and capecitabine. J Am Acad Dermatol. 2008 Aug;59(2 Suppl 1):S4-6. Wiechert A, et al: Subacute cutaneous lupus erythematosus in a leuprorelin-treated patient with prostate carcinoma. Br J Dermatol 2008; 159: 231-3. Marzano AV et al: Leflunomide-induced subacute cutaneous lupus erythematosus with erythema multiforme-like lesions. Lupus. 2008;17(4):329-31. Suess A, Sticherling M. Leflunomide in subacute cutaneous lupus erythematosus - two sides of a coin. Int J Dermatol. 2008 Jan;47(1):83-6. Internal Medicine Jeffrey Phillip Callen MD, FAAD Prof Med (Derm), Div Derm, Scho Med, U Louisville, Louisville, KY Saturday, March 07, 2009, 9:00 AM Room 305 This course focuses on skin manifestations of systemic disease. During the first half of the day we will focus on relatively common skin lesions that have systemic implications including leg ulcers, pruritus, blistering conditions, photosensitivity, sclerotic and fibrosing disorders, and purpura. In the afternoon we will focus on skin manifestations of internal diseases including skin signs of internal malignancies, vasculitis, lupus erythematosus, dermatomyostitis and sarcoidosis. Basic Dermoscopy Blanca Carlos-Ortega MD Friday, March 06, 2009, 9:00 AM Room 308 Great cases from Mexico City. Blanca Carlos Ortega Hospital Especialidades Centro Medico La Raza Mexico City. Dermoscopy improves the clinical diagnosis of many pigmented and nonpigmented skin tumors, but to date little is known about the impact of dermoscopy in the
  9. 9. diagnosis of eccrine poroma. Clinically, eccrine poroma may exhibit polymorphic features that can make the diagnosis difficult. Dermoscopic analysis revealed a polymorphous vascular pattern which is a well-known feature of hypomelanotic and amelanotic melanoma. We describe here, the clinical aspect and recent changes in the lesion were highly suggestive of amelanotic melanoma. Myasis is the infestation of living tissue by the larvae of flies. Cutaneous involment is the most common type of myasis. The larvae that commonly cause human furuncular myasis is Dermatobia hominis which is the most common agent of both cutaneous myasis and furuncular myiasis. Is found from Mexico to Argentina in areas of relatively high humidity and temperature. Dermoscopy has been described as an aid in the diagnosis of D. hominis. The pigmentation is the most common dermoscopy criteria of basal cell carcinoma at least in Mexico City, it can be as blue-grey ovoid nest, maple leaf-like and blue-grey multiple globules, this is possibly due to darker skin type. When the maple leaf-like structures are distributed around the tumor can simulate pseudopods. Physicians should therefore be aware of the dermatoscopic features of pigmented basal cell carcinoma that might mislead a diagnosis of malignant melanoma. The cardiofaciocutaneous syndrome is a rare genetic disorder characterized by hair and skin abnormalities, craniofacial dysmorphism mental and grown retardation and congenital heart defects, heart defects. Skin abnormalities include hyperkeratotic skin lesions, generalized ichthyosis-like condition and multiple melanocytic nevi among others. We describe the dermoscopic characteristics of melanocytic congenital nevi in a patient with this syndrome that show a distinct dermoscopy appearance. Basic Dermatopathology John Andrew Carlson MD Prof, Div Dermpath, Albany Med Col, Albany, NY Friday, March 06, 2009, 9:00 AM Room 304 Few diseases in clinical medicine cause as much diagnostic and therapeutic consternation as vasculitis. Vasculitis is simply inflammation directed at blood vessels identified by histologic examination. When blood vessel inflammation occurs, vessel wall destruction with hemorrhage and aneurysm formation or stenosis due to intimal hyperplasia can occur both of which may lead to tissue ischemia and infarction. Vasculitis can be a primary process (no known cause or association), or a phenomenon secondary to drug ingestion, infection or the presence of a systemic disease (e.g., rheumatoid arthritis) or to local factor such as trauma. Systemic and localized vasculitis often affects the skin and subcutis, likely due in part to their large vascular bed, hemodynamic factors (e.g. stasis in lower extremities) and environmental influences (e.g. cold exposure in cryoglobulinemic vasculitis). Frequent skin involvement by vasculitic syndromes, seen as diverse and dynamic patterns of discoloration, swelling, hemorrhage and/or necrosis, may be their initial and/or most accessible manifestations. Thus, dermatopathologists and dermatologists often become involved in the diagnosis and management of vasculitis. In this review, the vasculitides will be presented in the context of a histologic classification scheme that encompasses those entities that affect the skin. This classification system is based on the size of the vessels affected and inflammatory cell type associated with vessel damage. A primarily
  10. 10. morphologic based scheme is used rather than etiologic based one, as it is the most practical method to generate a relevant differential diagnosis when interpreting a skin biopsy showing vasculitis Basic Dermoscopy Patricia Cristodor PhD Friday, March 06, 2009, 9:00 AM Room 308 In evaluating a peculiar (especially a pigmented) skin lesion, the clinical and dermoscopical aspect, its confocal microscopy and its histological aspect represent a continuum which progressively uncovers more and more accurate and revealing details leading towards the correct diagnosis. The clinical diagnosis is non-invasive and may be rapidly performed in any place, but may be deceivingly belated; the confocal microscopy is still non-invasive and rapid, but requires an expensive non-mobile device, which is not always available or affordable; while the traditional microscopy, which still is “the golden standard” is in change invasive and time- consuming. Among all these, dermoscopy remains the most accessible, non-invasive, intravital and quick method, using a relatively low-cost device, which may be performed wherever the patient is located and which gives us a quite good dermoscopic-pathologic correlation. The end- point of the dermoscopical exam is to classify the skin lesions in three groups: 1) lesions to be excised (malignant tumors: melanoma, BCC, SCC or premalignant tumors: Bowen’s disease, actinic keratoses, etc), 2) lesions to be followed-up (a class of lesions which benefit the most of further investigation with confocal microscopy, referring mostly to atypical nevi), and 3) benign lesions which do not require re-evaluation (seborrhoeic keratoses, blue nevus, angiomas, common nevi, dermatofibroma, etc). Recently, dermoscopy proved to be a valuable tool in evaluating non-pigmented skin lesions, as well, providing means for the diagnosis of both malignant lesions (amelanotic melanoma, non-pigmented BCC) and benign lesions (lichen planus, psoriasis, keratoacanthoma, etc). In evaluating a skin lesion, one has to master the dermoscopic criteria, which are thoroughly described in manuals and textbooks, but in real life each new case represents a new challenge, where the “classical” criteria may or not be all present, and also, may be more or less evident. This is why we may consider Practice as our best teacher, since it provides us a permanently enlarging background of variants of the basic dermoscopic aspects, while the second best teacher is the permanent feed-back we receive from the pathological report. “Great Cases” are to be considered both cases which are 100% didactic, providing the students with all the typical elements one needs in order to recognize the lesion, and delusive cases, where only subtle, hard to notice, changes point to the diagnosis. When evaluating a skin lesion one must remember to take a good history, to take stock of all the criteria with an open mind and afterwards to fit them into a positive diagnosis (elements consistent with the diagnosis), while also attentively observing the criteria which might plead for another diagnosis or against the supposed diagnosis. The final balance between the “pro”s and the “con”s would be the next step to be taken in consciousness and responsibility. This presentation takes into account various skin lesions and diseases. It begins, of course, with melanoma, the most
  11. 11. fearful skin tumor. Typical cases of melanoma, together with soborrhoeic-keratosis-like melanoma, as well as other melanoma-like lesions and lesions of metastatic melanoma are presented. The next lesions presented are the BCCs: typical BCC, BCCs which were mistaken for herpes simplex with very delayed healing, BCC occurring on posttraumatic scars, relapsing BCC, follow-up of a BCC with topical treatment (the patient refused excision), sclerodermiform BCC, BCCs in the framework of a Gorlin syndrome. Blue nevus is a variant often clinically mistaken for melanoma, which, in change, is quite easy to diagnose dermoscopically, as our cases reveal. Among other nevi, there is a multitude of variants, from common nevi with reticular, globular or cobblestone pattern, to atypical nevi, or nevi holding special aspects due to their location (such as acral nevi, subungual nevi, or nevi on mucous membranes). Lentigo maligna has a special place in the presentation, since it is a quite frequent lesion with malignant, though slow, evolution. Seborrheic keratoses may be mistaken clinically with melanoma, or with nevi, or with papillomatous nevi, but they have very distinctive dermoscopic features. Angiomas are usually easy to diagnose clinically, but when thrombosed they may mimic melanoma, in which case dermoscopy is again salutary. Nail lesions are also presented, among which subungual hemorrhage and nevi occupy a major position. Dermoscopy is also a very useful tool in hair diseases, predicting the potential regeneration of the pellade, as well as the healing of Kerion Celsi. In the end, some unusual aspects are presented, including subcorneous hemorrhage, giant BCC, a conglomeration of multiple lesions (2 types of seborrheic keratosis and angioma), generalized keratoacanthoma and an acral foreign body. Dermoscopy is a rapidly developing science which gains, as time goes by, more and more accuracy and competence. It was born from the desire of diagnosing skin diseases without harming the patient and it is the love for our patients and for our profession which keeps it growing on. References: 1. Robert Johr, H. Peter Soyer, Giuseppe Argenziano, Rainer Hoffmann-Wellenhof, Massimiliano Scalvenzi. Dermoscopy The Essentials, Edinburgh: Mosby, 2004 2. Argenziano G, Soyer HP, Chimenti S, et al: Dermoscopy of pigmented skin lesions: results of a consensus meeting via Internet. J Am Acad Dermatol. 2003; 48:679-93 3. Malvehy J, Puig S. Dermoscopic patterns of benign volar melanocytic lesions in patients with atypical mole syndrome. Arch. Dermatol. 2004; 140 (5): 538-44 4. Malvehy J, Puig S, Braun RP, Marghoob AA, Kopf AW. Handbook of Dermoscopy. Taylor and Francis 2006, London 5. Mannone F, De Giorgi V, Cattaneo A, Massi D, De Magnis A, Carli P. Dermoscopic features of mucosal melanosis. Dermatol. Surg. 2004 (8); 30:1118-23 6. Pizzichetta MA, Massone C, Grandi C, Pelizzo G,Soyer HP. Morphologic changesof aquired melanocytic neviwith eccentric foci of hyperpigmentation (“Bologna sign”) assessed by dermoscopy. Arch Dermatol 2006Apr; 142(4):478-83 Challenges in MOHS Surgery Terrence A. Cronin Jr MD, FAAD Asst Prof Derm, Sch Med, U of Miami, Melbourne, FL Friday, March 06, 2009, 3:00 PM Room 3016 - West Unusual Wound Closures After Mohs Surgery In most repairs of Mohs surgery defects, a simple elliptical closure will be the closure method of choice, but a portion of the time dermatologic
  12. 12. surgeons will have to deal with a wound that requires an unusual closure method to provide a cosmetically appropriate result. In this lecture, the closure methods of second intention healing, partial closure, flaps, and grafts will be illustrated with many examples. The attending dermatologist should be able to gain insight into this process and learn new ways of dealing with difficult to closure skin cancer removal defects. Melanoma Update Marcia S. Driscoll MD, FAAD Sunday, March 08, 2009, 2:00 PM Room 102/103/104 Early case reports and case series dating back to the 1950's suggested a dismal prognosis for the woman diagnosed with melanoma during or around the time of pregnancy. It was suggested that melanomas may grow rapidly and metastasize due to the influence of hormones. This presentation addresses the question of whether a woman diagnosed with melanoma needs to delay pregnancy. This issue is significant due to ongoing controversy concerning the effect of hormones on melanoma. It is known that hormones may impact other types of cancer, such as breast and ovarian cancer, and that melanoma is one of the most common malignancies diagnosed during pregnancy. In addition, an increasing number of women are delaying pregnancy into their 30's and 40's. As a result, more women diagnosed with melanoma are faced with the specific question of whether to delay pregnancy. Direct and indirect evidence concerning this issue is presented, which aid in establishing guidelines for the timing of pregnancy after a diagnosis of melanoma. The best direct evidence concerning the prognosis for the woman who becomes pregnant after diagnosed with melanoma is based upon 3 case-control studies. These studies accounted for the most significant prognostic factors, such as Breslow depth of tumor, which was a limitation of many studies in the past. The earliest study is based upon data from the Duke University Comprehensive Cancer Center, reported in 1985.(1) Forty- three women who became pregnant within 5 years of diagnosis of localized melanoma (American Joint Committee on Cancer [AJCC] Stage I or II) were compared to 337 controls. There was no significant difference between groups in survival or disease-free interval. In a study from the World Health Organization reported in 1991, 85 women who became pregnant after a diagnosis of localized melanoma were compared to 143 controls. (2) There was no significant difference in survival or disease-free interval between groups. Finally, a study based on data from The Swedish National and Regional Registries reported in 2004, compared 402 women who became pregnant after a diagnosis of melanoma (all stages) to 1860 controls.(3) When key prognostic factors were considered, there was no significant difference in survival observed. When indirect evidence is considered concerning pregnancy and melanoma, there is additional evidence for a lack of effect of pregnancy on the prognosis for the woman diagnosed with melanoma. First, a total of 6 case-control studies and 2 large population-based studies have found no effect on prognosis when melanoma is diagnosed during pregnancy. (4) When 143 women who completed all pregnancies before a diagnosis of localized melanoma were compared to those who had melanoma diagnosed before, during, or between pregnancies, there was no
  13. 13. significant difference in survival or disease-free interval. In addition, the German Melanoma Group reported that women who had 5 or more pregnancies before a diagnosis of localized melanoma compared to those who had never been pregnant had a significantly longer survival rate.(5,6) If one considers the effect of exogenous hormones on melanoma prognosis, there is additional indirect evidence that hormones do not adversely impact melanoma. In a study reported in 2004, hormone replacement therapy (HRT) was prescribed to 206 women diagnosed with localized melanoma within 5 years of diagnosis. When these patients were compared with 123 controls, there was no adverse effect of HRT on survival. In fact, a survival advantage was noted in the HRT group. (7) Additional evidence concerning exogenous hormones and melanoma is provided by studies concerning the risk of developing melanoma after exposure to either oral contraceptive pills (OCPs) or HRT. There is extensive epidemiologic evidence that exposure to OCPs does not increase one's risk of melanoma. While there are fewer studies concerning HRT, the majority of stuides show that exposure to HRT does not increase the risk of developing melanoma.(4) Since there is both direct and indirect clinical evidence that endogenous hormones(pregnancy) or exogenous hormones (HRT, OCPs) do not impact the prognosis of melanoma, counseling on future pregnancies should be based solely on established prognostic factors, such as depth of the tumor, presence of ulceration, and AJCC stage of disease. The timing of future pregnancy is based upon one's risk of recurrence. Since the risk of recurrence is low for those with "thin" (less than 1 mm Breslow depth) melanomas without ulceration, pregnancy need not be delayed. For patients with depth of melanoma more than 1 mm, timing of future pregnancy is based upon when recurrence of disease is most likely. For AJCC stage I/II, the median time to recurrence is 2.6 years (8): therefore, women with tumors > 1 mm depth may wish to delay pregnancy for 2 to 3 years. For women with advanced stages of melanoma, the decision to become pregnant is a personal one, based on the age of the mother, fertility status, and the patient's support system. In the latter situation, the main concern is whether the patient will have recurrence of disease during pregnancy (which may limit her options for treatment) and/or whether she will survive to raise her child. Obviously, this situation is much more complex, and counseling should be individualized. In summary, the woman who has been diagnosed with melanoma and is contemplating pregnancy should be counseled based upon established prognostic factors, such as depth of tumor, ulceration, and stage of disease. There is no evidence that endogenous hormones (pregnancy) or exogenous hormones (HRT, OCPs) have an adverse influence either on the prognosis of melanoma, nor on the risk of developing melanoma. For women with an excellent prognosis, no delay in pregnancy is needed. For those with tumors more than 1 mm in depth, a delay of pregnancy for 2 to 3 years may be prudent, since this is the time period in which recurrence is most likely. For those with advanced melanoma, counseling is more complex, with the key question being whether the patient will survive through her pregnancy and /or survive a sufficient time to care for her child. References: 1. Reintgen DS, McCarty KS, Vollmer R, et al. Malignant melanoma and pregnancy. Cancer 1985;55:1340-4. 2. MacKie RM, Bufalino R, Morabito A, et al. Lack of effect of pregnancy on outcome of melanoma. Lancet 1991;337:653-5. 3. Lens MB, Rosdahl I, Albom A, et al. Effect of pregnancy on survival in women with cutaneous malignant melanoma. J Clin Oncol 2004; 22:4369-75. 4. Driscoll MS, Grant-Kels JM. Hormones, nevi and melanoma: an approach to the patient. J Am Acad Dermatol. 2007;57:919-931. 5. Bork K, Brauninger W. Prior pregnancy and melanoma survival [Letter]. Arch Dermatol 1986;122:1097. 6. Bork K, Brauninger W. Endocrine influences on malignant melanoma. Dtsch Med Wochenschr 1981;106:1329-33. 7. MacKie RM, Bray CA. Hormone replacement therapy after surgery for stage 1 or 2 cutaneous
  14. 14. melanoma. Br J Cancer. 2004;90:770-2. 8. Francken AB, Accortt NA, Shaw HM, et al. Follow- up schedule after treatment for malignant melanoma. Br J Surg 2008;95:1401-7. Cutaneous Lymphomas Madeleine Duvic MD, FAAD Prof Med & Derm, Derm Dept, MD Anderson Cancer Ctr, Houston, TX Monday, March 09, 2009, 9:00 AM Room 2020 - West The Cutaneous Lymphoma Symposium on the morning of Monday, March 9, will review the latest advances in the pathogenesis, staging, and treatment of the spectrum of cutaneous lymphomas. Dr. Madeleine Duvic from MD Anderson Cancer Center will moderate the discussion among a panel of experts in the field. Dr. Gary Wood, University of Wisconsin, will present a practical overview and information needed by the Dermatologist to correctly diagnose cutaneous lymphomas using H&E, immunohistochemical and molecular methods currently available. Dr. Youn Kim, Stanford University, will discuss how to categorize, diagnose, and treat cutaneous B-cell lymphomas and CD30+ lymphoproliferative disorders. Dr. Joan Guitart, Northwestern University, will present an overview of rare peripheral T cell lymphomas such as NK-T, subcutaneous and aggressive cytotoxic T-cell lymphomas, including those expressing CD8+. Dr. Ellen Kim, University of Pennsylvania, will review new information on the pathogenesis and treatment of Mycosis Fungoides and Sézary Syndrome, and Dr. Duvic will discuss the use of systemic and experimental agents for more advanced MF/SS. This Symposium should be of interest to clinicians wishing to increase their knowledge and hear about the latest advances in cutaneous lymphomas. Therapeutics Steven R. Feldman MD, PhD, FAAD Prof Dept Derm, Wake Forest U, Winston-Salem, NC Saturday, March 07, 2009, 2:00 PM Room 3022 - West Topical treatments are the foundation of dermatologic therapy. The use of topical medications allows dermatologists to target highly potent medications directly to the site of inflammation. Unfortunately the efficacy of topical therapy is limited by poor adherence. Using topical medications is more difficult than simply taking a pill. Poor adherence to treatment is ubiquitous in dermatology. When patients say the treatment is not working it may be that they are not using the medication. There are many reasons patients don’t use their medications. Patients may not fill the medication at all. They may start on medication but stop too early. Even before stopping patients may or may not use their medication very well. Electronic monitors have revolutionized
  15. 15. the ability to assess patients’ actual use of their medication. Studies of psoriasis have showed quite variable adherence to treatment. Studies of atopic dermatitis and acne show poor adherence behavior. In contrast the use of 5-fluorouracil, a medication that causes considerable irritation, is actually associated with good adherence behavior. Adherence behavior is quite unpredicatable. Dermatologists can use interventions to improve adherence to complement the prescriptions they write in order to achieve better treatment outcomes. To improve better adherence it is important to establish a partnership with patients and make sure that they are satisfied and trusting of their care. It is far more important to choose a vehicle that the patient is willing to use than it is to pick an ointment to moisturize the lesions. While the moisturizing characteristics of an ointment may be valuable, they aren’t helpful if the patient does not apply the medication. Moisturization is not necessary to eliminate inflammation. Clobetasol, cyclosporine and infliximab can all eliminate inflammation without moisturizing the skin. The timing of office visits can also be used to enhance good compliance behavior. Just as people floss their teeth before seeing a dentist, patients are more likely to use their medication right before their visit to the office. One of the benefits of poor adherence is that it limits patients’ side effects. Topical medications work much better when patients use them. It is important to form a strong trusting relationship with patients and get them to see the medication works by giving them a fast acting medication that they are willing to use and schedule a return visit to encourage good initial adherence behavior. Topical therapy can be extremely rewarding. Translational Research in Dermatology David E. Fisher MD, PhD Monday, March 09, 2009, 12:00 PM Room 3016 - West Molecular pathways which control skin pigmentation have been largely elucidated through analyses of naturally occurring mutations which produce abnormal or variant pigment phenotypes. The transcription factor MITF is derived from a gene whose mutation produces Waardenburg Syndrome, characterized by deficient melanocyte development/viability in heterozygously affected individuals. Very similar phenotypes occur for mutations in other genes—which has thus permitted molecular connections to be made among the corresponding gene products. One important receptor for melanocyte development is c-Kit, a receptor tyrosine kinase. Resent analyses by Bastian and colleagues identified activating mutations within the c- Kit gene among a fraction of melanomas arising on mucosal, acral, or chronically sun-damaged cutaneous surfaces. On the basis of this observation clinical trials have been initiated to test whether c-Kit targeted kinase inhibitors may be clinically efficacious in management of c-Kit mutated metastatic melanomas. Initial data reveal major clinical activity for such a treatment strategy, although additional efforts are needed to convert treatment responses into durable remissions. Other genetic clues to control of pigmentation include lessons learned from “redheads” which are pertinent to control of tanning and skin cancer prevention.
  16. 16. Resident Jeopardy Amit Garg MD, FAAD Asst Prof, Dept Derm, Boston U Sch of Med, Boston, MA Friday, March 06, 2009, 9:00 AM Room 3018 - West Gaming as a formal teaching strategy was introduced over 75 years ago, and its use in medical education has increased over the past decade. While individual dermatology training programs, including ours at Boston University, have been using various forms of gaming as a teaching tool, it is a novel and innovative approach to self-assessment specifically designated for resident physicians at this year’s annual American Academy of Dermatology meeting. Educational gaming is a modern teaching strategy that has been shown to be effective in improving learning outcomes and to motivate adult learners in becoming more engaged in learning. Adult learning theory informs us that adults, as learners, are self-motivated, self-directed, and prefer a learning environment in they may be involved actively. Structured educational gaming requires each of these learning concepts from participants and actualizes learning through a fun, non-threatening platform. “Through play, the educational strategy of structured gaming promotes self-directed learning using a cooperative and interactive learning approach. What could be more fun?” Amit Garg, MD. Department of Dermatology, Boston University. The Resident Jeopardy forum (F001, Room 3018 – West) will convene residents, fellows, and students with the goals of learning, as well as fostering professional interaction among peer colleagues. Hair Disease and the African American Patient Raechele Cochran Gathers MD, FAAD Saturday, March 07, 2009, 12:15 PM Room 110 In addition to being wonderfully unique in appearance, African American hair is also unique in its very morphology. While there are no known biochemical differences among African, Caucasian and Asian hair types, African American hair, under a microscope, appears elliptical or flattened in cross-section, while Caucasian hair appears oval, and the hair of an Asian would appear round. Further, African American hair follicles are typically curved, while they are straight in both Caucasians and Asians. Phenotypically, African hair type resembles a twisted oval rod, with frequent twists, random direction reversals and pronounced flattening. The unique curvature of African hair follicles, in addition to the elliptical flattened shape of the hair, often makes African hair type uniquely fragile and prone to injury and damage. The unique structure, physical properties, and grooming practices of those with African hair type may predispose this population to several disorders of both the hair and scalp. Common non permanent forms of hair disease experienced by African Americans may include: Trichorrhexis nodosa, secondary to
  17. 17. chemical alopecia or weathering; traction alopecia; seborrheic dermatitis and tinea capitis. Common permanent forms of hair loss seen in African Americans may include central centrifugal cicatricial alopecia, acne keloidalis nuchae, and dissecting cellulitis. Additionally, African American men are particularly prone to pseudofolliculitis barbae, commonly referred to as razor bumps. Identification of these disorders as well as culturally sensitive treatment protocols will be discussed. Hair is more than just a cosmetic concern. It is an important aspect of self image. Healthy hair expresses wellness, youth and physical appeal. Hair may help define identity, ethnicity and even social status. In traditional West African culture, hair was used to articulate marital status, geographic origin and ethnic group. During slavery, hair texture and style were used to articulate social class and status. In modern African American culture, hair texture and hair styling is a marker of beauty, economic power, education and beliefs. Hair loss has a considerable psychosocial impact, particularly among women. While African Americans only constitute 13% of the nation’s population, they account for at least 30% of all hair care expenditures. As many as 60% of African American women experience hair breakage, and more than half complain of dry scalp problems. Fifty-one percent of African American women cite thinning or hair loss as their top hair care concern. It has been estimated that alopecia (hair loss or balding) is the fifth most common reason for African Americans to visit their dermatologist. At Henry Ford Hospital’s Multicultural Dermatology Center, complaints of hair loss are even more common than this. Central Centrifugal Cicatricial Alopecia (CCCA) is the most common permanent form of hair loss seen among African American women. Previously called “hot comb alopecia,” it is a poorly understood form of hair loss. Initially, women with CCCA may develop a circular area of balding at the crown. Over time, this balding spreads outwards (centrifugally) until it affects much of the scalp. To date, the causes of CCCA are unknown, although recent data from our center suggest that chronic traction may play a significant causal role. Identification of this disorder, recent research into its causes, as well as treatment regimens will be discussed. Finally, popular hair styling techniques among African Americans, including relaxing, texturizing, heat restructuring, weaving, braiding, and natural hair styles will be reviewed. Best practices of these regimens will be discussed and suggestions will be made regarding counseling patients on recommended product ingredients, as well as ingredients and grooming practices to avoid. Infectious Diseases Gary Goldenberg MD, FAAD Tuesday, March 10, 2009, 9:00 AM Room 307 Human papillomavirus (HPV): • Members of the Papovaviridae family • More than 100 types • Infects skin, mouth, esophagus, larynx, trachea, and conjunctiva • DNA codes for early and late genes Important♣• Early genes o DNA replication, transcription control o E1 and E2 Host cell provides DNA polymerase needed for♣for DNA replication and infection Important for host synthesis of viral DNA o In♣replication o E6 and E7 malignant cells E1/E2 ratio is important
  18. 18. for transcription of E6 and E7, as the virus integrates into the chromosome of the host cell o High risk HPV E6 strongly binds to p53, causing its degradation (mimicking p53 mutation effect) o Low risk HPV E6 binds p53 weakly • Late genes o L1 and L2 encode major and minor capsid proteins, respectively Epidermodysplasia verruciformis: • Autosomal recessive, although autosomal dominant and X-linked recessive cases have also been reported • Genetic predisposition to a group of HPV types and their oncogenic potential o HPV 5, 8, 9, 12, 14, 15, 17, 19, 20-25, 36, 47, 50 • Related to EVER1 and EVER2 mutations o Integral membrane proteins localized to the endoplasmic reticulum • Disease presents in childhood as flat warts and/or lesions resembling pityriasis versicolor on the hands, face, neck, and trunk o Hyperkeratotic lesions with morphologies resembling actinic keratosis, seborrheic keratosis, and psoriasiform plaques have also been described • Malignant transformation occurs in approximately 30-50% of patients after the age of 30 years old, most commonly in lesions on sun exposed skin • Traditionally EDV malignancies are regarded as having a low potential for invasion and metastasis o Aggressive and metastatic disease has been associated with prior exposure to therapeutic radiation • Histology – characteristic enlarged keratinocytes in the upper Malpighian layer with blue-gray cytoplasm Verrucous Carcinoma: • Three clinical variants described o Oral florid papillomatosis – oral cavity o Giant condyloma of Buschke and Löwenstein – groin o Carcinoma cuniculatum – plantar surface • Regarded as a low grade variant of squamous cell carcinoma • HPV 6 and 11 DNA regularly found in VC o Reports associated with high risk HPV also found in literature • Histology – massive hyperkeratosis, papillomatosis, and acanthosis of the epithelium; keratinocytes show minimal atypia and rare mitosis Human herpesvirus 8: • Member of the human herpesviruses family o Linear double-stranded DNA o 8 types described o Three groups – alpha, beta, and gamma o Natural history of primary infection, latency and reactivation • Gamma herpesvirus • Two alternative phases of infection o Latent – restricted set of viral genes is expressed o Lytic – viral gene expression initiates lytic viral DNA replication and virion production • HHV-8 oncogenes, including ORFK1, ORF74, ORF71, and ORFK9, cause endothelial and/or fibroblast cell transformation in vitro as well as tumor development in vivo Kaposi’s sarcoma: • Systemic disease with possible multi-organ involvement • PCR evidence of HHV-8 noted in approximately 95% of KS lesions • 4 types described: Bluish-to-red macules,♣ Mediterranean region and Ashkenazi Jews ♣o Classic plaques, and nodules initially develop on distal lower extremities and later may Male predominance in adult and♣spread to other areas o African endemic Nodular, florid, and infiltrative disease affects adults •♣childhood disease Nodular disease resembles classic KS • Florid and infiltrative KS shows a more Lymphadenopathic variant mainly affects children •♣aggressive patters Patients with♣Fulminant and fatal course o Iatrogenically immunocompromised Clinically similar to♣organ transplants, autoimmune diseases, and malignancies ♣ Sirolimus and renal transplant recipients o AIDS-associated ♣classic KS Advanced HIV disease♣Serologic presence of HHV-8 predicts disease development Facial disease is common •♣ Disseminated cutaneous involvement commonly seen ♣ Expression♣Endothelial neoplasm o Vascular, lymphatic, or combination of both of vascular endothelial growth factor receptor-3 (VEGFR-3) and podoplanin noted • Markers of lymphatic differentiation • Histology o Similar regardless the clinical disease presentation o Atypical, irregular, and angulated vascular Irregular♣channels uniformly present o Promontory sign often described vascular channels which partially surround pre-existing blood vessels o HHV-8 99% sensitive and 100% specific for KS lesions♣immunohistochemical stain Merkel cell polyomavirus: • Previously unknown polyomavirus o Small double-stranded DNA virus o 3
  19. 19. types: avian, mammalian related to MuPyV, and mammalian related to simian virus 40 (SV40) o SV40 subgroup contains all human ≥30 million people in US may have been♣ BKV, JCV, KIV, and WUV ♣polyomaviruses ♣exposed to live SV40 in potentially contaminated polio vaccines 1955-1963 Found in human brain and bone cancers, malignant mesothelioma, and non- Hodgkin’s In♣lymphoma • Described by Moore and colleagues o Present in 8/10 (80%) MCC 6/8 cases viral DNA was integrated within the tumor genome in a clonal pattern o Present in 5/59 (8%) control tissues from various body sites and 4 of 25 (16%) control skin tissues References: 1. Tyring SK. Human papillomavirus infections: epidemiology, pathogenesis, and host immune response. J Am Acad Dermatol. 2000 Jul;43(1 Pt 2):S18-26. 2. de Oliveira WR, Festa Neto C, Rady PL, Tyring SK. Clinical aspects of epidermodysplasia verruciformis. J Eur Acad Dermatol Venereol. 2003 Jul;17(4):394-8. 3. Ramoz N, Rueda LA, Bouadjar B, Montoya LS, Orth G, Favre M. Mutations in two adjacent novel genes are associated with epidermodysplasia verruciformis. Nat Genet. 2002 Dec;32(4):579-81. Epub 2002 Nov 11. 4. Ramoz N, Taïeb A, Rueda LA, Montoya LS, Bouadjar B, Favre M, Orth G. Evidence for a nonallelic heterogeneity of epidermodysplasia verruciformis with two susceptibility loci mapped to chromosome regions 2p21-p24 and 17q25. J Invest Dermatol. 2000 Jun;114(6):1148-53. 5. Schell BJ, Rosen T, Rády P, Arany I, Tschen JA, Mack MF, Tyring SK. Verrucous carcinoma of the foot associated with human papillomavirus type 16. J Am Acad Dermatol. 2001 Jul;45(1):49-55. 6. Noguchi K, Fukazawa H, Murakami Y, Takahashi N, Yamagoe S, Uehara Y. Gamma-herpesviruses and cellular signaling in AIDS-associated malignancies. Cancer Sci. 2007 Sep;98(9):1288-96. Epub 2007 Jul 19. 7. Cloutier N, van Eyll O, Janelle ME, Lefort S, Gao SJ, Flamand L. Increased tumorigenicity of cells carrying recombinant human herpesvirus 8. Arch Virol. 2007 Oct 18. 8. Olsen SJ, Moore PS. Kaposi’s sarcoma-associated herpesvirus (KSHV/HHV-8) and the etiology of KS. In: Medveczky P, Friedman H, Bendinelli M, editors. Herpesviruses and immunity. New York: Plenum Publishing; 1998. 9. Stallone G, et al. Sirolimus for Kaposi's sarcoma in renal- transplant recipients. N Engl J Med 352:1317-1323, 2005. 10. Robin YM, et al. Human herpesvirus 8 immunostaining: a sensitive and specific method for diagnosing Kaposi sarcoma in paraffin-embedded sections. Am J Clin Pathol: 121 :330-334, 2004. 11. Moore PS, et. al. Science. 2008 Feb 22;319(5866):1096-100. 12. Vilchez RA, Butel JS. Clin Microbiol Rev. 2004 Jul;17(3):495-508. Laser Pearls Mitchel Paul Goldman MD, FAAD Assoc Clin Prof, Derm/Med, UC, San Diego, CA Tuesday, March 10, 2009, 12:00 PM Room 301 Cellulite occurs to some extent in 80% of women. Liposuction is the leading surgical cosmetic procedure in the USA. Recent advances in a variety of laser-based technologies have led to improvements in treating both cellulite and unwanted fat. This lecture will highlight comparative clinical and experimental studies on a variety of laser-based technologies to minimize the appearance of cellulite and enhance liposuction. Cellulite occurs from a combination of
  20. 20. alterations in the honey-comb fibrous strands connecting the skin to underlying fascia and an excess of adipose tissue within the “honey-combs.” Laser technologies serve to reduce excessive fat within the “honey-combs” normalize the fibrous strands and improve the quality of the skin. Comparative studies demonstrate similar efficacy amongst most laser and light-based technologies. However, adverse effects differ between these lasers and light based anticellulite machine. Recently, a subcutaneous laser has been used without liposuction to improve the skin texture minimizing the extrusion of fat which gives a “cottage cheese” appearance to the skin. Liposuction has proven to be both safe and effective when performed in the awake patient with tumescent anesthesia and small cannulas developed by dermatologists for the past 15 years. There have been relatively few advances in this procedure over the last 15 years. Recently, subcutaneous lasers have been demonstrated to both aid in melting unwanted fat as well as tightening overlying skin. This lecture will discuss experimental and clinical studies on a variety of subcutaneous lasers which have produced the first real advance in liposuction since local tumescent anesthesia. Goldman MP, Hexsel D: CELLULITE: PATHOPHYSIOLOGY AND TREATMENT 2nd Ed. Informa USA, New York, 2009 (in Press) Boyce S, Pabby A, Chuchaltkaren P, Brazzini B, Goldman MP: Clinical evaluation of a device for the treatment of cellulite: Triactive. Am J Cosmetic Surg 2005;22:233-237. Nootheti PK, Magpantay A, Yosowitz G, Calderon S, Goldman MP: A single center, randomized, comparative, prospective clinical study to determine the efficacy of the Velasmooth system versus the Triactive system for the treatment of cellulite. Lasers Surg Med 2006;38:908-912. Khoury JG, Saluja R, Goldman MP: Histologic Evaluation of Interstitial Lipolysis Comparing a 1064 nm, 1320 nm and 2100 nm Laser in an Ex-Vivo Model. Lasers Med Surg 2008;40:402-406. Cosmetic Surgery Mitchel Paul Goldman MD, FAAD Assoc Clin Prof, Derm/Med, UC, San Diego, CA Friday, March 06, 2009, 9:00 AM Room 102/103/104 Lasers have been used to resurface and rejuvenate the skin for over 15 years. The CO2 Laser was initially used to resurface the skin and though while achieving outstanding improvement resulted in 2-3 weeks of healing. This procedure needed to be performed under general anesthesia and had a measurable incidence of changes in skin pigment as well as post-operative pain. In an effort to minimize adverse effects, eliminate down-time and minimize procedure pain non- ablative lasers were developed but suffered from minimal efficacy. Most recently fractionated non-ablative lasers were developed to improve age-related changes of the skin. These lasers were stronger and the use of “fractionating” the laser energy so that “untreated – skipped” skin could lead to quick healing proved beneficial. Unfortunately, while minimizing down-time, results have also been minimal. It therefore became clear that some degree of “down-time” was necessary to achieve reproducible improvement in age and photo-damaged skin. The most recent advance has been fractionating the CO2 Laser which is an ablative laser. Many studies have demonstrated excellent improvement with far less downtime. In the last year, dozens of laser companies have come to market with similar fractionted CO2 lasers making it difficult for post
  21. 21. patient and physician to determine which laser is best. This lecture will compare a variety of fractionated CO2 Lasers in rejuvenating the face. Goldman MP: Observations on the Use of Fractionated CO2 Laser Resurfacing. J Drugs Dermatol 2009; 8:82-86. Saluja, R, Khoury J, Detwiler S, Goldman MP: An Evaluation of the Histologic and Clinical Response to Varying Density Settings with a Fractionally Scanned Carbon Dioxide Laser. J Drugs Dermatol 2009; 8:17-20. International Dermatology: Teaching and Learning as a Global Experience Ernesto Gonzalez MD, FAAD Monday, March 09, 2009, 12:15 PM Room 3009 - West The American Academy of Dermatology annual meeting has embraced a large representation of foreign participants that reflects the interest in exchanging knowledge and experiences on global issues. Moreover, the influx of physicians from other countries attending different institutional educational activities requires institutional structure for organized teaching and the willingness to exchange ideas in an open and unbiased manner. The session will deal with global learning. Prototypes of institutional training and educational formats offered to international physicians will be described emphasizing organizational structures that take into consideration prevalence of diseases in countries represented as well as the cultural and socio-economic impact on the management of these diseases in those countries. Brief presentations by international participants in these programs will demonstrate these nuances and will serve to frame it in comparison with the delivery of care in the USA. An intangible but important goal is to demostrate the development of a global fraternity for learning and collaboration. The second portion of the session will discuss the utilization of tele-dermatology as a tool to exchange information for distance-learning and tele-consultation. Several collaborative programs will be described as paradigms to accomplish these goals with emphasis on services to underdeveloped countries. Cryosurgical Update Gloria F. Graham MD, FAAD Clin Assoc Prof Derm, Wake Forest U Sch Med, Winston-Salem, NC Monday, March 09, 2009, 2:30 PM Room 111 Choosing the most effective cryosurgical technique may improve cure rate and cosmetic result, as well as avoid unwanted complications. Here are brief descriptions of some of the more commonly used and most effective techniques: • A small pointed probe can destroy sebaceous hyperplasia, molluscum contagiosum and verruca plana. (1) • Firm pressure with a flat probe is
  22. 22. effective for small seborrheic keratoses and verruca vulgaris. (1,2) • Spray is preferred for many keratotic lesions that do not have a flat surface and a cone around the lesion allows for more precise freezing and less damage to surrounding pigment cells. (3) • Forceps dipped into liquid nitrogen and touched gently or used to grasp skin tags may quickly destroy many of these pesky spots. • Monitoring with thermocouple needles and read on a pyrometer is the most useful method for assuring a sufficient freeze at the base of the tumor. Thermocouple monitoring is useful for assuring adequate freeze to -50° C when treating skin cancer when one is learning the technique. • Ultrasound may help determine lesion margins and depth of freezing(1). • Shave excision combined with curettage and freezing is the preferred technique by many cryosurgeons and may be used in place of electrodesiccation. (4,5,6) • Palliative treatment of large tumors has been reported to clear some for long periods, ridding the patient of the foul smell and draining sites, as well as eliminating much of the pain. (7) • While 10 seconds of intermittent freezing can eradicate an actinic keratosis that is flat, 20 seconds may be needed for thicker hyperkeratotic actinic keratoses. Take care to freeze enough, but not more than is needed. • Use of the cone around a lesion will avoid treating more skin than is necessary and concentrates the spray to the lesion. Attention to proper technique will improve cure rate and cosmetic result. This talk will discuss in detail the ways that adhering to strict guidelines can improve the overall results. (8) Pertinent review of the recent literature will be presented. While cryosurgery is a useful technique that is both effective and cost saving for a wide range of skin conditions, determining the most appropriate conditions for management by cryosurgery requires experience, attention to specific criteria (such as the age and general condition of the patient), skin type and diagnosis of the lesion, which is often determined by clinical judgment alone. Clinicians wishing to use this technique need to accurately diagnose skin lesions of all types. This makes cryosurgery an excellent technique for dermatologists, who possess these skills at a higher level than other physicians. (9) Cryosurgery is commonly used as the treatment of choice for cases of actinic keratosis, seborrheic keratosis, lentigo, verruca vulgaris and certain types of keloids. Skin cancers respond with precision to specified amounts of freezing and cure rates of up to 98.6% have been reported in some studies. (4,5) However, the cosmetic result is at times not as satisfactory as that obtained by excision, due to the predictable pigment loss from the longer freezing needed with some deeper skin cancers. (10) While selected lentigo maligna show excellent clearing, many prefer excision thus ruling out an incipient melanoma. (1) The depth of a lesion can be estimated by palpation and ballottement, or by newer imaging techniques, such as ultrasounds, CT scans and MRIs. The location of the lesion is equally important; some areas, like the backs of hands and arms, are easier to freeze than others. For diagnosing skin cancer the biopsy many be done at the time of or before the cryosurgery. This is especially true in cases of Bowen's Disease, squamous and basal cell carcinoma and lentigo maligna. (1) Cosmetic result and the cost are important components to consider before selecting cryosurgery. Cryosurgery results in good cosmetic results, but may be associated with hypopigmentation, which is more apparent in darker skin persons. Patients should be informed prior to treatment of the expected results, along with the post-freezing side effects of blistering and exudation. (1) Various other treatment options (topical, destructive and surgical) should be considered in the management of various skin tumors. Photodynamic therapy is also used in the treatment of actinic keratosis and some skin cancers. Lasers are another effective method for treatment of many of the same lesions that respond to freezing. (11-16) References: 1. Graham GF. Cryosurgery for benign, premalignant and malignant lesons. In: Wheeland RG,editor. Cutaneous surgery. Philadelphia: Saunders; 1994, pp 835-869. 2. van Brederode RL, Engel ED. Combined cryotherapyl70%
  23. 23. salicylic acid treatment fro plantar verrucae. 1 Foot and Ankle Surg 200 1;40:4. 3. Damstra R1 ,van Vloten W A. Cryotherapy in the treatment of condylomata acuminata: a controlled study of 64 patients. 1 Dennatol Surg Oncol 1991; 17 :273 4. Graham, GF, Clark LC. Statistical analysis in cryosurgery of skin cancer. In: Breitbart EW, Dachow-Siwiec E, eds.Clinics in Dennatology: Advances in Cryosurgery. New York: Elsevier, 1990:101-7. 5. Kuflik EG. Cryosurgery for skin cancer: 30-year experience and cure rates. Dermatol Surg 2004;30:297-300. 6. Nordin P, Larko 0 ,SteinQuist B. Five-year results of curettage-cryosurgery of selected large primary basal cell carcinomas on the nose: An alternative treatment in a geographical area underserved by Mohs' surgery. BrJ Dermatol 1997; 136: 180-3. 7. Pasquali P. Palliative treatment of skin cancers .Syllabus for Congress ofCryosurgery in the Americas, Montreal Canada 2004; Presented as a lecture and abstract. 8. Graham G, Barham K. Cryosurgery. CUff Prob Dennatol 2003;15:225- 250. 9. Smith ES, Feldman SR, Fleischer AB lr, Leshin B, McMichael A. Characteristics of office-based visits for skin cancer. Dennatologists have more experience than other physicians in managing malignant and premalignant skin conditions. Dennatol Surg. 1998 Sep;24(9):981-5. 10. Thiessen MR, Nieman FH, Ideler AH,Berretty Pl, Neumann HA. Cosmetic results of cryosurgery versus surgical excision for primary uncomplicated basal cell carcinoma of the head and neck. Dermatol Surg 2000;26:759-64. 11. Beutner KR, Geisse lK, Helman 0, Fox TL, Ginkel A, Owens ML. Therapeutic response of basal cell carcinoma to the immune response modifier imiquimod 5% cream. 1 Am Acad Dennatol. 1999 Dec;41(6):1002-7. 12. Huber A, Huber 10, Skinner RB et al. Topical imiquimod treatment for nodular basal cell carcinomas: An open-label series. Dermatol Surg 2004;30:429-30. 13. Gibbs S, Harvey I, Sterling 1, et al. Local treatments for cutaneous warts: systematic review. BMl 2002;325:46l. 14. Lebwohl M, Dinehart S, Whiting 0, et al. Imiquimod 55 cream for the treatment of actinic keratosis: Results from two phase III, randomized, double-blind, parallel group, vehicle-controlled trials. 1 Am Acad DennatoI2004;50:714-2l. 15. Manuskiatti W, Fitzpatrick RE. Treatment Response of keloidal and hypertrophic sternotomy Scars. Arch DennatoI2002;138:1149-55. 16. Marks R, Gebauer K, Shumack S. et al. Imiquimod 5% Cream in the treatment of superficial basal cell carcinoma: Results of a multicenter 6 week dose-response trial. 1 Am Acad DennatoI2001;44:807-13. Use of Physician Extenders Robert David Greenberg MD, FAAD Private Practice, Vernon, CT Sunday, March 08, 2009, 3:00 PM Room 306 Director Robert D. Greenberg MD, FAAD Speakers Ponciano D. Cruz Jr. MD, FAAD Roger I. Ceilley MD, FAAD Abel Torres MD, JD, FAAD Melodie S. Young, MSN, RN, A/GNP Bethany L. Grubb, MPAS, PA-C Learning Objectives Following this forum, the attendee will be able to: 1. Identify and discuss issues related to the use of physician extenders in the practice of dermatology. 2. Recognize the education and dermatologic training afforded physician extenders specializing in dermatology. 3. Summarize the legal and ethical aspects related to the supervision and training of physician extenders in dermatology. Description The increasing demand for dermatologic services and undersupply of dermatologists nationwide contribute to the use of
  24. 24. physician extenders in many dermatology practices. Speakers will relate how physician extenders are educated, trained, and used in dermatology practices. Speakers will provide information about hiring, training, and supervising these professionals. Both a dermatology NP and PA will discuss their respective professional training and clinical experience in dermatology. Details will be provided on how physician extenders are used successfully, what pitfalls to avoid, how to bill for their services, and what the ethical and legal implications are in having physician extenders in your practice. The Use of Physician Extenders forum is scheduled for Sunday, March 8, 2009 from 3:00 pm to 5:00 pm in the Moscone Center South building Room 306. 2 Category 1 CME Credits Use of Physician Extenders Bethany Lesch Grubb MPAS Sunday, March 08, 2009, 3:00 PM Room 306 The Role of Physician Extenders Bethany Grubb, MPAS, PA-C President, Society of Dermatology Physician Assistants Physician “Extender” Physician Assistant Health care professional licensed to practice medicine with physician supervision. (aapa.org) “Fifth best job in America” (Money magazine, May 2006) Nurse Practitioner Advanced practice nurse who provides high-quality healthcare services similar to those of a doctor. (aanp.org) Physician Assistant-Authority Accreditation-ARC-PA Certification-NCCPA Licensure-State Medical Boards Supervision-MD or DO Scope of Practice Physician Assistant-Accreditation 142 Accreditation Review Commission-PA (ARC-PA) accredited programs Masters degree (113) Baccalaureate degree (21) Certificate/Associates degree (8) Physician Assistant-Certification National Commission on Certification of Physician Assistants (NCCPA) PANCE upon graduation PANRE every 6 years 100 hours of CME q 2 years 50 hours-Category 1 CME Physician Assistant-Licensure Regulatory Agencies State Board of Medical Examiners i.e. Texas State Board of Medical Examiners Licensure does not create independent practice. The profession retains its commitment to PA practice with physician supervision. Licensure should be independent of identification or approval of supervising physicians or supervisory arrangements and independent of employment. (aapa.org) Physician Assistant-Licensure State Statutory and Regulatory Requirements for Licensure Graduation from an accredited PA program Passage of NCCPA exam (PANCE) Current NCCPA certification Renewal requirements-CME and/or PANRE Prescribing Privileges (all 50 states) Physician Assistant- Supervision Supervising physician is a licensed MD or DO who accepts responsibility for supervision of services provided by the PA. Guiding principles: (a) to protect the public health and safety, and (b) to preserve the physician assistant's access to physician consultation when indicated. (aapa.org) Physician Assistant-Supervision The direction of the medical practice of the PA is provided and assured by supervising physicians, but this does not necessarily require the physical presence of a supervising physician at the place where services are rendered. The PA and supervising physician can be in contact with each other by telecommunication. (aapa.org) Large groups or multiple supervising physicians should document physician supervision
  25. 25. Physician Assistant-Scope of Practice PAs should be permitted to provide any legal medical service that is delegated to them by the supervising physician when the service is within the PA’s skills and is provided with supervision of a physician. Skills should not extend the scope of the supervising physician beyond what is reasonable in the practice. (aapa.org) Prescribing/Dispensing DEA number Physician Assistant-My Journey 2002: Graduate, UT Southwestern PA program 2003: Dermatology Postgraduate program at UTSW (Master’s Degree, U of Nebraska) 2004: Full-time, private practice with solo dermatologist (85% onsite supervision) 2006: Half day each week, Pigmented Lesion Clinic at UTSW (100% onsite supervision) 2008: Same private practice setting (2 days/week) with 2 dermatologists and one other PA Physician Assistant Supply Current annual PA output- 5000 (total) Bureau of Labor Statistics: 27% increase in PA jobs (2006 to 2016) 83,000 PAs by 2016 Growth defined as “much faster than average” Postgraduate Physician Assistant Education 44 programs in 19 states, 16 specialties Credentials include certificate of completion and/or Master’s degree Most programs are eligible to award Category 1 CME for didactic education content Program length varies from 6-24 months-averaging 12 months Dermatology-one program at UTSW (Dallas) www.appap.org Postgraduate PA Education in Dermatology at UTSW Co-chairs: Ponciano Cruz, M.D. Eugene Jones, PhD., PA-C 10 graduates (2000 to 2008) Formal didactic training: Basic Science lectures Surgery lectures Dermatology Grand Rounds/Patient Presentations Kodachrome slides Hospital rounds Postgraduate Physician Assistant Education Treated as a 1st year dermatology resident Training at Parkland Hospital, VA Center, Children’s Hospital and private faculty clinics, including connective tissue, CTCL and vesiculobullous clinics PA fellows present a one hour, evidence-based medicine lecture at the Grand Rounds venue SDPA Member Survey 2007 593 respondents (out of 1805) (33%) Demographics: Mean age: 37 years 71% female 64% have worked as a PA in dermatology for over 3 years 3% over 10 years The majority hold a Masters degree SDPA Member Survey 2007 Demographics Respondents by region: West 27% Midwest 18 Northeast 38 South 17 SDPA Member Survey 2007 Education 60% had a dermatology rotation in PA school 65% report this rotation being “very significant” in their decision to choose dermatology as a career 12% report formal training at a teaching institution since graduating from PA school SDPA Member Survey 2007 Job Satisfaction The majority of PAs are extremely satisfied with their career as a dermatology PA But only 31% note the same level of satisfaction with current position Job frustrations include inefficiency of practice administration, salary negotiations, coding issues, and bonus structure SDPA Member Survey 2007 Work Duties Average-36 hours per week over 4.5 days/week 50% single-location dermatology office 77% the practice’s main office 90% have medical assistants in daily practice The majority see mostly medical patients SDPA Member Survey 2007 Supervision Members of the SDPA are required to work for a board certified dermatologist The majority meet daily with supervising physicians Second most frequently, two-three times a week Supervising physician is onsite 82% of the time, the remaining 18%, available by phone or email. SDPA Member Survey 2007 Compensation 82% receive a set base salary The majority receive from 70 to $100K Higher base salaries is directly proportional to years of experience The majority with 3-5 yrs of experience receive a base salary between $80K-$100K 6 or more years of experience, a base salary greater than $100K reported SDPA Member Survey 2007 70% receive a bonus in addition to base Bonus based on a percentage of collections or billings The majority receive at least 16- 20% of collections or billings as a bonus The mean level before a bonus percentage begins is $169K SDPA Member Survey 2007 Benefits Mean paid time off - 22.4 days CME venues – 7.6 days 90% of practices pay for malpractice insurance The majority of practices pay for health
  26. 26. insurance, AAPA dues, SDPA dues, NCCPA certification, DEA registration, and 401K or other retirement match Dermatology Distance Learning Initiative Modular, case-based CME for experienced PAs in dermatology. (for SDPA fellow members with one year of dermatology experience 10 modules, 7-10 cases each Joint undertaking: SDPA, UTTC, UTSW and Coria Laboratories SDPA members receive Diplomate status Dermatology Distance Learning Initiative Ten modules including Vesiculobullous Disorders-Amit Pandya, M.D. Connective Tissue Disorders-Richard Sontheimer, M.D. Pediatric Dermatology-Bethany Grubb, PA-C Pigmented Lesions-Paul Bergstresser, M.D. Eczematous Disorders-Ponciano Cruz, M.D. Nail Disorders- Phoebe Rich, M.D. Dermatology DLI Ten Modules (continued) Hair Disorders - Amy McMichael, M.D. Disorders of Pigmentation - Amit Pandya, M.D. Pharmacologic Dermatology - Stephen Wolverton, M.D. Cutaneous Manifestations of Internal Disease - Eric Sorenson, PA-C Dermatology DLI 5 modules now available 41 hours of Category 1 CME (4 modules) 380 registrations and growing Signaling Pathways Targeted by Curcumin: Basis for Antiphotoaging and Anticarcinogenic Therapy Madalene Choon-Ying Heng MD, FAAD Monday, March 09, 2009, 12:15 PM Room 113 Ultraviolet light exposure (UVA and UVB) are implicated in photoaging and photocarcinogenesis (1). Although UVB (290-320 nm) causes redness, burning and blistering, these rays are less damaging than UVA (320-400 nm) because of their limited penetration into the epidermis, and because they induce photoproducts that are easily repaired, and therefore less mutagenic. Ultraviolet A, although an asymptomatic invader, penetrates deeply into the dermis, producing bipyrimidine dimers that are poorly repaired, isomerizing into Dewar products that are highly mutagenic (2). Unlike UVB, UVA rays are not blocked by sunscreens, penetrate through skin and clothing, and are blocked only by bone. Although both UVA and UVB act synergistically, UVA radiation is considered the more damaging of the two, and is the major radiation implicated in photoaging and in both melanoma and non-melanoma skin cancers (3,4). Recently, attention as been increasing focused on anti-inflammatory phytochemicals, particularly curcumin, and its potential for repairing photodamaged skin. Photocarcinogenesis can be divided into three steps: (a) tumor initiation, (b) tumor promotion, and (c) tumor transformation, with dysregulated growth and increased metastatic potential. Tumor initiation occurs when point- mutations, induced by both UVB and UVA, occur in the promoter sequence of the DNA. Clonal expansion of the DNA damaged cells involves several mechanisms. The first step involves injury-induced activation of gene transcription regulators, such as NF-kB (nuclear factor kappa B) and AP-1 (activator protein-1). Activation of NF-kB results in the subsequent activation of over 200 genes involved in cell proliferation, inhibition of apoptosis and increased cell survival. In the non-activated state, NF-kB exists in the cytoplasm as a pair of dimers (p50/p65). When activated by free radicals generated by ultraviolet light, the dimers translocate to the nucleus where they bind to the DNA, and subsequently increase transcription of over 200 genes. Before
  27. 27. the dimers can translocate to the nucleus, an inhibitory protein (IkBα) must be removed. The removal of IkBα is catalyzed by IkBα kinase, a serine-threonine kinase, activated by phosphorylase kinase and inhibited by curcumin (selective phosphorylase kinase inhibitor), thus blocking gene transcription at the very outset of the injury-cycle. The second gene transcription activator, AP-1, is implicated in growth regulation and cell cycling by activating the cyclin D1 gene, which promotes entry into the G1 phase of the cell cycle. AP-1 by suppressing the p53 suppressor gene, leads to uncontrollable growth and increased metastatic potential. Curcumin also suppresses the activation of AP-1 (5). A series of mitogen-activated protein kinases (MAP kinases) stimulate cell proliferation, resulting in expansion of the abnormal DNA-damaged clone. These MAP kinases fall into two series, depending on whether they are serine/threonine specific or tyrosine kinase specific. Both the serine/threonine kinases as well as the tyrosine kinases are activated by phosphorylase kinase and inhibited by curcumin. The balance between cell survival and cell death determines the number of existing cells. In cancers and precancers, the balance is tipped towards survival of the DNA damaged cells due to decreased apoptosis and increased cell survival kinases. Decreased apoptosis in skin cancers may, in turn, be due to decreased apoptotic proteins and increased antiapoptotic proteins. Curcumin promotes NF-kB- dependent apoptosis of the photodamaged cells and inhibits Akt, the serine/threonine cell survival kinase (5). Further damage to the DNA involving the p53 suppressor gene results in tumor transformation with uncontrollable growth. The p53 suppressor gene encodes the p21WAF-1 protein which binds to and stabilizes the DNA, resulting in regulated cell growth and proliferation. Damage or deletion of p53 gene results in decreased p21WAF-1 protein, with uncontrollable growth and tumor transformation. Curcumin has been shown to cause apoptosis of dysregulated cells, including basal cell carcinomas, in a p53-dependent manner (6). The mechanism whereby curcumin inhibits protein kinases of both serine/threonine and tyrosine kinase specificities is due to its inhibitory effect on phosphorylase kinase. This dual specificity is highly unusual because protein kinases usually catalyze phosphotransfer reactions from ATP to either serine/threonine or tyrosine molecules. This is because protein kinases, with the exception of phosphorylase kinase, allow only one configuration of the substrate binding site. In the case of phosphorylase kinase, however, the substrate binding site may be altered by utilizing a hinge joint between the subunits of the phosphorylase kinase molecule, thus altering the size of the substrate binding site. In addition, the substrate binding site may be made to swivel in one plane by binding to either magnesium, or in another plane by binding to manganese, leading to dual specificity (7). The flexibility provided by both the hinge joint and the swivel mechanism allows phosphorylase kinase to adopt different substrate configurations, such as serine/threonine kinase, tyrosine kinase and phosphotidylinositol kinase. etc Graves et al 1999 (8) provided evidence that the spatial determinants can be manipulated so that phosphorylase kinase can utilize other substrates. Since curcumin is a selective phosphorylase kinase inhibitor, it is surmised that curcumin achieves inhibition of multiple enzyme substrates by its inhibition of phosphorylase kinase. Through its inhibition of phosphorylase kinase, topical curcumin has been shown to be effective in blocking similar signaling pathways in multiple injury-induced clinical conditions, producing salutary effects on photoaging skin, including resolution of lesions such as solar lentigenes, telangiectasia, solar elastosis and actinic keratoses. Curcumin gel is also also effective in preventing post-surgical scarring, in the prevention of scars in acne vulgaris and acute burns, and in the resolution of psoriasis. Although psoriasis has a genetic basis, the lesions are frequently induced by injury. Phosphorylase kinase is activated (switched-on) 5 mins after injury by Type I cyclic AMP protein kinase, which causes a change in the molecular
  28. 28. configuration, thus exposing multiple hidden sites for phosphorylation reactions in wound healing. After the wound is healed, Type II cyclic AMP protein kinase causes another change in the molecular configuration, causing these phosphorylation sites to become hidden, thus serving as a switch-off mechanism for phosphorylase kinase activity when the wound is healed. Type II cyclic AMP protein kinase has been found by Tournier et al 1996(9) to be abnormal in psoriatics, resulting in persistently elevated levels of phosphorylase kinase in psoriatic epidermis (10). Suppression of phosphorylase kinase activity by curcumin gel has been reported to correlate with resolution of psoriasis (11). REFERENCES: 1. Bachelor MA, Bowden GT. UVA-mediated activation of signaling pathways in skin tumor promotion and progression. Semin Cancer Biol 2004;14:131-138 2. Douki T, Reynaud-Angelin, A, Cadet J, Sage E. Bipyrimidine photoproducts rather than oxidative lesions are the main type of DNA damage involved in the genotoxic effect of solar UVA radiation. Biochemistry2003;42:9221-9226. 3. Runger TM. Role of of UVA in the pathogenesis of melanoma and non-melanoma skin cancer. A short review. Photodermatol Photoimmunol Photomed1999;15:212-216. 4. Hayward R. Sunscreens inadequately protect against ultraviolet A-induced free radicals in the skin: implications for skin aging and melanoma. J Invest Dermatol 2003;121:862-868. 5. Aggarwal B, Kumar A, Bharti AC. Anticancer potential of curcumin: preclinical and clinical studies. Anticancer Research 2003;23:363-398. 6. Jee SH, Shen SC, Tseng CR, Chiu HC, Kuo ML. Curcumin induces a p53-dependent apoptosis in human basal cell carcinomas. .J Invest Dermatol 1998;111:656-661. 7. Yuan CJ, Huang CYE, Graves DJ. Phosphorylase kinase: a metal ion dual specificity kinase. J Biol Chem 1991;268:17683- 17686. 8. Graves D, Bartleson C, Bjorn A, Pete M. substrate and inhibitor recognition of protein kinases: what is known about the catalytic subunit of phosphorylase kinase? Pharmacol and Therapeutics 1999;82:143-155. 9. Tournier S, Raynaud F, Gerbaud P et al Retinoylation of the type II cAMP-binding regulatory subunit of cAMP-dependent protein kinase is increased in psoriatic human fibroblasts . J of Cell Physiol 1996;167:196-203. 10. Heng MCY, Song MK, Heng MK. Elevated phosphorylase kinase activity in psoriatic epidermis: correlation with increased phosphorylation and psoriatic activity. Br J Dermatol 1994;130:298-306. 11. Heng MCY, Song MK, Harker J, Heng MK.. Drug-induced suppression of phosphorylase kinase correlates with resolution of psoriasis as assessed by clinical, histological and immunohistochemical parameters. Br J Dermatol 2000;143:937-949. MOC Self-Assessment: Dermatopathology Molly A. Hinshaw MD, FAAD Asst Prof of Derm and Dermpath, U of WI Sch of Med and Public Health, Madison, WI Friday, March 06, 2009, 3:00 PM Room 2022 - West This Maintenance of Certification forum in dermatopathology provides a set of dermatopathologic cases through which attendees demonstate their skill in histopathogic diagnosis. The use of special stains, immunihistochemistry, immunofluorescence, and electron microscopy are highlighted. The forum is intended for board-certified dermatologists and dermatopathologists. Each case is presented with a focus on histopathology though clinical images may accompany each case. Participants choose from potential diagnoses in a live
  29. 29. audience response format. Each case is then discussed by the presenter who comments on the correct response and why each incorrect response is incorrect. Attendees receive a handout with cases and responses at the completion of the forum. The Medical Expert: Legal and Ethical Issues Paul Hirsch MD, JD, FAAD Clin Prof Med/Derm, USC Sch Med, Los Angeles, CA Monday, March 09, 2009, 7:15 AM Room 2009 - West The purpose of the medical expert is to educate the Trier of fact, whether judge or jury, and to understand the issues not commonly known. These include and not limited to understanding the concept of "standard of care," types and results of tests, and any other scientifc evidence. Health care costs continue to rise, and they are factored into the equation, directly or indirectly, to the costs for litigation in medical negligence or malpractice. An ethical, knowledgeable and unbiased medical expert can significantly help either the defendant or plaintiff resolve a lawsuit to achieve justice for both parties. A medical expert that is ethical and knowledgeable of the litigation process is a direct benefit for all involved parties, including insurance carriers, to resolve claims as expediously as possible. Proper resolution of claims can be a significant factor in decreasing costs for malpractice insurance and, in turn, could lower health care costs. Most, if not all, dermatologists may at one time in their medical career be asked to offer an opinion related to a medical malpractice litigation, and/or to become a medical expert witness, and accepting such a position necessitates knowledge of one's ethical and legal responsibilities. There are a few, if any, formal training programs for dermatologists as a potential medical expert witness. This lecture will be a learning process to educate dermatologists in the ethical and legal issues that pertain to assuming the role of medical expert witness. Patient Safety Hillary D. Johnson-Jahangir MD, PhD Friday, March 06, 2009, 9:00 AM Room 3022 - West Patient safety may be defined as the prevention of inadvertent harm to patients. The key is understanding the causative factors of potential adverse events. There is science of patient safety used to discover root causes and contributing factors for design of effective interventions. Risks and vulnerabilities are identified and controlled to provide the safest medical practice environment. Interventions are designed with a focus on the system, or the entire working environment, rather than the individual. The old approach condemning the person responsible

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