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ODAC Sessions

Jan 10
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Hyperhydrosis: Where Are We Now?

By Medical Dermatology, ODAC Sessions 6 Comments
Video of Dr. Adam Friedman

Source:Dermatology News

When you extend your hand to a new patient, and he reflexively wipes his palm before shaking hands, be alert. It’s possible you’re seeing primary hyperhidrosis, a condition that’s both more common and more disabling than once thought.

“Looking at the biology of sweating, normally, it’s a good thing – we need it to survive. However, hyperhidrosis is too much of a good thing – it’s an excess of what is needed for normal biology,” said Adam Friedman, MD, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

Recent data, he pointed out, show that hyperhidrosis is more prevalent than previously thought – about 4.8% of individuals may have the condition, with about half having axillary hyperhidrosis. Symptoms peak in early adulthood, with adults aged 18-54 most affected. “These are the prime working years,” he said.

About 2% of teens are affected, and many adults report that symptoms began before they were 12 years old. Hand hyperhidrosis is a factor for computer and electronic device work, sports, and even handling paper and pencils, noted Dr. Friedman, professor of dermatology at George Washington University, Washington.

“Does it affect quality of life? Yes. We have data to support the impact. The adverse impact is actually greater than that of eczema and psoriasis,” he said, adding that patients won’t always bring up their concerns about sweating. “Often, it’s the patient who apologizes for having sweaty palms or who sticks to the paper on the exam table. It’s worth asking these patients if they are bothered by excessive sweating.”

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Dec 15
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ODAC Dermatology Conference Returns to Orlando, Florida

By Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology No Comments
Orlando Florida Hotel

Source: Dermatology Times

The Orlando Dermatology Aesthetic & Clinical Conference (ODAC), formerly known as Orlando Derm, is scheduled for January 18-21 at the JW Marriott in Orlando.

This year’s meeting will open with presentations from physicians who will address advances in treating skin of color, hot topics in surgical dermatology and cutaneous malignancy, the latest on photodynamic therapy, and a year in review from the Journal of Drugs in Dermatology, among others.

Drs. Eric Bernstein and Jason Pozner will host a panel discussion on “My Top Picks for Laser and Energy Based Treatments.” And, Dr. Joel Cohen will give an overview of facial arterial supply.

During the general session on Saturday, Jan. 19, Dr. Brian Berman will address managing urticaria, which will be followed by talks by Dr. Deirdre Hooper on platelet rich plasma for hair growth and skin rejuvenation; Dr. Andrew Alexis on keloids and disorders of hyperpigmentation in skin of color; and, Drs. Bernstein and Pozner will address advances in non-surgical skin tightening.

On Sunday, January 20, Dr. Jean Bolognia will open the day’s general session with a review of advances in systemic therapies for melanoma.

For more information, visit ODAC online at https://staging.orlandoderm.org.

Feb 02
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Vascular Compromise

By ODAC Sessions, Patient Care One Comment
Dr. Joel Cohen presenting at ODAC dermatology conference

Source: Dermatology Times

Avoiding and treating vascular compromise with hyaluronic acid (HA) injections requires understanding the subtleties of underlying facial anatomy and keeping a well-stocked arsenal of treatments for impending necrosis, said an expert at the Orlando Dermatology Aesthetic and Clinical Conference (ODAC) in Miami.

“Some blood vessels may actually be in different locations than in some of the anatomic diagrams and cartoons that have long characterized their course,” said vice conference chair Joel L. Cohen, M.D., from Greenwood Village, Colorado, who serves on the teaching faculty for both the University of California, Irvine and the University of Colorado.

Although textbooks commonly depict the angular artery tracking adjacent to the nasofacial sulcus, he said, “it’s more common for the angular artery to be more lateral to that area, closer to the infraorbital distribution. In a recent cadaver study, only 19% of the time did the facial artery actually project upward along the side of the nose-cheek junction. But 32% of the time, the angular artery came off the facial artery earlier, and therefore coursed to more of the medial cheek area.”

The technique of aspirating before injecting is not foolproof. “There can be false negatives. A study indicates you probably have to pull back on the plunger for several seconds in order to physically be able to see if you’re in a vessel. We all surely realize that it is very difficult to have the needle in the exact spot you plan to inject, and then reposition your hand to pull back on the plunger of the syringe to try to aspirate, and then have your needle-tip remain in the exact same spot when you reposition again in order to inject. As you change your hand position to pull back on the plunger, you probably move a bit, maybe just a millimeter, from the original location to the location you later inject,” Dr. Cohen said.

A recent report also shows that it is possible to puncture and get into a vessel with small cannulas — the injectors aspirated blood despite using a cannula.

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Jan 16
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Five Pearls Target Wound Healing

By Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology One Comment
Robert Kirsner at the ODAC Dermatology Conference

Source: Dermatology News

Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.

In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.

Avoid opioids for postoperative pain

“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”

Emerging evidence suggests opioids also impair wound healing (J Invest Dermatol. 2017;137:2646-9). This study of 715 patients with leg ulcers, for example, showed use of opioids the most strongly associated with nonhealing at 12 weeks. “We found if you took an opioid you were less likely to heal,” Dr. Kirsner said. They found opioids significantly impaired healing, even when the investigators controlled for ulcer area, duration, and patient gender.

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Jan 12
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Best Practices Address Latest Trends in PDT, Skin Cancer Treatment

By Medical Dermatology, ODAC Sessions One Comment
ODAC Dermatology Conference Audience

Source: Dermatology News

Pearls for providers of photodynamic therapy (PDT) include tips on skin preparation, eye protection, and use of three new codes to maximize reimbursement. Also trending in medical dermatology are best practices for intralesional injections of 5-FU to treat the often challenging isomorphic squamous cell carcinomas (SCCs) or keratoacanthomas on the lower leg, as well as use of neoadjuvant hedgehog inhibitors to shrink large skin cancer lesions, according to Glenn David Goldman, MD.

“This talk is about what you can do medically as a dermatologic surgeon,” Dr. Goldman said at the Orlando Dermatology Aesthetic and Clinical Conference.

Use new billing codes for photodynamic therapy

There are now three new PDT billing codes. “Make sure your coders are using these properly. They are active now, and if you don’t use them, you won’t get paid properly,” said Dr. Goldman, professor and medical director of dermatology at the University of Vermont, Burlington. Specifically, 96567 is for standard PDT applied by staff; 96573 is for PDT applied by a physician; and 96574 is for PDT and curettage performed by a physician.

“Be involved, don’t delegate,” Dr. Goldman added. “If you do, you will get paid half as much as you used to, which means you will lose money on every single patient you treat.”

What type of PDT physicians choose to use in their practice remains controversial. “Do you do short-contact PDT, do you do daylight PDT? We’ve gone back and forth in our practice,” Dr. Goldman said. “I’m not impressed with daylight PDT. I know this is at odds with some of the people here, but at least in Vermont, it doesn’t work very well.”

The way PDT was described in the original trials (a photosensitizer applied in the office followed by PDT) “works the best, with one caveat,” Dr. Goldman said. The caveat is that dermatologists should aim for a PDT clearance that approaches the efficacy of 5-fluorouracil (5-FU). “If you can get to that – which is difficult by the way – I think your patients will really appreciate this.”

An additional PDT pearl Dr. Goldman shared involves skin preparation: the use of acetone to defat the skin, even in patients with very thick lesions. Apply acetone with gauze to the site for 5 minutes and “all of that hyperkeratosis just wipes away,” curette off any residual hyperkeratosis – and consider a ring anesthetic block to control pain for the patient with severe disease, he advised.

Another tip is to forgo the goggles that come with most PDT kits. Instead, purchase smaller, disposable laser eye shields for PDT patients, Dr. Goldman said. “They work better. You can get closer to the eye … and they are more comfortable for the patient.”

Dr. Goldman’s practice is providing more PDT and much less 5-FU for patient convenience. “I believe if someone is willing to go through 3 weeks of 5-FU or 12-16 weeks of imiquimod, they get the best results. However, most people don’t want to do that if they can sit in front of a light for 15 minutes.”

Consider intralesional injections for SCCs and KAs on the legs

An ongoing challenge in medical dermatology is preventing rapid recurrence of SCCs and/or keratoacanthomas (KAs) near sites of previous excision on the legs. “We all see this quite a bit. Often you get lesions on the leg, you cut them out, and they come right back” close to the excision site, Dr. Goldman said.

He does not recommend methotrexate injections for these lesions. “Methotrexate does not work. It doesn’t hurt, but I’ve injected methotrexate into squamous cell carcinomas many times and they’ve never gone away.” In contrast, 5-FU “works incredibly well. They go away, I’ve had tremendous success. This has changed the way we treat these lesions.” 5-FU is inexpensive and can be obtained from oncology pharmacies. One caveat is 5-FU injections can be painful and patients require anesthesia prior to injection.

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Jan 10
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JDD honors Adam Friedman, M.D., for Educational Contributions

By Medical Dermatology, ODAC Sessions One Comment
Adam Friedman, MD faculty headshot

Source: Dermatology Times

Adam Friedman, M.D., was honored with the Innovations in Residency Training Award by the Journal of Drugs in Dermatology (JDD) at the Orlando Dermatology Aesthetic & Clinical Conference (ODAC) held in January. The award recognizes individuals who serve as exemplary role models for dermatology residents and innovate improvements in residency programs.

“Dr. Adam Friedman embodies the spirit of the award and more,” says Shelley Tanner, CEO and president of SanovaWorks, parent company of the JDD and ODAC. “He looks towards the future of dermatology and those who will carry it forward.”

Dr. Friedman is the residency program director and director of translational research at the George Washington University School of Medicine. He is also deputy chair of the American Academy of Dermatology’s Poster Task Force, senior editor of the Dermatology In-Review online workshop and cram pack, and director of the Oakstone Institute Dermatology Board Review.

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Apr 17
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Understanding and Using Biosimilars

By Medical Dermatology, ODAC Sessions, Patient Care One Comment
Dr Leon Kircik at ODAC Dermatology Conference

Source: Dermatology Times

One of the only things the dermatology community knows about biosimilar use is that there are many unknowns. Still, biosimilars are on dermatologists’ radars as having the potential to lower the high costs of biologic treatments for chronic skin diseases, including psoriasis.

There also are misperceptions—even among dermatologists—about what biosimilars are and if these drugs can be used to treat patients, according to Leon H. Kircik, M.D., clinical associate professor of dermatology at Indiana University School of Medicine, Indianapolis; clinical associate professor of dermatology at Mount Sinai Medical Center, New York City; and medical director of Physicians Skin Care in Louisville, Ky. who presented “Biosimilars: What You Need to Know” at the Orlando Derm Aesthetic and Clinical conference in Miami, Fla., in January 2017.

Misperception number one

The first misperception is that biosimilars are generic biologics. They’re not, he says.

“You cannot have a generic of a biologic because every biologic is made differently. So, it is important for everybody to understand that biosimilars are not generics,” says Dr. Kircik,

As a result, the approval process for biosimilars is different for that of generics. Biosimilars came about because of the Biologics Price Competition and Innovation Act of 2009, which passed in Congress as a provision of the Affordable Care Act. Biosimilars have an abbreviated licensure pathway, but it’s a different pathway compared to a generic.

“Biopharmaceuticals are biopolymers of organic molecules that are manufactured in living systems. Function is based not only on the amino acid number and sequence but also on posttranslational modification (e.g. glycosylation) that are added by virtue of manufacture in living systems.”

Complexities and blurred lines

The FDA’s definition of a biosimilar, according to Dr. Kircik is, “A biological product that is highly similar to the reference product, notwithstanding minor differences in clinically inactive components. There are no clinically meaningful differences from the reference product in terms of the safety, purity, and potency”

“Those are very vague terms,” Dr. Kircik says.

The first biosimilar (not for use in dermatology), Zarxio [Sandoz], was FDA approved in March 2015. Zarxio is biosimilar to Neupogen (Amgen, filgrastim)1

More than a year later, the first biosimilar to have dermatologic indications received FDA approval—a biosimilar of infliximab, by the name of Inflectra (Celltrion). Interestingly, Inflectra, a biosimilar to Janssen Biotech’s Remicade, has an indication for psoriasis but no data on dermatologic disease, including psoriasis, Dr. Kircik says.

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Mar 11
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Nasal Reconstruction After Surgery

By Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Surgical Dermatology One Comment
Explore By Region

Source: Dermatology Times

Options for repairing nasal defects after skin cancer surgery should be based on location, size and depth of the defect, as well as patient preference.

“If the defect is centrally located in the alar groove, you may want natural healing to occur,” says Joel L. Cohen, M.D., associate clinical professor of dermatology at the University of Colorado in Denver, and director of AboutSkin Dermatology in Greenwood Village and Lone Tree, Colo. He spoke with Dermatology Times prior to his presentation on skin cancer nasal reconstruction at the recent Orlando Dermatology Aesthetic & Clinical Conference (ODAC) in Miami.

“In such a case, the natural concavity is often recapitulated by simply letting the skin granulate, without the need for any sutured repair.”

However, in many instances of nasal reconstruction, dermatologists have to decide which procedure will achieve the best aesthetic outcome and also, the level of wound care that can be managed by the patient.

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Feb 11
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Laser Resurfacing for Minimizing Post Surgery Scars

By Aesthetic Dermatology, Medical Dermatology, ODAC Sessions, Patient Care, Surgical Dermatology One Comment
Adam Friedman, MD at ODAC Dermatology Conference

Source: Dermatology News

In his practice, Joel L. Cohen, MD, spends a good part of his day doing Mohs surgery, “with the goal of cancer removal, and after surgery, having the patient look good,” he said at the Orlando Dermatology Aesthetic and Clinical Conference.

“Having resurfacing in my practice has allowed me to treat not only wrinkles and etched lines, but also help skin cancer patients by blending and minimizing their skin cancer scars,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in Denver.

For example, one of his patients was a kindergarten teacher who had a large rotation flap scar on her cheek after excision of a melanoma in situ. The children asked her about it all the time during the 2 months after the surgery, and she decided to come in for some laser sessions. “With three ablative fractional laser sessions, she really looked great just 3 months later and wasn’t even interested in wearing makeup at that point.”

Resurfacing in his practice using a variety of lasers is very helpful, Dr. Cohen said. He published a study in November that compared pulse dye laser, CO2 ablative fractional lasers, or a combination of both for modification of scars following Mohs surgery (J Drugs Dermatol. 2016 Nov 1;15[11]:1315-9).

The prospective, multicenter study revealed that although both monotherapy approaches were safe and effective, the combination of pulse dye laser and fractional ablative laser offered some synergy that was preferred by patients.

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Feb 11
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FDA Approval: Corticosteroid-Sparing Topical for Eczema

By Medical Dermatology, ODAC Sessions, Patient Care One Comment
Dr. Friedman Presenting at the ODAC Dermatology Conference

Source: Dermatology Times

The FDA announced it has approved Eucrisa (Anacor Pharmaceuticals, crisaborole) ointment to treat mild to moderate eczema in patients two-years-of-age and older.

Applied twice daily, Eucrisa is a phosphodiesterase 4 (PDE-4) inhibitor. Its precise mechanism of action in atopic dermatitis, however, isn’t known, according to an FDA press release.

“We welcome this corticosteroid-sparing topical option,” says Elaine C. Siegfried, M.D., professor of pediatrics and dermatology at Saint Louis University, Cardinal Glennon Children’s Hospital, St. Louis, Mo. “The other two alternatives (pimecrolimus cream and tacrolimus ointment) carry black box warnings and labelled limitation on duration of use. Although most pediatric dermatologists prescribe these medications in infants and children without long-term safety concerns, prescribing Eucrisa is not hampered by this medicolegal burden. However, cost and access could be a limitation.”

Adam Friedman, M.D., associate professor of dermatology and director of translational research in dermatology at George Washington School of Medicine and Health Sciences, tells Dermatology Times that this most recent approval represents the exciting first of hopefully many new approved therapies for an exceedingly common disease state, which until recently was largely ignored.

“I envision crisaborole being used in a similar manner to calcineurin inhibitors, both as proactive treatment for affected delicate areas like the eyelids, face, body folds, groin or mild disease elsewhere. But, more importantly, [I envision it] as preventative maintenance therapy for disease areas that recur frequently after topical steroid use has been discontinued (though without the baggage of a black box warning and possible substance P induced burning at the onset of use),” he says.

Dr. Friedman, who is presenting on the topic of eczema at the January 16 to 19, 2017 Orlando Derm Aesthetic and Clinical conference in Miami, Fla., says this approval, however, should not overshadow the basic and requisite elements for properly managing this often chronic condition. These basics are: clear patient education on a broad range of topics, including realistic expectations; proper soap, moisturizer and treatment use; and myths about treatment safety, in order to gain the patient’s confidence, which in turn, increases the likelihood of regimen compliance, according to Dr. Friedman.

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