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The Chronicle of


in association with

Wound management in hidradenitis suppurativa Foot wound care tips

Practical advice on treating acne and rosacea in patients with darker skin

Vitiligo in skin of colour Identifying rashes in patients with darkly pigmented skin

Higher suspicion needed for skin cancer in skin of colour

Supplement to The Chronicle of Skin & Allergy, December 2018

Proceedings of the 2018

Dear Colleague:

Ethnodermatology is a term you likely would not have encountered during your medical undergraduate years. Today it is a fact of our 21st Century lives as practitioners.

We needn't tell you that patient populations are more diverse than ever. This is true in Canada's largest cities, where what were once described as visible minorities are, according to census data, now a majority, or close to one. It is also true that across Canada, in homes and workplaces, in towns and villages, we are a multi-cultural, multi-ethnic, variegated people, and all the more proud for that (in a typically understated Canadian way, of course.)

As dermatologists, we know that levels of melanin may represent the very least of differences among patients.

We recognize that there are special considerations when treating darkly pigmented skin. However, we may or may not be attuned to cultural differences which may affect treatment or outcome, and this is true across the entire spectrum of patients. Underlying this is the awareness that we are all, regardless of geography or circumstances, ethnic.

For that reason, the Skin Spectrum Summit series of meetings began five years ago. It was established as a forum to examine and share knowledge about the emerging field known as Ethnodermatology. The series began in Toronto and is now held annually in three cities: Toronto, Vancouver and Montreal.

We have been honoured with the participation of a remarkable faculty from across Canada and the U.S.A. In particular, Dr. Andrew F. Alexis of New York City's Icahn School of Medicine, whose early work with the U.S.-based Skin of Color Society (SoCS) qualifies him as a trailblazer in Ethnodermatoloy, was an immediate and enthusiastic supporter of the first and subsequent Skin Spectrum Summits.

As chairs of the upcoming 2019 Skin Spectrum Summit, we are delighted to report that Ethnodermatology is thriving in Canada, and we could not be more pleased. This Proceedings publication marks further evidence of the field's expansion. We hope you enjoy this monograph, and we warmly invite our colleagues to attend in person the meetings this Spring in Ontario, Quebec and British Columbia. As you will see in the articles contained herein, there is much more to learn, and much information to be exchanged. Please register for the series at the conference website, Thank you for your interest. We hope to see you at an event this spring. 2019 Curriculum Chairs TORONTO DR. GAR RY SIBBALD

Dermatologist and Internist Professor of Medicine and Public Health, University of Toronto


Dermatologist CHU Sainte-Justine University of MontrĂŠal


Dermatologist Clinical Professor of Dermatoloogy University of British Columbiia

Published annually as a supplement to The Chronicle of Skin & Allergy by Chronicle Infor mation Resources Ltd., from offices at 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3 Canada. Telephone: 416.916.2476; Fax 416.352.6199. E-mail:

Contents Š Chronicle Information Resources Ltd, 2019, except where noted. All rights reserved worldwide. The Publisher prohibits reproduction in any form, including print, broadcast, and electronic, without written permission. Printed in Canada. Single copies: $47.95 per issue. Single copies are subject to 13% HST. Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917.




Practical advice on treating acne and rosacea Dr. Jerry Tan in patients with darker skin Patient-specific factors to consider when creating Dr. Renita Ahluwalia treatment plans for acne Accommodating adolescent lifestyles in systemic acne Dr. Julia Carroll Topicals for acne play key role in Dr. Joseph Doumit maintenance therapy, scar reduction Increased tolerability, patient compliance Dr. Monica Li with combination topical Tx Determining isotretinoin treatment duration Dr. Marcie Ulmer Reducing pruritus lessens dyspigmentation Dr. Afsaneh Alavi in patients with ethnic skin AD severity scores may need to be adjusted Dr. Haneef Alibhai for patients with ethnic skin AD flares may be prevented with topical pimecrolimus Dr. Katie Beleznay Moisturization critical to AD therapy Dr. Joël Claveau Written treatment plans can improve Dr. Maha Dutil patient understanding of atopic dermatitis Corticophobia lessened by alliance between Dr. Simone Fahim patients, caregivers, physicians AD severity scores may need to be adjusted for Dr. Danielle Marcoux patients with ethnic skin ‘Alberta Hydration Protocol’ as adjunct treatment Dr. Jaggi Rao AD in darker-skinned children harder to identify, Dr. Ronald B. Vender often more severe Non-surgical cosmetic procedures: Recognizing adverse effects Dr. Charles Cheng Higher suspicion needed for skin cancer in skin of colour Dr. Afsaneh Alavi Melanoma: Examine feet for signs Dr. Joël Claveau Skin cancer: Risks and presentation in dark skin Dr. Sunil Kalia Treating scalp psoriasis in women with Afro-textured hair Dr. Andrew F. Alexis

HAIR & SCALP / PSORIASIS HAIR & SCALP Safe management and styling of Afro-textured hair HIDRADENITIS SUP- Wound management in hidradenitis suppurativa PURATIVA /WOUNDS PIGMENTATION Pigment abnormalities in dark-skinned individuals

Dr. Renée A. Beach Dr. Afsaneh Alavi


Dr. Andrew F. Alexis



Dealing with pigmentation disorders Post-inflammatory dyspigmentation in patients with ethnic skin: How to treat it Identifying clinical mimickers can help reduce PsO underdiagnosis in ethnic skin Longer endpoints in psoriasis treatment for patients with ethnic skin Psoriasis severity measures can help create personalized treatment plans Treating psoriasis in patients with skin of colour Identifying rashes in patients with darkly pigmented skin Dermatology 2020: What Lies Ahead

Technology anticipated to be the future of personalized dermatologic care Vitiligo in skin of colour Best practices in wound care Ensuring efficient wound healing Foot wound care tips A letter from the 2019 Curriculum Chairs Scenes from 2018 Skin Spectrum Summit

Dr. Andrew F. Alexis Dr. Yves Hébert Dr. Monica Li Dr. Andrew F. Alexis Dr. Jaggi Rao

Dr. Isabelle Delorme Dr. Andrew F. Alexis Dr. Michele Ramien

Dr. Animesh A. Sinha Dr. Yvette MillerMonthrope Chantal Labrecque Dr. Anthony Papp Dr. Gary Sibbald

4 5 6 7 8

9 10 11

12 13 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 2 14


Practical advice on treating acne and rosacea in patients with darker skin DR . J ERRY TAN

at Skin Spectrum Summit Toronto EVIDENCE-BASED GUIDELINES are key to accurate diagnosis of both acne vulgaris and rosacea in darker-skinned patients, Dr. Jerry Tan reported at Skin Spectrum Summit 2018 in Toronto. “You will notice that inflammatory lesions in patients of colour don’t look red. Sometimes they will look brown, sometimes they will look violet, and this doesn’t just apply to rosacea, it also applies to acne,” said Dr. Tan, adjunct professor with the Department of Medicine at the Schulich School of Medicine and Dentistry

at Western University, Windsor, Ont., Campus. “Practical tip two . . . when an acne patient is in front of you, don’t just look at their face, always look at their body,” said Dr. Tan. Many patients bothered by acne are embarrassed and will not voluntarily reveal their chest or back. Dr. Tan urges physicians to engage and ask the patient how much the acne and rosacea brothers them to get a better understanding of the scope of the condition and its effects. A third practical tip suggested

Practice Pearls from Dr. Andrew Alexis on acne and rosacea diagnosis and exacerbating factors commonly seen in darkly pigmented skin •

• •

Individuals with acne and darkly pigmented skin tend to develop post-inflammatory hyper-pigmentation (PIH), keloids and hypertrophic scars, Dr. Alexis said. He urged physicians to be aware of beauty and skin products that may be exacerbating the acne or rosacea, including cocoa butter, oil-based foundations, “hair grease,” and “fade creams.” There is a major under-diagnosis of rosacea in patients with darkly pigmented skin, noted Dr. Alexis. “It does occur and one does have to have an index of suspicion to make sure you recognize it.”

Dr. Alexis is Chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West, an associate professor of Dermatology at the Icahn School of Medicine at Mount Sinai, and a director of the Skin of Color Center, New York City. 4 n J o U R N A L o F E T H N o D E R M AT o L o G Y

by Dr. Tan is to talk to your patients about their diet and urge them to avoid high glycemic index foods and dairy products. These foods are linked to an increase in IGF-1, which has been shown to be a major player in the hormonal trigger of acne, he explained. In terms of rosacea diagnosis, the guidelines have changed, he noted. “The diagnostic criteria in the past were based on the congregation of multiple features,” said Dr. Tan. However, erythema can be sometimes difficult to identify in patients of skin of colour. Early and accurate diagnosis of both acne and rosacea are important for success and speed of treatment, noted Dr. Tan. “We can probably do it with infrared imaging. And that’s what we are going to be moving forward to in the proper management and follow-up of patients of colour,” said Dr. Tan. —John Evans, J Ethnoderm Editorial staff

Patient-specific factors to consider when creating treatment plans for acne SPECIFIC FACTORS with in patients with acne, in addition to the type of acne that they have, must be considered when selecting appropriate topical therapies, according to Dr. Renita Ahluwalia during her presentation at the Skin

“If [patients] can do something simple every day as a monotherapy, they are going to be much more likely to comply”

D R . R ENI TA AHL UWAL I A at Skin Spectrum Summit Toronto

Spectrum Summit 2018 in Toronto. When creating acne treatment plans, physicians must consider patient features such as the type of health coverage the patient has, whether or not they will be able to afford the medication, and what kind of regimen they are most likely to adhere to. “Most of our patients would not like to do complex treatment and if they can do something simple every day as a monotherapy, they are going to be much more likely to comply,” said Dr. Ahluwalia, a staff dermatologist at Women’s College Hospital in Toronto. Aside from choosing treatments based on efficacy and tolerability, it is also important to select therapies that are in line with patients’ goals and priorities. According to Dr. Ahluwalia, this is why it is important to actively listen to patients during consultations in order to understand their expected outcomes. For instance, it may be necessary to develop aggressive treatment plans for some patients with mild acne, if their condition is severely affecting their quality of life. “On the other hand, in some patients who have severe acne, physicians think immediately that they need to be started on systemic therapies such as oral isotretinoin. But they may not be

ready. In these cases you have to first gain [the patient’s] trust. So initially, you engage them by giving them a good topical regimen that can at least minimally improve symptoms, until they are ready to move on to stronger treatment,” said Dr. Ahluwalia. When prescribing topical therapies, physicians should also educate patients about potential adverse effects that they may experience and provide them with strategies for how to manage symptoms. “Benzoyl peroxide-containing products, for example, are sometimes associated with more instances of burning, stinging, scaling, and worsening of erythema. So, physicians need to tell patients how to prevent this,” said Dr. Ahluwalia. “Putting their moisturizer on first before their medication and short contact application are techniques that we can share with patients.” According to Dr. Ahluwalia, every patient with acne is unique and has different priorities. All of these factors must be taken into account when creating tailored therapeutic plans that will reap the most benefits for patients. Dr. Ahluwalia’s presentation was supported through an unrestricted grant from Bausch Health. —Bianca Quijano, J Ethnoderm Editorial staff n 5

Accommodating adolescent lifestyles in systemic acne Tx DR . J UL I A CAR RO L L

at Skin Spectrum Summit Toronto COMMON DIETARY HABITS of young people should influence systemic retinoid therapy for acne, but their social habits may provide an opportunity to start a discussion with parents and caregivers about the use of the potent oral medications. These were two points examined by Dr. Julia Carroll in a presentation at the Skin Spectrum Summit 2018 in Toronto. Dr. Carroll, medical director of Compass Dermatology in Toronto, noted that the high-fat meals used in the clinical trials of isotretinoin to maximize bioavailability do not resemble how adolescents and young adults typically eat in the mornings. “One of the things I was taught in residency was to just take [isotretinoin] with a spoonful of peanut butter. But if you actually look at the studies, what they did in the original studies was like a Denny’s Grand Slam. It is a huge breakfast. Nobody is going to have that,” said Dr. Carroll. Dyslipidemia is a potential side effect of isotretinoin, and that raises other concerns about this type of highfat breakfast, she said. “We also know adolescents skip breakfast and they are also more interested in eating a quick bar or something on the way. So [the big meal requirement] is not ideal.”

Isotretinoin formulated with a lipid base, such as Epuris (Cipher) is more easily absorbed in a fasted condition, noted Dr. Carroll, citing research that showed while Epuris and conventional isotretinoin were absorbed equally well when taken with a fatty meal, in fasted patients there was 83% more absorption of the Epuris formulation than conventional isotretinoin. “I do see in my practice that when I switched over to using [Epuris], you do actually see more chelitis, more dermatitis. So that tells you there is a lot more active medication,” said Dr. Carroll. Some parents are hesitant to start their children on isotretinoin. In those cases, it can be valuable to help patients and their caregivers to consider the impact of severe acne on a broader scale than just

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lesions and scars, Dr. Carroll said. “Maybe the teen or the young adult is interested in [isotretinoin therapy], but there is a lot of bad press out there and the parents will fight me,” she said. To counter those concerns, she will ask the parents about what the child’s facial acne is preventing them from doing. “Are they not trying out for the swim team? Are they not going to the beach? In terms of their dating life, are they restricting what they are doing?” “Then if you do have somebody who does not try out for that volleyball team, push that forward. Where are they going? Are they then not getting the scholarship for university because of volleyball? You can imagine that this could be quite wide. So it is not just about the acne that they have on their face that day. It is about how it is affecting their life.” Dr. Carroll’s presentation was supported through an unrestricted grant from Cipher Pharmaceuticals. —JE

Young patients’ social habits may provide an opportunity to start a discussion about the use of the potent oral medications

Topicals for acne play key role in maintenance therapy, scar reduction ASIDE FROM CONTROLLING patients’ acne and reducing inflammation, topical treatments also play a key role in maintaining positive results that may have been achieved through more aggressive forms of treatment. Dr. Joseph Doumit, a dermatologist at Clini-Derma in Montreal, discussed this and other principles in the treatment of acne using topical therapies at Skin Spectrum Summit 2018 in Montreal. “Physicians cannot have the patient on isotretinoin for all their life. They could have relapses. We cannot have them on antibiotics indefinitely. Once their inflammation is resolved, patients are not yet out of the hot water. At that point, physicians have to give them a good maintenance program,” said Dr. Doumit. Aside from minimizing disease relapse, topical treatments are also an important factor at an even later stage of treatment— when patients and clinicians need to treat and improve the appearance of scars and post-inflammatory hyper- or hypopigmentation that patients may have developed because of their acne. “Some of the topical treatments—especially the retinoids— have a big component in the treatment of scarring,” said Dr. Doumit. He said the latest topical treatments for acne fall under four main groups: retinoids, antibiotics, benzoyl peroxide, and topical dapsone. Retinoids have a primarily comedolytic and anti-comedogenic effect. They help to reduce inflam-


at Skin Spectrum Summit Montreal mation. They can also help normalize differentiation and hyperproliferation of follicular epithelium. “And they do facilitate the deeper absorption of other topical agents into the pilosebaceous unit,” said Dr. Doumit. Antibiotics discourage the growth of P. acnes and some variants, such as clindamycin, have anti-comedogenic and anti-inflammatory effects. Clindamycin also inhibits pro-inflammatory cytokines. Benzoyl peroxide also has an anti-microbial effect. Unlike antibiotics, however, it is not associated with bacterial resistance. The medication also has anti-inflammatory properties. Patients should be informed that it may cause cutaneous irritation and dryness. An effective combination is clindamycin 1% and benzoyl peroxide 5% (BenzaClin, Bausch Health). Another option for patients is topical dapsone 7.5% (Aczone, Bausch Health)—a sulfone that has both anti-inflammatory and antimicrobial properties. In vitro studies have suggested that dapsone suppresses neutrophil recruitment, inhibiting neutrophil chemotaxis and the release of lysosomal enzymes (J Drugs Dermatol Oct. 2007; 6(10):981–987). “This is one of the most recent therapies that have been introduced to patients,” said Dr. Doumit. “I like [topical dapsone] especially for

those patients presenting with hormonal acne. One of my colleagues has also seen significant results in using it for pustular acne.” In selecting the most appropriate type of topical therapy for patients, Dr. Doumit says that it is important to subcategorize the type of acne that patients have. “Think about the pathogenic factors. For example, is this patient presenting to you with a very sebaceous skin where you have to think about retinoids, or is he or she presenting with inflammatory lesions where you have to consider options that have an anti-inflammatory and possibly an antibacterial effect?” said Dr. Doumit. In general, retinoids and antimicrobial topicals are best for controlling follicular keratinization while antibiotics and benzoyl peroxide are best for managing P. acnes follicular colonization (J Am Acad Dermatol 2009; 60(5):S1–50). Other considerations that physicians need to factor into their decision-making processes include: a patient’s history with other therapies, whether or not they have sensitive skin, their Fitzpatrick skin type, their age, and the location of their lesions Dr. Doumit’s presentation was supported through an unrestricted grant from Bausch Health. —Kyra White, J Ethnoderm correspondent


Acne: Increased tolerability, patient compliance with combination topical Tx DR . MO NI CA L I

at Skin Spectrum Summit Vancouver COMBINING TOPICAL THERAPIES can increase patient compliance with treatment plans and continues to be an effective way of managing acne symptoms, according to Dr. Monica Li during her presentation at the Skin Spectrum Summit 2018 in Vancouver. Combination therapies typically incorporate a number of additive factors and mechanisms of action into one product, which can simplify treatment regimens. Various topical combination therapies are available for patients such as the combination of clindamycin 1.2% with tretinoin 0.025% (Biacna, Bausch Health). The treatment features a tretinoin microsphere gel technology that is slowly released into the skin over time. The medication is formulated as an aqueous-based alcoholfree gel. “Because the formulation has two forms of tretinoin, first the solubilized form and then the crystallized component that is slowly released over the skin, patients experience less cutaneous irritation. This ultimately increases patient compliance with the product,” said Dr. Li, a staff dermatologist at Project Skin MD clinics in Vancouver and Richmond, B.C. Aside from increased tolerability, the combined clindamycin 1.2% and tretinoin 0.025% therapy

also causes clinically significant results in the reduction of acne symptoms. Tretinoin has been shown to effectively target inflammatory and non-inflammatory skin lesions. The combination therapy also does not lead to an increase in the resistance of P. acnes to clindamycin. Additionally, benzoyl peroxide or retinoids used in combination with antibiotics decreases the potential for the development of antibiotic resistance—a concern with care plans featuring monotherapies (J Am Acad Dermatol May 2009; 60(5 Suppl):S1– 50). Furthermore, the micronized tretinoin gel showed minimal degradation when exposed to UVA or fluorescent light, according to a

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study published in J Clin Aesthet Dermatol (2012; 5(1):27–29). A phase III study for the combination clindamycin and tretinoin gel also showed that the treatment resulted in a greater reduction in total acne lesion counts in patients with all six Fitzpatrick skin types combined, compared to clindamycin 1% alone (J Clin Aesthet Dermatol June 2011; 4(6):31–40), Dr. Li reported. “These studies have also shown that clindamycin can improve retinoid tolerability. We can see that there are fewer adverse effects in terms of skinning, burning, scaling, and worsening of redness of the face in treatment,” said Dr. Li. Furthermore, combination therapies can also be effective maintenance treatments. Dr. Li outlined a case involving an 18year-old male who had cystic acne and Fitzpatrick skin type V. After a course of oral isotretinoin, Dr. Li found favourable results in the reduction of his scars by prescribing a benzoyl peroxide wash along with the topical clindamycin 1.2%/ tretinoin 0.025% gel. “The combination of tretinoin and clindamycin can be an alternative option for patients who may not be able to tolerate adapalene in the adapalene and benzol peroxide combination, but are willing to use benzoyl peroxide as part of their skin care management,” she said. Dr. Li’s presentation was supported through an unrestricted grant from Bausch Health. —KW

Determining isotretinoin treatment duration

WHILE, HISTORICALLY, ISOTRETINOIN product monographs have suggested continuing treatment until a cumulative dose of 120 to 150 mg/kg is reached, treating to clearance may be a more practical approach, said Dr. Marcie Ulmer at Skin Spectrum Summit 2018 in Vancouver. Dr. Ulmer is a clinical instructor in the Department of Dermatology & Skin Science at the University of British Columbia, and operates a dermatology practice at Pacific Derm in Vancouver. For patients with severe acne,


at Skin Spectrum Summit Vancouver

oral isotretinoin is still the recommended choice, according to a consensus document published as recently as Feb. 2018, Dr. Ulmer noted. A newer formulation of isotretinoin is available in 10 mg, 20 mg, and 40 mg capsules for flexible individualized dosing (Epuris, Cipher). This oral formulation is absorbed under fasting conditions, and does not require patients to consume a high-fat meal. “I tell [patients] it is the best drug we have for acne to induce remission or cure. I tell them it is a monotherapy. That is appealing because a lot of the things we prescribe are often topical or two topicals plus an oral. And [isotretinoin] really has a long track record. It has been used for over three decades.” However, because of the side effects and restrictions on alcohol consumption and pregnancy, it is important to patients to know how “[Isotretinoin] really has a long track long they should exrecord. It has been used for over three pect to be on the medication to achieve decades” lasting results.

“Dr. Jerry Tan . . . did a systematic review of the literature from 1980 to 2013, and found a lack of high-quality studies to support this cumulative dose [of 120 to 150 mg/kg],” said Dr. Ulmer. Some patients will need more than the four to six months of treatment the cumulative dose approach represents. “We really need therapeutic doses.” The consensus recommendation from that literature review is to continue isotretinoin therapy until the patient achieves full clearance of acne, plus one month. “I think that is actually much easier,” said Dr. Ulmer. “[Clinicians] do not have to calculate [cumulative dose] every time.” Choosing to use the 120 to 150 mg/kg cumulative dose benchmark can still be done with confidence, she said. “It is what we have been doing for three decades. Or you could do clear plus one month, which may be easier.” Additional research would be valuable to determine a total cumulative dose that maintains remission, Dr. Ulmer said. After finishing the isotretinoin course, Dr. Ulmer moves all her patients onto a maintenance therapy program using a topical retinoid. Dr. Ulmer’s presentation was supported through an unrestricted grant from Cipher Pharmaceuticals. —JE n 9

Atopic dermatitis: Reducing pruritus lessens

dyspigmentation in patients with ethnic skin DR . AF S AN E H AL AVI

at Skin Spectrum Summit Toronto COMPARED TO ATOPIC DERMATITIS (AD) patients with Caucasian skin, it is more common for patients with skin of colour (SoC) to have erythema, lichenification, follicular accentuation, and post-inflammatory dyspigmentation. These abnormalities also appear differently and can be more difficult to detect in patients with pigmented skin, but blanching of the skin is an effective way to recognize these symptoms, said Dr. Afsaneh Alavi during her lecture at Skin Spectrum Summit 2018 in Toronto. “In patients with Fitzpatrick skin types IV, V, and VI, the cutaneous signs that are classic for atopic dermatitis in patients with lighter skin may not be evident. Erythema can be especially hard to detect on simple visual inspection, as such, redness may be appreciated on skin blanching,” said Dr. Alavi, staff dermatologist at Women’s College Hospital and assistant professor in the Faculty of Medicine, Division of Dermatology at the University of Toronto. Once sequelae have been properly diagnosed, Dr. Alavi advises that reducing the severe itching that AD patients experience is a good way to prevent scratching, which will in turn prevent any further dyspigmentation in patients with ethnic skin. For example, a more common

presentation of AD in patients with pigmented skin is lichen simplex chronicus, which induces severe pruritus. This puts patients with SoC at high risk of post-inflammatory hyperpigmentation. “In one of the most severe cases of lichen simplex chronicus that I have treated, which appeared in the lower leg, I [saw favourable results] by prescribing a topical steroid and intralesional steroid injection. Then I put the patient on zinc oxide paste for four

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weeks only. This way, she does not have access to the lower leg to scratch it,” said Dr. Alavi. Then, patients can be started on maintenance therapy once the itch has been managed. “In the management of atopic dermatitis, the first step is using emollients to repair an impaired barrier. Topical anti-inflammatory agents, both topical steroids and calcineurin inhibitors, have been used,” said Dr. Alavi. “Phototherapy in some patients has been used but phototherapy in patients with skin of colour can be problematic because of the risk of postinflammatory hyper-and hypopigmentation.” —BQ

“We find that there is actually a six times higher risk of severe atopic dermatitis in patients with darker skin, compared to their Caucasian counterparts”

AD severity scores may need to be adjusted for patients with ethnic skin

BECAUSE OF THE WAY melanin is created and distributed in the skin, one valuable way to categorize pigmentary disorders is by histology, noted Dr. Haneef Alibhai, speaking at Skin Spectrum Summit 2018 in Vancouver. Dr. Alibhai is the medical director of MD Cosmetic & Laser Clinic in Vancouver, and a clinical instructor in the University of British Columbia’s faculty of medicine. Apparent pigmentation is a factor of both the number and activity of the melanocytes. “When you look at hypopigmentation, histologically there are two subtypes. Type one is


at Skin Spectrum Summit Vancouver melanopenic, where there are decreased melanosomes,” said Dr. Alibhai. This includes conditions such as pityriasis alba, post-inflammatory hypopigmentation, tinea versicolour, and tuberous sclerosis. Once a primary cause of pigment change has been identified and managed, steps can be taken to normalize skin tone. “Treatment options in these melanopenic cases are sun protection, reducing the triggers [of pigment loss], and perhaps UV [ultraviolet] light stimulation,” he said. Topical growth factors are also being explored as a treatment for this type of hypopigmentation, he said. “The second histological category would be the melanocytopenic, where we have decreased melanocytes,” Dr. Alibhai said. This includes vitiligo, burns, and halo nevi. In these cases, initial treatments may be similar to those of melanopenic conditions—sun protection and the reduction of inflammation—but may also include surgical grafting of pigmented skin, or in cases where the pigment loss is widespread depigmentation of the remainder of the skin to achieve a uniform skin tone. Hyperpigmentation can also be categorized histologically, Dr. Alibhai said.

“The two classifications would be melanotic and melanocytotic. The melanotic would be due to an increased number of melanosomes.” This category includes ephelides (freckles), melasma, faculative pigmentation (tanning), and post-inflammatory hyperpigmentation. This type of hyperpigmentation can be treated with various topical lightening agents, such as hydroquinone, and kojic, azaleic, and other acids, sometimes combined with vitamin A. Other options included chemical peels, microdermabrasion, broad-band light, and ablative and non-ablative laser resurfacing. “Melanocytotic hyperpigmentation is due to too many melanocytes. In this category are Nevus of Ota, Nevus of Ito, Mongolian spots, blue nevi, lentigines, and DPN [dermatosis papulosa nigra],” he said. For these types of hyperpigmentation, the most important step is prevention, Dr. Alibhai said. “Number one is UV light protection. Diminishing hormonal influences, and preventing the transfer of the melanin and the production of melanin [are other goals].” Additionally, promoting the loss of existing pigment through exfoliation, pigment translocation, and ablation is important. —JE


AD flares may be prevented with topical pimecrolimus DR . K AT I E B E L E Z NAY

at Skin Spectrum Summit Vancouver TOPICAL CALCINEURIN INHIBITORS such as pimecrolimus (Elidel, Bausch Health) may fit into a typical atopic dermatitis (AD) treatment regimen as a way to reduce or eliminate the need for corticosteroids, according to a presenter at Skin Spectrum Summit 2018 in Vancouver. The medication may be used in the long-term to minimize the severity or prevent the occurrence of AD flares. “Certainly, when patients have a big flare, they are likely going to need a topical steroid. But if physicians prescribe—at the first sign of symptom or a flare—a non-steroid like pimecrolimus, we can prevent the big flares and increase the time between treatment of flares,” said Dr. Katie Beleznay, director of the Vancouver Acne & Rosacea Clinic and dermatologist at Carruthers & Humprey Cosmetic Dermatology and Seymour Health

Centre in Vancouver. During her lecture, Dr. Beleznay highlighted that the efficacy of pimecrolimus as part of a longterm maintenance treatment for AD has been clinically proven, particularly among pediatric patients. She outlined a one-year, controlled, double-blind study of 713 AD patients aged two to 17 years published in the journal Pediatrics (2002; 110(1 Pt 1):e2). Participants were randomized 2:1 to a pimecrolimus-based or a conventional regimen with emollients for AD. Patients in the pimecrolimus group were instructed to apply the cream twice per day to affected areas at the first signs (i.e., erythema) or symptoms (i.e., pruritus) of AD to prevent the progression to flare. Participants in both groups were permitted to use second-line topical corticosteroids for flares not controlled by study medication. The incidence of flares was selected as the primary efficacy endpoint at the six- and 12-month mark. “The proportion of patients who completed six or 12 months with no flares was about twice as high in the pimecrolimus group compared to the control group regardless of the severity. When looking at the proportion of patients that required no steroid at all, it was again about twice as

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high in the patients that used pimecrolimus versus the control group,” said Dr. Beleznay. In addition, more than half of the patients on pimecrolimus (n=324) did not use a topical corticosteroid at all over one year. Pimecrolimus patients also spent fewer days on topical corticosteroids versus control patients. The researchers concluded that conventional treatments are inadequate in preventing AD flares in approximately two-thirds of patients over a one-year period. Treatment with pimecrolimus, however, was well-tolerated and not associated with clinically relevant adverse events compared with the conventional treatment group. “How I utilize this data is that when I have a patient with AD, I am not only counselling them on how to treat the flare aggressively. Rather, in the time between flares, or when they are just starting to flare, or if they always get AD in their folds, I will advise them to use one of these non-steroids. I tell them to use these creams consistently, two times or three times per week to prevent that flare from coming,” said Dr. Beleznay. She said that these results support a shift in thought among physicians who are now not only actively targeting visible symptoms, but also trying to prevent AD from becoming severe. Dr. Beleznay’s presentation was supported through an unrestricted grant from Bausch Health. —BQ

Moisturization critical to AD therapy A KEY PREVENTIVE STEP to avoid exacerbation of atopic dermatitis (AD) is moisturization, according to Dr. Joël Claveau, associate professor, Department of Medicine, Laval University, Quebec City, and director of the Melanoma and Skin Cancer Clinic at Le Centre Hospitalier Universitaire, Hôtel-Dieu de Québec. “The skin has a lot of functions,” Dr. Claveau told attendees at the Skin Spectrum Summit 2018 in Montreal. “It has a barrier that protects against the environment and the sun.” One of the keys to keeping the skin barrier intact is sufficient hydration, with ceramide-rich moisturizers offering particular benefit in restoring the skin barrier and addressing transepidermal water loss, Dr. Claveau said. The weather is a factor that can affect the severity of AD, he said, noting patients with AD will have worsening of their condition

Effectively managing AD will help avoid the development of the atopic march— the development of allergic rhinitis and asthma


at Skin Spectrum Summit Montreal in the winter months. AD is the leading dermatologic condition that affects children, noted Dr. Claveau. AD resolves on its own in the majority of children before they reach adulthood, he added. Like other dermatologic conditions such as psoriasis, AD has an impact on quality of life. It can affect family life when a child has AD. Numerous studies have linked AD with poor quality of sleep in children affected by it, owing often to nocturnal itching. Sleep quality of parents of children who have AD has been reported to be adversely affected. School and/or work absenteeism has been reported (Allergy Asthma Proc

2018 Nov 1; 39(6):406–410. doi: 10.2500/aap.2018.39.4175). Effectively managing AD will help avoid the development of the atopic march—the development of allergic rhinitis and asthma, noted Dr. Claveau. To measure the extent and severity of AD, the Eczema Area and Severity Index (EASI) is the instrument that is used, he added. In terms of treatments for AD, topical steroids have been the mainstay. Other topical therapies are on the horizon for AD, and they include crisaborole, an inhibitor of phosphodiesterase 4 (PDE 4). “It is an alternative to steroids,” pointed out Dr. Claveau, noting the PDE 4 inhibitor is designed to manage mild-to-moderate AD. Specific immune targets have been addressed in the development of the first biologic for moderate-to-severe AD, with dupilumab designed to inhibit the signalling of IL-4 and IL-13, explained Dr. Claveau. “There is rapid improvement [with dupilumab] and improvement in quality of life,” he said. Other therapies, such as Janus kinase (JAK) inhibitors, are offering promise in the management of AD according to data from recent investigations, noted Dr. Claveau. —LG

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Scenes from 2018 Skin Spectrum Summit Clockwise from right: 1. Toronto speaker Dr. Yvette Miller-Monthrope, 2. Vancouver moderator Dr. Jason Rivers,3. speaker Dr. Jerry Tan, 4. speaker Dr. Renee Beach, 5. national curriculum chair Dr. Gary Sibbald and delegates,6. Toronto moderator Dr. Shafiq Qaadri, 7. Montreal moderator Dr. Danielle Marcoux




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Written treatment plans can improve patient understanding of atopic dermatitis DR . MAHA D U T I L

at Skin Spectrum Summit Toronto WITH ATOPIC DERMATITIS, physicians must explain to patients that the condition is a chronic disease requiring longterm treatment in order to ensure that they follow the maintenance therapy plan, Dr. Maha Dutil said during a presentation at Skin Spectrum Summit 2018 in Toronto. “One of the common problems is you give patients a treatment and once they get better, they stop everything. And then they quickly relapse,” said Dr. Dutil, a dermatologist in private practice, consultant at Women’s

College Hospital in Toronto, and assistant professor of medicine in the dermatology department at the University of Toronto. Complex dosing schedules and the need to use multiple medications are other reasons why patients and their caregivers feel incapable of properly complying with treatment plans. “They have to do something different for the face and folds, then they do something different for the body. They also have to do something differently if they flare and if they have maintenance regi-

“One of the common problems is you give patients a treatment and once they get better, they stop everything. And then they quickly relapse”

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mens. All of this causes a lot of anxiety in the parents and patients,” said Dr. Dutil. She says that resources like an Eczema Action Plan (EAP), which outlines treatment plans for patients using simple language and diagrams, can help boost patient and caregiver compliance. An EAP can be tailored to each patient according to their age, location, and disease severity. It can be downloaded from the American Academy of Dermatology website, the Australian Society of Clinical Immunology and Allergy website, and other sources. A study comparing an EAP with routine verbal instruction (VI) found that the EAP significantly improved participants’ understanding of their individualized treatment plan, treatment duration, anatomic location of medication use, benefits and risks of the prescribed medication, recognizing disease exacerbating factors, and adjusting treatment based on disease severity (JAMA Dermatol 2018; 149(4):481–483). “If you give them a written plan, it actually reduces anxiety in the caregiver and patient,” said Dr. Dutil. Researchers found that incorporating written treatment plans lengthens consultations by three to five more minutes but improves future check-up time and treatment outcomes. An EAP can also significantly improve quality of life for patients and their caregivers. —JE

Atopic dermatitis: Corticophobia lessened by

alliance between patients, caregivers, physicians

WHEN TREATING PATIENTS with atopic dermatitis, one of the greatest challenges to treatment adherence is corticophobia, Dr. Simone Fahim reported during her presentation at Skin Spectrum Summit 2018 in Montreal. “No matter how much time you spend with patients, they will go home, go on Google, and look up the medication you prescribed them,” said Dr. Fahim, who is an assistant professor in the Department of Medicine, Division of Dermatology, University of Ottawa and a dermatologist at Vital Medical Centre in Ottawa. “Dr. Google will tell them that steroids are bad and so it becomes a big issue for patients to use steroids.” Fear of steroids is a significant problem. In a survey of patients and parents with children with atopic dermatitis, 73% reported being worried about using topical corticosteroids on themselves and on their children while 24% admitted to noncompliance due to concerns with side effects (Br J Dermatol 2000; 142(5):931–936). Patients and parents were concerned about skin thinning (35%), non-specific longterm effects (24%), as well as effect on growth and development from systemic absorption (10%). Although these side effects can develop in rare cases in patients using topical corticosteroids, the concern expressed by patients and parents is out of proportion in comparison to evidence of harm for topicals. “Their main concern is skin atrophy and skin thinning. But when you ask them what else, some peo-


at Skin Spectrum Summit Montreal ple say ‘I don’t know, but it’s bad. I’m not going to use it.’ It is a nonspecific fear,” said Dr. Fahim. Aside from corticophobia, other factors that undermine therapy adherence are complexity of treatment regimes, lack of confidence in physicians, and patient dissatisfaction with short-term results. According to Dr. Fahim, the first step in improv-

ing patient compliance is to explain the mechanisms of atopic dermatitis and their treatment plan using comprehensible language. “Explain to them what atopic dermatitis is. Then give them an idea of what you are going to do, see what they prefer,” said Dr. Fahim. For example, with parents, it is important to explain the “atopic march” and how treating atopic dermatitis early on in children can help prevent them from developing food allergies and asthma later in life. Including children in the communication process can also be a way to develop a therapeutic alliance between caregiver, patient, and physician. This will create confidence and ownership in the prescribed treatment. “I tell kids, ‘You can help mommy put the cream on and tell her if she forgets.’ You can see their eyes brightening up. They feel like they can go through with their therapy,” said Dr. Fahim. Finally, scheduling regular visits can also be a way for clinicians to ensure that patients and caregivers are following treatment plans. “Usually with an infant or child with severe atopic dermatitis, I try to bring them back one month after their first consultation,” said Dr. Fahim. Dr. Fahim’s presentation was supported through an unrestricted grant from Bausch Health. —BQ

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AD severity scores may need to be adjusted for patients with ethnic skin DR . DAN I E L L E M AR CO U X at Skin Spectrum Summit Montreal SIGNS OF ATOPIC DERMATITIS present differently in patients with skin of colour, compared to those patients with lighter skin tones. For this reason, results of disease severity scores may need to be adjusted when treating this patient group, said Dr. Danielle Marcoux during her presentation on advances in managing atopic dermatitis (AD) at Skin Spectrum Summit 2018 in Montreal. For example, to assess disease severity, commonly used clinical scoring tools like SCORAD (SCORing Atopic Dermatitis) and EASI (Eczema Area and Severity Index) rely on manifestations of symptoms such as erythema. “It is very difficult to assess the erythema on pigmented skin,” said Dr. Marcoux, clinical associate professor at the University of Montreal and dermatologist at CHU Sainte-Justine in Montreal. “Therefore [these measuring tools] can dramatically underestimate the severity of atopic dermatitis in patients with skin of colour.” Since erythema is not as visible in darker pigmented skin, its severity can be underestimated, affecting overall disease severity scores. Physicians have to adjust their assessments of signs such as erythema when treating patients with ethnic skin, in order that a more accurate score can be achieved. “Once the scores are adjusted,

we find that there is actually a six times higher risk of severe atopic dermatitis in patients with darker skin, compared to their Caucasian counterparts,” said Dr. Marcoux. To prevent these assessment discrepancies, Dr. Marcoux and her colleagues are developing a more visual version of SCORAD called POSCORAD. By design, it is a patient-oriented scoring of AD that

allows patients to conduct their own evaluation of their disease severity after diagnosis. Dr. Marcoux is also a contributor to a project called MADE, a project that is mapping the expression of AD among patients with different skin types using schematic diagrams. “My objectives are to find the best ways to recognize how atopic dermatitis is different in patients with skin of colour, as well as how to better diagnose these patients,” she said. —BQ

“We find that there is actually a six times higher risk of severe atopic dermatitis in patients with darker skin, compared to their Caucasian counterparts”

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Atopic dermatitis

‘Alberta Hydration Protocol’ as adjunct treatment IN PATIENTS WITH atopic dermatitis, applying moisturizers alone is not enough to restore skin barrier dysfunction and prevent dry skin, said Dr. Jaggi Rao during a presentation at Skin Spectrum Summit 2018 in Vancouver. “You have to do a little bit more,” he said. Dr. Rao is founder of the Rao Dermatology Centre in Edmonton and a clinical professor of medicine at the University of Alberta. After years of working in an extremely cold and dry climate, Dr. Rao has developed what he calls the “Alberta Hydration Protocol” as a maintenance therapy for patients with atopic dermatitis. The


at Skin Spectrum Summit Vancouver system prevents dry skin and restores the skin’s barrier. “This is what I recommend on a daily basis. It might be a little bit contrary to what you might have heard but it works for us,” said Dr. Rao. The first step involves daily soaks in warm water that last for 10 to 15 minutes. “We find that water helps to extinguish fires. The root of inflammation is fire in the skin. It makes sense to add water,” said

Dr. Rao has developed what he calls the “Alberta Hydration Protocol” as a maintenance therapy for patients with atopic dermatitis

Dr. Rao. He advised against adding soap to the bath as it can be a very drying agent. Instead he suggests gentle cleansers that are less drying to the skin and do not compromise the skin barrier. “We use Cetaphil, CeraVe, and so forth. It is also important not to use these cleansers on the entire body. Advise patients to only use on certain areas such as the armpits, groin, intergluteal cleft, and scalp,” said Dr. Rao. Once patients have completed their soak and the skin has been gently patted down, it is imperative that moisturizer is applied immediately to the skin. The term “moisturizer” may even be a misnomer in this case, as it will be used not necessarily to hydrate the skin, but to seal in the water that is now in the epidermis. “We filled up their reservoir. Imagine now putting something on the surface that will prevent that from evaporating. If this is not done very quickly, especially in a dry environment like Alberta, the water in the skin will evaporate and symptoms can even get worse,” said Dr. Rao. According to Dr. Rao, it does not matter what type of moisturizer is used as long as it is comfortable for the patient and does not cause other issues. —BQ

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AD in darker-skinned children harder to identify, often more severe DR . RO NAL D B. VE N DE R at Skin Spectrum Summit Toronto ATOPIC DERMATITIS (AD) is most frequently seen in young children, but can be more difficult to identify and cause significant pigmentation challenges in children of colour, noted Dr. Ronald Vender in a presentation at the Skin Spectrum Summit 2018 in Toronto. The skin condition most commonly occurs in the first year of life—60% of individuals who experience AD do so in this window, said Dr. Vender, a dermatologist in Hamilton, and the founder and director of Dermatrials Research Incorporated. Some 85% of AD cases will occur by five years of age. While AD skin will typically become red with irritation, “if you have a darker-skinned individual, the redness can be difficult to see,” said Dr. Vender. “It can appear to be a darker colour, or it can appear as a lighter colour as well— ashy or purple.” Darker-skinned people also tend to have more severe AD, said Dr. Vender, which he said he suspected was due to greater water retention. More severe AD in dark skin is compounded because both the inflammation of AD and the skin damage that can occur due to scratching itchy areas can contribute to post-inflammatory pigment changes in darker skin. Both hyperpigmentation and hypopig-

mentation are possible. “The hypopigmentation can

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be so severe that sometimes it looks similar to vitiligo,” he said. Preventing flares is therefore important. “Unfortunately, atopic dermatitis has a lot of triggers,” Dr. Vender said. Airborne allergens, certain natural fibres in clothing, extremes in temperature, irritants, and stress are a few triggers he listed. Regarding food triggers, if a potentially severe allergen—such as peanut—is suspected, young patients should be referred to an allergist. For other foods, Dr. Vender does not recommend large elimination diets. “I think that if a parent tells me that whenever a child is having a certain type of food, they flare, they should try to avoid it for three weeks and then slowly re-introduce it and see if their eczema gets worse.” Gently cleansing without soap and frequent, regular use of emollients is important for the prevention of flares, said Dr. Vender. Products containing ceramides and essential fatty acids can help protect and restore the skin’s natural barrier. “Topical steroids can be used, and used very safely, but they really should be used for rescue,” he said. “If patients use topical calcineurin inhibitors, like pimecrolimus [Elidel, Bausch Health] to reduce the early flares, they may be able to reduce the amount of topical steroids that they use.” Dr. Vender’s presentation was supported through an unrestricted grant from Bausch Health. —JE

Non-surgical cosmetic procedures: Recognizing adverse effects NON-SURGICAL COSMETIC procedures are popular among certain Asian populations, but a proliferation of inadequately trained and unlicensed individuals performing these procedures means dermatologists and general practitioners may see more patients presenting with adverse events as a consequence of these procedures. For this reason, it is important for practitioners to be aware of the presentation of the common adverse effects and ways to address them, said Dr. Charles Cheng in a presentation at the Skin Spectrum Summit 2018 in Vancouver. Dr. Cheng is the medical director of the Skin Matters Medical Centre in Vancouver, and a clinical assistant professor in the faculty of medicine at the University of British Columbia, Vancouver. One popular treatment among Asian patients is botulinum toxin to adjust the facial contours, Dr. Cheng noted. He said that, out of curiosity, he had performed a Google search for clinics offering Botox within a 100 km radius of Vancouver, and found 127 such locations. In comparison, he said, there were only


at Skin Spectrum Summit Vancouver 100 locations of the Starbucks coffee shop chain in the same radius. Side effects from botulinum toxin cosmetic treatments are mostly aesthetic and transitory, resolving on their own in two to three months, Dr. Cheng said. Some adverse effects are more problematic, such as palpebral ptosis, which may be mistaken for myasthenia gravis. “There is actually significant resolution [of palpebral ptosis] by itself by about six weeks,” Dr. Cheng said. In the meantime, an alpha adrenergic agonist eye drop prescribed for myasthenia gravis— aproclonidine 0.5%—which increases the strength of Mueller’s muscle, underneath the eyelid levator muscle and provides some improvement in the ptosis. Filler products that add volume are also growing more popular, he said. “Some of the Asian patients in my clientele like a certain look, a V-look with a super-sharp chin,” Dr. Cheng said. Much of this, including shaping the chin and the forehead, can be done with injectable fillers. A capable injector may attempt to dissuade a patient from adopting a more extreme look, but “people get what they want,” he said. Individuals will keep searching for someone who will inject filler to give them a specific de-

sired look, even if the individual has to go to an unlicensed injector. “So you have to be watching out for certain side effects.” Non-absorbable, non-organic fillers including PMMA products can cause permanent, abnormal changes to appearance as the face naturally ages around the unchanging artificial material, Dr. Cheng said. In some cases, these products can cause chronic granulomas. “Sometimes we can decrease the inflammation and reduce the scar tissue [of the chronic granulomas] with intralesional corticosteroids or 5-FU.” Surgical removal of the filler material may also be an option. More commonly used are hyaluronic acid fillers. These are somewhat safer than permanent fillers, as the body absorbs them over time, and they can be dissolved with injections of the enzyme hyaluronidase, he said. However, with filler injections there is always a risk of embolic ischemia which can result in tissue loss or blindness. This sort of ischemia has to be treated as an emergency when it presents, said Dr. Cheng, and not just by sending the patient to a hospital. Without knowing the problem is an ischemia, the hospital may attempt to treat the patient with antibiotics for a suspected infection, he said. —JE


Higher suspicion needed for skin cancer in skin of colour DR. AF SAN E H AL AVI

at Skin Spectrum Summit Toronto AWARENESS IS ESSENTIAL of the differences in presentation of skin cancer in individuals with Fitzpatrick skin types IV through VI, and to have an elevated level of suspicion in this population which often experience delayed diagnosis and consequently worse outcomes. This was a key message from Dr. Afsaneh Alavi in a presentation at the 4th annual Skin Spectrum Summit 2018 in Toronto. Dr. Alavi is a dermatologist in private practice in Richmond Hill, Ont., and is a past-president of the Canadian Hidradenitis Suppurativa Foundation, and regional director (Ontario) of the Canadian Dermatology Association. She described a case of a 40year-old woman with Fitzpatrick skin type IV, referred to the wound clinic at Women’s College Hospital with what was believed to be a diabetic foot ulcer. “She had this ulcer for eight or nine months. As soon as you see it, you can see that it is not a typical diabetic foot ulcer. You see melanin there,” said Dr. Alavi. Multiple doctors had seen the patient before the referral. Initially, the patient thought the small lesion on the ball of her foot was a wart, and purchased overthe-counter wart treatment from a pharmacy. When the wart treatment did

not resolve the lesion, she went to her family doctor, who was unable to diagnose the lesion due to the change in appearance that resulted from the salicylic acid-based wart treatment. From there the patient was referred to a chiropodist and the wound was treated with a combination of regular debridement and salicylic acid for eight months before being referred to the wound centre. “When we did a biopsy it was a melanoma, and it was stage 4, and it was metastatic. We could not help this patient very much,” Dr. Alavi said. Melanoma is 10 to 20 times less frequent in African-American skin compared to Caucasian skin, and three to seven times less common in Hispanic skin than in Caucasian skin, she said. “But if you look at five-year survival, in white skin it is 91 per cent, while in black skin it is 57 per cent. That is more aggressive.” A lower index of suspicion, different clinical presentation in darker skin, and a lower level of access to specialty clinics by minority populations all likely contribute to the increased mortality and morbidity in patients with skin types IV through VI, she said. “Melanoma in skin of colour is mainly in non-sun-exposed areas,” Dr. Alavi said. “The pre-

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dominant type we see is acral lentiginous melanoma. That can easily missed in a physical exam.” The clinical appearance of acral lentiginous melanoma may appear benign, but dermoscopy can allow a practitioner to more easily diagnose the lesions, she said. Squamous cell carcinoma, particularly Marjolin’s ulcer on the legs or in the anogenital area, is the second most common form of skin cancer seen in skin of colour, Dr. Alavi said. —JE

Melanoma: Examine feet for signs MELANOMA AND OTHER skin cancers do occur in darkerskinned individuals, and some, such as acral melanomas, may go undiagnosed because sites such as the feet may not typically be examined, according to Dr. Joël Claveau, associate professor, Department of Medicine, Laval University, Quebec City. Speaking at the Skin Spectrum Summit 2018 in Montreal, Dr. Claveau said “Often we do not look at the feet, and the patient may also not be looking at their feet. Looking at the feet should be part of our examination.” A patient may be inappropriately treated at a wound care clinic for what appears to be an ulcer on the foot when in fact the patient has a skin cancer, explained Dr. Claveau, director of the Melanoma and Skin Cancer Clinic at Le Centre Hospitalier Universitaire, Hôtel-Dieu de Québec. He noted fairer-skinned patients (Fitzpatrick Skin Type I and II) report melanoma with much greater frequency than darker-pigmented individuals (Fitzpatrick Skin Type IV, V, and VI), who have a greater melanin barrier that decreases penetration of both ultraviolet A and B radiation through the skin. Still, melanoma should be a condition that is top of mind for dermatologists when they examine their darker-skinned patients. “It is much more common in [individuals with] light skin, but we do see it in [individuals with] darker skin,” said Dr. Claveau. The ABCDE rule to diagnose melanoma (asymmetry where one half of the mole does not match the


at Skin Spectrum Summit Montreal other, border irregularity, colour isn’t uniform, diameter greater than 6 mm, evolving size, shape, or colour) does not apply to all melanomas that present, he said.

“ABCD is not used to diagnose nodular melanoma,” he said. “It [nodular melanoma] can grow fast and is a killer.” Clinicians need to watch for lesions in locations such as the scalp or the ears where melanomas may be overlooked, noted Dr. Claveau. Melanoma may present on the nails, and one clinical clue is that the colour is extremely dark, said Dr. Claveau. “It’s concerning if there is one black nail.” Nails that become dark brown, however, may not signal melanoma, but may be a side effect associated with medication use. “You may see eight of 10 nails that are dark brown,” he said. “It can be associated with taking medication, such as AZT [azidothymidine] to treat HIV.” Like fairer-skinned individuals, darker-skinned individuals should take preventive steps such as applying sunscreen and minimizing their UV exposure to protect themselves from developing melanoma, pointed out Dr. Claveau. And while melanoma is much more common in fairer-skinned individuals, the five-year survival rate for African-Americans is much lower than that of Caucasians, according to data from the American Academy of Dermatology. —Louise Gagnon, J Ethnoderm correspondent

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Skin cancer

Risks and presentation in dark skin DR . S UNI L K AL I A

at Skin Spectrum Summit Vancouver RISK FACTORS, sub-types, and presentation of skin cancers in patients with darkly pigmented skin differ from those in lighterskinned patients, said Dr. Sunil Kalia in a presentation in Vancouver as part of the Skin Spectrum Summit 2018 ethnodermatology conference. “When we look at skin of colour patients, what [risk factors] really comes down to in importance is the history of skin cancer, [ultraviolet radiation] exposure and sunburn,” said Dr. Kalia, who is president of the Dermatology Society of British Columbia, and codirector of the Clinical Trials Unit at the Skin Care Centre in Vancouver. Other risk factors in this population are chronic inflammation, human papilloma virus, and immunosuppression. “If you have a patient with lichen planus—especially the hypertrophic lichen planus subtype—or if you have a patient with a discoid lupus lesion, or lichen sclerosis, that type of chronic inflammation can lead to squamous cell carcinoma,” said Dr. Kalia. “That is why monitoring these patients is important.” In dark-skinned patients, subtypes of cancers may present differently, he said. In his practice, he has had several patients referred with atypical moles or suspected melanomas which, on

closer inspection, had the translucency and rolled borders characteristic of basal cell carcinoma (BCC). “In terms of melanoma, acral and subungual melanoma are the most common subtypes that we see in darker-skinned individuals,” said Dr. Kalia. He noted that the differential diagnosis of subungual melanoma is important, as there are a number of benign causes of pigment change of the nails. Sub-

ungual melanoma, in contrast with longitudinal melanonychia, is typically characterized by a band of colour that is asymmetric and extends beyond the nail plate. The colour may also not be uniform. Ethnic variation in nail colour may also be mistaken for subungual melanoma, Dr. Kalia said. “The helpful thing is knowing that if you have four or five nails with pigmentation, it is likely not to be melanoma.” While these are the most common causes of pigment change in nails, other causes such as medications, should not be forgotten. —JE

“In terms of melanoma, acral and subungual melanoma are the most common subtypes that we see in darker-skinned individuals. . . The helpful thing is knowing that if you have four or five nails with pigmentation, it is likely not to be melanoma”

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Treating scalp psoriasis in women with Afro-textured hair

WHEN TREATING PSORIASIS patients who have deeper skin pigmentations, physicians must adjust therapies not only because the

“A one-size-fits-all approach . . . where you tell your patient that they have to wash their hair more frequently is not going to work.”


at Skin Spectrum Summit Montreal condition presents differently in these groups, but also because of unique cultural practices that can influence treatment adherence. For example, when scalp psoriasis occurs in women of African descent, physicians must consider how treatment will be incorporated into patients’ hair care practices, Dr. Andrew Alexis reported during Skin Spectrum Summit 2018 in Montreal. “The frequency with which they wash their hair, how they style their hair, and the type of products they use in their hair regimens that will not spoil their hairstyles—these are extra questions that [dermatologists] have to take into account,” said Dr. Alexis, chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York, and director of the Skin of Color Center. On average, hair washing frequency is lower among women of African ancestry for reasons associated with the structure of the hair as well as convenience—restoring a hairstyle after washing can be time consuming. Dr. Alexis recommends that a typical compromise when treating scalp psoriasis in this patient group is to have them wash their hair once a week with a medicated shampoo. The treatment plan should rely more on leave-in topical products contained in a vehicle that the patient finds compatible with their overall hair care routine.

“A one-size-fits-all approach . . . where you tell your patient that they have to wash their hair more frequently is not going to work. You have to negotiate the recommendations based on their hair care practices,” said Dr. Alexis. Giving patients the opportunity to provide input into the selection of vehicle, when there is a choice, can also improve patient outcomes, he said. Furthermore, topical medications have more limitations when used on patients with Afro-textured hair and hairstyles. For this reason, physicians should adopt a lower threshold for the use of non-topical therapies including oral and biologic agents, when desired results are not seen. “This is important to remember, given the tremendous adverse quality of life impact of scalp psoriasis in this patient population,” said Dr. Alexis. Meanwhile, more medications tailored for patients with darker pigmented skin are being developed. During his lecture, Dr. Alexis cited one study testing calcipotriene- and betamethasone-containing castor oil and mineral oil on patients with scalp psoriasis. Researchers found that the combination treatment was well tolerated in a cohort of Hispanic and African-American patients (Int J Dermatol 2010; 49(11):1328–1333). —BQ


Safe management and styling of Afro-textured hair DR . R ENÉ E A. B E ACH

at Skin Spectrum Summit Toronto NORMAL HAIR CARE PRACTICES for patients with afro-textured hair will be different than what is normal for patients of European or Southeast Asian backgrounds, and it is valuable for dermatologists to know what hair practices and products to recommend to help patients maintain good scalp and hair health. This was Dr. Renée A. Beach’s message during her presentation at 4th annual Skin Spectrum Summit 2018 in Toronto. Toronto-based dermatologist Dr. Beach, who leads the alopecia clinic at Women’s College Hospital, noted that because Afro-textured hair is both more brittle and often tightly curled or kinked—which produces points of weakness—it is much more prone to breakage from manipulation. This shape also makes it more difficult for sebum to travel along the hair shaft, which simultaneously makes the hair drier and the scalp more oily. “And we know that the hair growth rate of patients with Afro-textured hair, depending on the comparison source of hair or texture, is anywhere from one-half to three-quarters that of, for example, patients from western European or south-east Asian background who have straighter hair textures.” Because of these differences, individuals with Afro-textured hair engage in different grooming practices than those with naturally

straighter hair, Dr. Beach said. “What I mean by that is your patients with Afro-textured hair may shampoo their hair or shampoo their scalp weekly, and that is perfectly acceptable given the moisture balance of the hair.” However, these individuals will frequently use hair conditioner alone, as the lubricating ingredients make it easier to manipulate the hair—combing and setting—without damaging it. “I do ask patients to use shampoo on their scalp,” noted Dr. Beach. “However, I ask them to find shampoo that does not con-

DR. BEACH told delegates to the Montreal Skin Spectrum Summit 2018 another common hair condition among populations with Afro-textured hair is traction alopecia. The condition occurs in 30% of women with Afro-textured hair. Headaches, disappearing hairlines, pain with hairstyles, and the “fringe line”— retained hairs along the frontal and/or temporal rim—are accurate indications of the condition. “Hairstyle modification is the most important treatment for traction alopecia,” said Dr. Beach. “off-label use of minoxidil 5 per cent can be effective. But it is only secondary to hairstyle modification.” 26 n J o U R N A L o F E T H N o D E R M AT o L o G Y

tain certain ingredients—at least in the first three or four ingredients listed.” She said that foaming agents such as sodium lauryl sulfate, dilauryl sulfate, or cocamidopropyl betaine will likely dry Afro-textured hair further. The poor distribution of sebum along the hair shaft in this type of hair is compounded by the use of oil-based scalp treatments in this population, said Dr. Beach, which leads to a build-up of layers of oil on the scalp. This in turn contributes to a high rate of seborrheic dermatitis. Historically, 70 to 75% of women with Afro-textured hair have chemically altered their hair, either using relaxers or double-processing with a relaxer followed by a permanent treatment to create looser curls, Dr. Beach said. However, she said that an increasing number of these women and some men with Afro-textured hair are adopting ‘chemical-free’ hairstyles that incorporate the natural curl and kink of the hair. To protect their hair and scalp, Dr. Beach advises patients with Afro-textured hair to: • Avoid keeping a hairstyle in for more than eight weeks continuously; • Extensions should be no more than twice the length of natural hair to minimize weight stress on the hair shaft; • To colour hair, rinses are preferable to semi-permanent and permanent dyes, which can damage the hair shaft— particularly if lighter colour is attempted; and • If combining hair straightening and colouring, always use the relaxer before the dye or the hair is likely to disintegrate. —JE

Wound management in hidradenitis suppurativa

BECAUSE OF THE chronic nature of the inflammatory skin disorder hidradenitis suppurativa (HS) and its associated lesions, wound care in this patient population is necessarily different, Dr. Afsaneh Alavi reported during a talk at the Skin Spectrum Summit 2018 in Toronto. These patients “are on medical therapy, they have had surgery, they have recurrence,” said Dr. Alavi, who has a clinical practice in Richmond Hill, Ont., and is the past-president of the Canadian Hidradenitis Suppurativa Foundation, and regional director (Ontario) of the Canadian Dermatology Association. Decisions about dressings have to take into account that the patient will likely be changing their own dressings, and will be doing so for years. “You have to choose a ‘cheap and cheerful’ dressing,” Dr. Alavi said. “There is no home care that can cover a patient for their whole life.” For routine day-to-day care, any choice of dressing should be both inexpensive and easy to apply. If a patient’s lesions become more severe—large nodules and draining tunnels, for example— surgical deroofing and debridement are often needed. “When you are dealing with large post-surgical wounds, the story [of wound management] is different,” said Dr. Alavi. “You want the patient to go back to


at Skin Spectrum Summit Toronto

work as soon as possible, if they are working.” For patients with larger, post-

surgical wounds, the first step is to evaluate how much exudate the patient has, she said. For those with little exudate, less bulky dressings may be sufficient. Foam dressings are suitable for moderate exudate, but super-absorbent dressings are needed for high levels. “Sometimes patients, to decrease the cost, are creative,” Dr. Alavi said, recounting a patient who was using a pad designed for breast feeding babies as part of her dressing, as it was inexpensive and worked well enough to catch exudate. “If patients have critical colonization, and smell, then your choice of dressing will be the same but plus an antiseptic,” she said. “You can use silver dressing, iodine dressing, whatever you desire, or use an antiseptic wash and the same absorbent.” Particularly large post-surgical wounds over complicated areas such as the buttock can take as much as six months to heal without other intervention, noted Dr. Alavi. “That is when you need advanced therapy, such as negative pressure wound therapy, or possibly a skin graft,” she said. —JE

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Pigment abnormalities in dark-skinned individuals DR . AN DRE W F. AL EX I S

at Skin Spectrum Summit Vancouver AS PART OF A TALK on identifying pigment changes in darker skinned individuals at the Skin Spectrum Summit 2018 in Vancouver, Dr. Andrew Alexis described some pigment changes that might concern patients but that are actually just normal variations in pigment. He also addressed methods of differentiating normal variations from medical conditions that may need intervention. “It is important to know what is normal, because sometimes we are presented with patients or referrals from colleagues that ask us to weigh in on a finding that turns out to just be something that doesn’t require treatment, and is just considered a variation of normal in this population,” said Dr. Alexis, chairman of the Department of Dermatol-

ogy at Mount Sinai St. Luke’s and Mount Sinai West in New York and director of the Skin of Color Center at Mount Sinai St. Luke’s. Dr. Alexis is also an associate professor of dermatology at the Icahn School of Medicine at Mount Sinai. The first striking—but essentially normal—pigment variation he mentioned was pigmentary demarcation lines, also known as Voight or Futcher lines. These are a darker complexion on the latter aspect of the extremities, with a sharp line of demarcation. “The patient might present and say ‘I have uneven skin tone, what can you do about this, doctor?,’” said Dr. Alexis. “The answer is there is no treatment required. This is just a variation of normal.” Pigmentary changes can also

“Any new lesions should be re-evaluated and assessed to determine if they are atypical, or melanoma—which, thankfully, is uncommon but can occur on the mucosal surfaces”

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occur in the oral mucosa, particularly the gums and lips, and individuals with Fitzpatrick type VI skin may experience mottled hyperpigmentation on the palms of the hands and soles of the feet. Physicians need to have the confidence to distinguish these pigmented spots from abnormal melanocytic lesions, including melanoma, Dr. Alexis said. The spots should be checked for uniformity of colour, and the stability of their appearance should be monitored, he said. “Any new lesions should be reevaluated and assessed to determine if they are atypical, or melanoma— which, thankfully, is uncommon but can occur on the mucosal surfaces.” On the nails, particularly in individuals with Fitzpatrick type V and VI skin colouration, linear hyperpigmented bands known as melanonychia can appear. “We are often faced with the challenge of differentiating [melanonychia] from abnormal melanocytic lesions, including melanoma,” said Dr. Alexis. Some helpful clues for differentiating normal, benign melanonychia are: the involvement of multiple nails; the coloured band having sharp, clearly demarcated borders; the width of this band being uniform from the proximal base to the distal end, with no taper; and there should be no extension of this band onto the proximal or distal nailfold—the so-called Hutchinson’s sign. “That would be very much abnormal.” “In most cases, benign melanonychia is 3 mm in width or less. But that is not always the case,” said Dr. Alexis. —JE

Dealing with pigmentation disorders BECAUSE OF FUNCTIONAL and biological distinctions, darkly pigmented skin is at greater risk of hyperpigmentation and treating this condition takes special considerations, Dr. Yves Hébert reported at Skin Spectrum Summit 2018 in Montreal. Dr. Hébert is a cosmetic physician and medical director at Medecine Esthetique Dr Yves Hébert in Montreal. With photoaging effects, a person with lightly pigmented skin will experience thinning of the skin and loss of collagen resulting in sagging and wrinkles, but rarely pigmentary disorders, he explained. However, an individual with darkly pigmented aging skin will not develop as many wrinkles but will commonly experience changes in pigment. “This is very important to consider because you must approach aging a different way in cosmetic medicine in patients with darkly pigmented skin,” he said. When treating patients with epidermal pigmentation disorders, such as solar lentigines, freckles, melasma, and pigmented seborrheic keratoses, multiple factors must be considered when choosing a treatment option, explained Dr. Hébert. Treatments for these conditions cause relatively little pain, have a relatively quick recovery, decreased risk of scarring, and rarely result in bleeding. Deeper hyperpigmentation conditions, including nevi of Ota, nevi of Ito, mongolian spots, blue nevi, and melasma require different treatment considerations, he


at Skin Spectrum Summit Montreal noted. “Treatments may lead to retinoids and chemical peels, to bleeding, have relatively increased promote pigment loss. However, pain, relatively longer recovery, and he notes these treatments typically increased scarring risk,” he said. have a limited capacity to peneDr. Hébert frequently sees patrate the skin and can sometimes tients with darkly pigmented skin worsen the hyperpigmentation. trying to correct hyperpigmenta“Microdermabrasion will brighten tion. He suggests asking questions the skin and make it look more raand investigating the hyperpigdiant, but it does not solve any mentation in these individuals becondition, in my opinion. Using cause it may be melasma. “The light therapy, for example IPL, is principle of treatment requires the first treatment to use, but two things . . . prevent pigment again it is not necessarily good for gain and promote pigment loss,” deep melasma and there is a danhe said. ger of overheating the skin,” he To prevent pigment gain, Dr. said. —KW Hébert recommended sun avoidance and lightening agents. Hydroquinone 2% to 5%, azelaic acid, and kojic acid are all lightening agent options, he said. A hormonal workup is not usually warranted unless a sudden-onset of melasma is experienced by patients. “You must approach aging a different Dr. Hébert recommends way in cosmetic medicine in patients topical exfowith darkly pigmented skin” liants, such as


Post-inflammatory dyspigmentation in patients with ethnic skin: How to treat it DR . MO NI CA L I

at Skin Spectrum Summit Vancouver IN ATOPIC DERMATITIS and patients with pigmented skin, sequelae such as post-inflammatory hyperpigmentation and hypopigmentation are more pronounced and more challenging to treat. For this reason, physicians must prescribe and plan treatments differently when treating these patients, said Dr. Monica Li during a lecture at Skin Spectrum Summit 2018 in Vancouver. “For example, in my practice I talk to my patients with skin of colour about the use of sunscreen, ideally SPF 30 and higher broadspectrum UVA/UVB coverage, ideally with a physical blocker containing titanium or zinc oxide,” said Dr. Li, staff dermatologist at Project Skin MD in Vancouver and Richmond, B.C.. “I would also talk to them about engaging in as much photoprotection as possible so as to not exacerbate or worsen the post-inflammatory hyperpigmentation or hypopigmentation.” Dr. Li initially begins treating post-inflammatory dyspigmentation with topical agents, prescribing 50% azelaic acid or a triple or quadruple compound combination. “I have had success with patients by combining hydroquinone, kojic acid, tretinoin, plus or minus a low potency corticosteroid, plus or minus ascorbic acid, for several months at a time and

then re-evaluate depending on the results,” said Dr. Li. An updated chart created by the American Academy of Dermatology outlining treatment strategies for post-inflammatory hyperpigmentation is also a helpful tool for clinicians who do not have much experience treating patients with ethnic skin (J Am Acad Dermatol 2017; 77(4):607–621). The guideline explains how to treat several types of post-inflammatory dyspigmentation. For example, when treating epidermal post-inflammatory hyperpigmentation (PIH) that is light to dark brown in colour, it is recommended to prescribe the topical retinoid adapalene once daily for 12 to 18 weeks or hydroquinone 4% twice each day for 12 weeks. Alternative plans are also provided, which include a soy moisturizer twice daily for 12 weeks, niacinamide 4% once daily for nine weeks, and azelaic acid 15% twice

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daily for 16 weeks. Finally, secondline therapies (i.e., undergoing a glycolic acid peel once every three weeks starting at 50%), are also described.

Different treatment options are outlined for other types of PIH such as dermal PIH that is bluegrey in colour as well as mixed epidermal and dermal PIH that is brown in colour. “We understand that some of the clinical findings may appear differently in patients with ethnic skin,” said Dr. Li. “There is definitely need for more therapeutic studies to study this population because many of the studies in the past have largely focused on fairskinned patients.” Until more is learned about the mechanisms of ethnic skin types, Dr. Li says that physicians can use these practical measures when treating this population group. —KW

Identifying clinical mimickers can help reduce PsO underdiagnosis in ethnic skin

THE MISCONCEPTION of the rarity of psoriasis in pigmented skin contributes to the challenge of diagnosing psoriasis in these patients, said Dr. An-


at Skin Spectrum Summit Vancouver

“You must approach aging a different way in cosmetic medicine in patients with darkly pigmented skin” drew Alexis during the Skin Spectrum Summit 2018 in Vancouver. “When it comes to psoriasis in skin of colour, it is not rare—it is quite common,” said Dr. Andrew Alexis, chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York, and director of the Skin of Color Center. Furthermore, psoriatic plaques manifest differently in ethnic skin. This is another contributing factor to the underdiagnosis of the condition, according to Dr. Alexis. For example, plaques have different hues on melanized skin tones, and so they can be mis-

taken for other skin conditions and clinical mimickers. Particularly in Fitzpatrick Types V or VI skin, the colour may appear reddish-brown as opposed to a more salmon-pink. “In the background of more melanized skin the red can look more purplish or violaceous,” said Dr. Alexis. “This can make it appear to be a different purple scaly skin condition, such as lichen planus.” Relying on clues in terms of the morphology of the individual plaques will help distinguish between psoriasis and other skin conditions. Sharply demarcated plaques, the quality of the scale, and the distribution will support the diagnosis of psoriasis, said Dr.

Alexis. The background pigment may almost completely mask the erythema, and only the effects of the scale and greyish plaques will be apparent. “In some cases, erythema from psoriasis may be completely masked and you will need to rely on palpation and scale to assess the severity,” said Dr. Alexis. “Rather than looking for erythema in this situation, by comparing lesional skin to non-lesional skin and looking at a contrast of colour, you can see a hypochromia within the plaques of psoriasis,” advised Dr. Alexis. However, he also reported that due to the difficulty in distinguishing clinical mimickers, “it is not unusual to have to perform a biopsy in these kind of diagnostic dilemma scenarios.” In the treatment of psoriasis for patients of darker skin types, the success is not simply determined by the resolution of the scaling, the erythema, or the plaques. From diagnosis to final resolution and treatment, patients with more pigmented skin require specialized medical attention for their psoriasis. This attention includes a more careful diagnosis, as well as a different timeline and endpoint for treatment, he said. —Isabelle Cheng, J Ethnoderm correspondent

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Longer endpoints in psoriasis treatment for patients with ethnic skin DR . AN DR E W F. AL E XI S

at Skin Spectrum Summit Toronto IN PSORIASIS PATIENTS with darker pigmented skin, postinflammatory pigment alterations can extend treatment endpoints. Physicians must educate these patient groups about the nuances of their treatment plans in order to manage expectations and establish realistic timelines, said Dr. Andrew Alexis during Skin

Spectrum Summit 2018 in Toronto. “Once the plaques resolve they can leave behind excess pigment in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York, and director of

“Once the plaques resolve they can leave behind excess pigment in the form of hyperpigmentation or hypopigmentation. This can be just as disfiguring to the patients as the original plaques themselves”

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the Skin of Color Center. “This can be just as disfiguring to the patients as the original plaques themselves.” In patients with skin of colour, pigment alterations can exist for weeks, months, and even up to one year depending on the case. Explaining these factors to patients can help them understand why it can take significantly longer for them to achieve desired clearance of their lesions and scarring. “Treatment nuances in patients with skin of colour do not just involve appearance of the scaling, plaques, and the erythema or other colour aspects to the plaques,” said Dr. Alexis. “But once the plaques have resolved, the pigment alteration that persists mean that patients . . . may not be satisfied with the treatment that is working because there is still persistent hyperpigmentation.” Other considerations that must be made when treating patients with darker pigmented skin is that psoriasis can be more challenging to diagnose in certain areas of the body. Plaques can also appear darker, and in more of a violet hue, rather than the reddish tones seen in patients with lighter skin. “There are some interesting clinical and therapeutic nuances for psoriasis in patients of colour,” said Dr. Alexis. “One has to calibrate the eye to detect the erythema in the background of darker skin.” —BQ

Psoriasis severity measures can help create personalized treatment plans

IN THE PAST, specialists employed a step-wise ladder approach when treating patients with psoriasis, regardless of the severity of the condition. This is no longer a viable approach, according to Dr. Jaggi Rao, speaking at Skin Spectrum Summit 2018 in Vancouver. “Patients can present with the worst case of psoriasis and we would say, ‘Well let us try some creams.’ Then we will go to pills, and light therapy, and so forth. Nowadays that does not make sense. It wastes time and it causes more debilitation. It actually costs the [healthcare] system more,” said Dr. Rao, clinical professor of medicine at the University of Alberta and founder of the Rao Dermatology Centre in Edmonton.

Qualifying for advanced treatments Dermatologists now treat patients more aggressively and tailor therapies appropriate to disease presentation, he said. Different techniques are used to assess what type and intensity of treatment is best suited for patients. For example, measuring the percentage of body surface area affected by psoriasis can help physicians determine if patients qualify for more advanced therapies. “Your palm including the fingers constitute about one per cent body surface area for an individual. If you can count 10 areas of involvement like that, that would constitute about 10 per cent body surface area, which would mean [their psoriasis] is moderate to severe,” said Dr. Rao. Alternatively, 5% body surface area involvement and significant


at Skin Spectrum Summit Vancouver psychosocial impact as measured through quality of life surveys, can also qualify patients for advanced therapies. Dr. Rao advised that in these cases, general practitioners should refer patients to dermatologists or psoriasis experts. The anatomical location of psoriatic plaques are also effective markers of severity. Plaques that appear on the joints, hands, nails, and genitalia will cause more debilitation. Furthermore, the characteristics of the plaques (i.e., redness, thickness, and scales) can help determine best treatment options.

Newest therapies available Once symptom severity has been properly diagnosed, there are a wide range of treatment options. The latest offerings include Enstilar, a spray foam that hyperconcentrates a combination of calcipotriene and betamethasone dipropionate on the surface of the skin. It also has a cooling effect that may reduce pruritus. Another new option is a patch called Betaflam that contains betamethasone valerate. The patch, designed for use on flexor surfaces such as the elbows and

knees, helps the medications to absorb deeper into the skin and creates a humid environment to increase moisture. Physicians may also recommend phototherapy procedures such as a narrowband UVB with a wavelength of 311 nanometers. Finally, more biologics are being developed to inhibit particular interleukins involved in psoriasis. The newest medication is guselkumab, an interleukin-23 antagonist. “For psoriasis there is no cure, but this is the best time to have the condition. Why? Because we can bring it down with all these different therapeutic options,” said Dr. Rao. He says that co-managing treatment plans with patients, specialists, and family doctors can help achieve optimum symptom reduction. —BQ


Treating psoriasis in patients with skin of colour DR . I S AB EL L E DE L O R M E

at Skin Spectrum Summit Montreal PSORIASIS IS A CHRONIC, inflammatory condition that needs to be treated in a holistic fashion, taking into account the presence of comorbidities, according to Dr. Isabelle Delorme, a dermatologist based in Drummondville, Que. “The comorbidities are real, and they are more severe with more severe cases of psoriasis,” said Dr. Delorme, speaking at the Skin Spectrum Summit 2018 in Montreal. Among Asian and darkskinned patients in North America, the incidence of psoriasis is lower than it is in Caucasians, she noted.

“The patients may isolate themselves. Psoriasis affects the patient’s relationship with others in their world”

Comorbidities associated with psoriasis include diabetes, obesity, metabolic syndrome, and hypertension, as well as psychiatric comorbidities such as depression and anxiety. “There is a psychosocial impact of the disease,” said Dr. Delorme. “The patients may isolate themselves. Psoriasis affects the patient’s relationship with others in their world.” There are numerous variants of psoriasis, such as guttate psoriasis, pustular psoriasis, and plaque psoriasis, with the most common being plaque psoriasis, she noted. Many of the newer therapies have been designed to manage chronic

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plaque psoriasis. Dermatologists need to work in conjunction with other specialists to manage the co-morbidities associated with psoriasis, and patients with chronic plaque psoriasis need to be informed that treatment will likely be indefinite, said Dr. Delorme. The advent of biologic agents has produced high standards for efficacy in managing psoriasis, she said. “The objective is to have improvement of PASI (Psoriasis Area Severity Index) 90, which can be reached with the newer treatments,” said Dr. Delorme. Patients should be screened before they are prescribed a biologic agent, but generally do not require monitoring once they are on a biologic therapy, said Dr. Delorme. The targets of the biologic therapies include TNF-alpha, IL-23 and IL-17, she added. Traditional systemic treatments such as cyclosporin, methotrextate, and the oral retinoid acitretin, while effective, have less favourable side effect profiles than biologic agents and require monitoring to detect any possible liver toxicities, she said. Phototherapy is another treatment option, but response is variable. Moreover, it will need to be re-initiated if psoriasis recurs, she explained. For milder forms of psoriasis, clinicians can look to topical corticosteroids and analogs of Vitamin D such as calcipotriol, she said. —LG

Identifying rashes in patients with darkly pigmented skin

EDUCATION REGARDING the different clinical presentations of rashes in patients with darkly pigmented skin is leading to more accurate diagnosis of skin conditions, according to Dr. Andrew Alexis who presented at the 4th annual Skin Spectrum Summit 2018 in Toronto. “One way to classify dermatologic conditions of racial skin is using . . . [a] system [of] identifying what are normal variants in this darkly pigmented skin population,” said Dr. Alexis, chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York, and director of the Skin of Color Center. He divided skin conditions into three categories, those with unique characteristics in pigmented skin, those that are more prevalent in darkly pigmented skin, and lastly, those which could almost be considered unique to darkly pigmented skin.

Lichen planus Lichen planus, a rash with unique manifestations in pigmented skin, can present with more than the commonly described characteristic six Ps (planar, purple, polygonal, puritic, papules, and plaques). In patients with darkly pigmented skin, the purple feature may be a challenge to identify, noted Dr. Alexis. The purple may appear more grey because of the increase in skin pigment. Dr. Alexis added that the annular variant is the most common in patients of African ancestry and can be used to help identify the condition. Another common variant, the


at Skin Spectrum Summit Toronto hypertrophic variant of lichen planus is commonly mistaken for prurigo nodularis and can be difficult to differentiate. “Often a biopsy would be necessary to really determine [the accurate diagnosis],” said Dr. Alexis. “When lichen planus is resolved with treatment, hyperpigmentation is a major issue and tends to be more severe than other

post-inflammatory hyperpigmentations,” said Dr. Alexis. Sun protection, chemical peels, and other procedures may be used to treat hyperpigmentation.

Acne keloidalis nuchae Acne keloidalis nuchae is primarily seen in men of African ancestry, and rarely presents in other populations. Bumps on the back of the head, resembling keloids, are a key identifier. Severe cases involve larger areas and coalescing of the keloid-like plaques resulting in alopecia. Treatment options include topical corticosteroids of higher potency and topical antimicrobials to prevent secondary infections that can worsen the condition. The alopecia-like patches are commonly elevated, boggy, suppurative nodules called dissecting cellulitis in the scalp. Treatment options include intralesional steroids, isotretinoin, TNF inhibitors, and biologic therapy. “Because of structural variations, variations in cultural skin and hair care practices, as well as differences in cultural standards of beauty and health, we see differences in clinical presentation and overall skin disorders when we look across the broad spectrum of non-white racial ethnic groups,” Dr. Alexis reported. —KW

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Dermatology 2020: What Lies Ahead DR . MI CHE L E R AM I EN

at Skin Spectrum Summit Montreal DERMATOLOGY IN 2020 and beyond is looking promising, according to Dr. Michele Ramien in her presentation at Skin Spectrum Summit 2018 in Montreal. Dr. Ramien is an assistant professor in the department of pediatrics and academic dermatologist, chief of the division of rheumatology at the University of Ottawa. “Machine learning-based deci-

sion support systems are particularly well-suited to specialties where pattern recognition is critical. Dermatology is certainly that,” said Dr. Ramien. She said that artificial intelligence (AI) and machine learning will play a significant role in dermatology as tools used in diagnosis. She mentioned a study published in Nature (Feb. 2017; 542(7639):115–118) in which 21 board-certified dermatologists were outperformed by a machine-

“In the next two years I think we will start to see increasing use of confocal microscopy, optical coherence tomography, and photoacoustic imaging” based learning system in the diagnosis of squamous cell carcinoma and malignant melanoma. Although machine-based learning has many advantages, she mentioned some limitations, including the inability of decision-making algorithms to take into account the patient context. “In our clinical practice over the next two years I think we will start to see increasing use of confocal microscopy, optical coherence tomography, and photoacoustic imaging, which are all modalities to see beneath the

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surface of the skin without actually cutting into the skin itself,” said Dr. Ramien. These modalities are already being used in other parts of the world, including Europe, and will prove extremely valuable in the coming years, she explained. Dr. Ramien discussed the concept of big data, which is data collected from a network of practitioners across the country and across health systems used to study patient outcomes and assess quality to optimize efficiency. “It will also enable us to study diseases and conditions that are more rare,” she said. Comparing patient outcomes and physician practices will also enable a strong analysis of inefficiencies and best practices. Personalized medicine was another topic of discussion that will revolutionize the dermatology industry in the coming years, explained Dr. Ramien. Already used in oncology with the Cobas 4800 test to determine if patients are eligible for vemurafenib treatment, precision medicine will dramatically impact dermatology and the way in which patient conditions are managed, she noted. The increasing temperatures brought on by global warming will mean that suncare practices will need to be reinforced, Dr. Ramien noted. “We know that every increase by two degrees Celsius increases the risk of skin cancer by 10 per cent and that is specifically related to an increase in UV exposure,” she said. —KW

Technology anticipated to be the future of personalized dermatologic care

TECHNOLOGY IS LEADING to “the promised land of personalized and individualized medicine” in dermatology, Dr. Animesh Sinha reported at the Skin Spectrum Summit 2018 in Toronto. Technology has had a dramatic impact on many facets of society, and Dr. Sinha pointed out that the medical field has also been affected by technology, most notably in the specialties of pathology, radiology, and dermatology. “We have to be prepared and informed because patients and hospital administrators and the health economists are going to force us to understand and adapt,” he said. Dr. Sinha is a professor of dermatology in the Department of Dermatology at the University at Buffalo’s Jacobs School of Medicine & Biomedical Sciences. One way technology is being adapted to personalize and individualize healthcare is the use of smartphones and smartphone applications. Currently Dr. Sinha, his team, and two pharmaceutical companies are working on an application that allows for better tracking of chronic and complex autoimmune diseases. The app will allow doctors to simultaneously improve not only patient care on an individual level, but also look at larger trends at a population level. He hopes that by empowering patients to record their symptoms and adverse reactions to medications, he will be able to receive real-time data to better improve their care. “This sort of technology can help us identify trends as they are


at Skin Spectrum Summit Toronto happening . . . At the individual level [it] will help predict when a flare might happen. That is the goal of our app. Right now we chase our tails, we wait until a patient has a flare and then we go up on their prednisone [dosage] or

give them another immunosuppressant. In the future, we can leverage tech and data to help inform us [of the best way to proceed],” said Dr. Sinha. —Kylie Rebernik, J Ethnoderm Editorial staff

“We have to be prepared and informed because patients and hospital administrators and the health economists are going to force us to understand and adapt”


Vitiligo in skin of colour DR.YVETTE MILLER-MONTHROPE at Skin Spectrum Summit Toronto WHILE VITILIGO IS not more common in skin of colour, it is more noticeable in darker skin, so accurate diagnosis and effective treatment in these patients is important, Brampton, Ont.-based dermatologist Dr. Yvette Miller-Monthrope said during a presentation at the Skin Spectrum Summit 2018 in Toronto. “In terms of the actual prevalence of pigment disorders amongst people of colour, it is quoted as being the third most common reason for a person of colour to visit a dermatologist,” Dr. Miller-Monthrope said. Dr. Miller-Monthrope was codirector of the ethnic skin research unit (ESRU) at Women’s College Hospital in Toronto, and is currently in practice at the Wellmedica Centre in Brampton, Ont. The cause of vitiligo is not completely understood, said Dr. MillerMonthrope, and many different factors have been implicated. These include genetics, an autoimmune response, the presence of free radicals in the skin, a neuronal component with chemical signals from nerve endings down-regulating the production of melanin, and possibly a viral component. “It is always important to ask what else [pigment loss] could be,” Dr. Miller-Monthrope noted, presenting a case photograph of a 50year-old female patient of hers. The lighter spots on the woman’s face were hypopigmented under a

Wood’s lamp, not depigmented, which ruled out vitiligo. Other differential diagnoses included hyopigmented sarcoidosis, pityriasis versicolour, or progressive macular hypomelanosis, she said. “This was actually pityriasis versicolour. It is interesting because in patients of colour, they can get pityriasis versicolour on the face. We usually think about it on the trunk,” Dr. Miller-Monthrope said. Once a diagnosis of vitiligo is confirmed, the first approach to managing the condition is sunscreen, in order to reduce Koebnerization arising from sunburn. “Koebnerization is when there is damage occurring on the skin, resulting in more vitiligo,” she said. Use of sunscreen reduces photodamage to depigmented skin, and reduces the contrast between the depigmented areas and the darker uninvolved areas, she said. Cosmetic and camouflage products can be used to improve the appearance of the spots while other treatments are being implemented. Topical treatments are often used for vitiligo, Dr. Miller-Monthrope said. These include high-potency topical steroids, calcineurin inhibitors, and vitamin D analogues, though she noted that vitamin D analogues are not particularly helpful unless they are paired with a topical steroid. For patients with vitiligo affect-

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ing more than 20% of their body surface area, phototherapy is indicated. “Psoralen plus [ultraviolet] A, or PUVA tends to work fairly well, especially in patients with darker skin,” said Dr. Miller-Monthrope. “But really the gold standard is narrowband UVB. That is 311 nanometres, done at a medical facility or sometimes home UVB booths.” Lasers, particularly the 308 nm excimer laser, can be helpful with more localized vitiligo, she said. There are some new and offlabel therapies that have been tried in vitiligo, Dr. Miller-Monthrope said. Antioxidants such as phenylalanine or superoxide dismutase have been studied in vitiligo. “Some of them have had fairly decent results,” she said, “but nothing spectacular that we are all going to start using these on a regular basis.” Dermabrasion, alone or in combination with 5-FU, has shown some success. Systemically, prednisone is reserved for cases of rapid depigmentation. Systemic steroids have been used in vitiligo, but are uncommon. There has been some research on the use of biologics in these patients, but the results have been disappointing, Dr. Miller-Monthrope said. “TNF inhibitors in fact have even been shown to increase vitiligo in some studies.” Surgical therapies, such as miniature punch grafting, are only indicated in stable vitiligo, due to the risk of the Koebner phenomenon from trauma in active vitiligo. As well, in dark coloured skin surgical approaches carry the risk of keloid scarring. —JE

Best practices in wound care

CHRONIC WOUND CARE and best practices for various types of wounds were discussed by Chantal Labrecque at the Skin Spectrum Summit 2018 in Montreal. She is a registered nurse and wound care consultant at CliniConseil Inc. in Terrebonne, Que. Labrecque presented an overview of acute versus chronic wounds. Examples of chronic wounds included arterial leg ulcers, diabetic foot ulcers, pressure injuries, and venous leg ulcers. All have a slow or no healing process. The MEASURE acronym comes highly recommended by Labrecque during wound assessments. Measurements, Exudate, Appearance, Suffering (Pain), Undermining, Re-evaluation, Edges are all necessary steps to take into consideration to ensure proper care is taken. During wound bed preparation, she recommended cleaning to prevent infection, using antimicrobials, if necessary, optimizing moisture balance, and using adjunctive therapies, if necessary. She outlined some tips and guidelines clinicians can use to determine whether or not a wound is healable. A healable wound should be treated if it has good vascular supply, and the cause of the wound can be corrected. A non-healable wound should be kept dry if it has poor or no vascular supply and inadequate factors for healing. A wound should be maintained to prevent infection if there is a lack of patient adher-



at Skin Spectrum Summit Montreal ence to treatment and lack of system resources. “For non-healable and maintenance wounds you have no ac-

tive debridement, no moisture, dry dressings,” said Labrecque. She recommended antiseptics that are low toxicity and broad spectrum, such as chlorhexidine and providone-iodine, respectively. “You have to think about treating the case, the local wound care, treat the patient and after that look at the local wound care with the DIME acronym,” said Labrecque. DIME stands for debridement, inflammation vs. infection, moisture balance and edges effect. Common debridement methods include surgical, enzymatic, autolytic, biological, and mechanical, she explained. To determine infection level the NERDS acronym is used for superficial infections, whereas the STONEES acronym is used for deep infection. She also discussed general treatment objectives with associated products and dressings. To keep the wound bed moist, she recommended the use of hydrogel or hydrocolloid wound care products. To keep the surrounding skin dry and intact, skin barriers are highly recommended. When absorbing surplus exudate, she recommended hydrocellular foam dressings, calcium alginate, gelling fibers, and absorbent clear acrylic dressings. —KW

n 39

Ensuring efficient wound healing DR . AN TH O N Y PAP P

at Skin Spectrum Summit Vancouver WITHOUT A PROPERLY PREPARED wound bed, wound healing becomes more challenging, Dr. Anthony Papp reported in a presentation on wound management at the Skin Spectrum Summit 2018 in Vancouver. “The wound needs to be cleaned before it can heal. If it has a lot of necrotic tissue or it is infected it will not heal,” said Dr. Papp. “It is surprising how often

“Antiseptics will make the wound cleaner, but they will also kill keratinocytes which will prevent or slow down epithelialization”

this is neglected.” Dr. Papp is the medical director for the BC Professional Firefighters’ Burn Unit as well as the lead plastic surgeon of the Spinal Cord Injury Wound Clinic and Complex Wound Clinic at Vancouver General Hospital. He is a clinical professor of Plastic Surgery at the University of British Columbia and leader of the Provincial Burn Program. Dr. Papp stressed the importance of cleaning the wound before treatment. He described two necessary procedures to clean the wound—debridement and infection treatment, and the best practices for these procedures. Dr. Papp said that, as a surgeon, he favours surgical debridement, which can be completed in five to 10 minutes, to quickly remove the non-viable tissue. Alternatively, Dr. Papp indicated that enzymatic debridement can be done, if surgical debridement is not practical due to a lack of equipment or technical skill. Enzymatic debridement can also work quite well but is less efficient than surgical debridement. Following debridement, any wound infections must be treated. To do this, topical antimicrobials can be used, as well as silver dressings, said Dr. Papp. He emphasized the importance of silver dressings that use silver in a free form, such

40 n J o U R N A L o F E T H N o D E R M AT o L o G Y

as Ag+. “The important thing to think about is where you want the silver to be. Ideally, we want a product that will deliver the silver to the wound bed in high concentrations to kill bacteria,” said Dr. Papp. Without embedding of free form silver, silver dressings are ineffective to treating infections and do not adequately clean the wound for further treatment. Additionally, antibiotics, as an option for infection treatment, are rarely used in dressings unless in a situation regarding an invasive infection with systemic infection as well. Dr. Papp stressed that although wounds may be swabbed for infection and return a positive result, it doesn’t mean that the wound is necessarily infected. “It may be colonized by bacteria, which most burns are, but not every positive swab means antibiotics are needed,” said Dr. Papp. After the wound is clean it is then possible to promote healing and eventually restore and protect the epithelial layer. Epithelialization is the main goal; therefore, Dr. Papp warned against the use of antiseptics. “Antiseptics will make the wound cleaner, but they will also kill keratinocytes which will prevent or slow down epithelialization,” cautioned Dr. Papp. He also discussed the means to promote healing, restore and protect the epithelial layer, as well as treatment for various types of ulcers. —Isabelle Cheng, Correspondent

Foot wound care tips EFFECTIVE ASSESSMENT and management of foot ulcers involves factors including the evaluation of heal ability, ensuring a healthy wound bed, and controlling moisture, Dr. Gary Sibbald said at the Skin Spectrum Summit 2018 in Toronto. Dr. Sibbald is a dermatologist and internist with a special interest in wound care and education. He is a professor of Medicine and Public Health at the University of Toronto and an international thought leader in wound care. Foot wound care is important to diabetic patients, he said, as good care can reduce the overall cost to the healthcare system. When a diabetic patient presents with a foot ulcer, it is important to determine whether the wound is able to heal, which is in large part determined by vascular supply, Dr. Sibbald said. “How do we determine heal ability from vascular supply? If you can feel a dorsalis venous pulse—and about eight per cent have aberrance— you check the posterior tibial [blood pressure], and if there is roughly 80 mm of mercury, that will heal.” “If we are dealing with a maintenance [wound] or a nonhealable wound, we really want tissue debridement of slough. We want bacterial reduction and moisture reduction.” Bacterial reduction can be accomplished with antiseptics, said Dr. Sibbald. Two that can be considered are chlorhexedine or its derivative PHMB—polyhexamethylene


at Skin Spectrum Summit Toronto biguanide. He also mentioned povidone iodine. “Iodine is actually such a small molecule it gets into biofilms. And 80 per cent of human bacterial disease is biofilm-related. We have a slow release providone iodine which is even safer, and it will allow the patient to go two or three days without a dressing change.” Sodium hypochlorite and Eusol—Edinburgh University solution of lime—are too damaging to tissue to use in these wounds, and hydrogen peroxide only has antibacterial action while it is foaming, and presents a risk of air embolism if packed into a wound, Dr. Sibbald said. “For wounds that can heal we can debride, and sharp surgical debridement will actually improve clearing of wounds, because you are creating an acute wound in a chronic wound,” he said. Knowing what healthy tissue looks like is important. “An inexperienced wound healer takes a dressing off and finds a mound of red friable material, with blood on the dressing, and they think it is healthy,” Dr. Sibbald said. “That is not healthy. Healthy tissue is pink and firm. Debris means the cells are dying on the surface, and a smell means there is gram negative colonization.” When choosing material for dressings, an important factor to

consider is moisture balance, he said. Too much moisture will produce maceration, but too dry a wound will also not heal correctly, so wound characteristics such as the amount of exudate need to be considered. “Hydrogels are 70 to 90 per cent water, they donate water. Transparent films are mainly protective,” said Dr. Sibbald. “Hydrofiberous alginates absorb moisture, with the alginates providing hemostasis, but they will also return moisture.” There are also fluid-loving and fluid-hating hydrocolloid products, he said. Highly absorbent wound dressings, which Dr. Sibbald called ‘diapers,’ contain polymers that draw in and hold moisture away from the surface of the wound and are suitable for wounds with high levels of exudate that produce peri-wound maceration. “And there is a difference between a diaper and a sponge, which gives back [moisture]. But the sponges can also have chlorhexidine, betadine, or sodium hypochlorite attached or within them.” Dr. Sibbald said that foams are overused wound dressing materials, costing $5 to $10 per use, compared to less than $0.50 for a diaper. —JE





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