Journal of Ethnodermatology - SSS2019 Proceedings

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Proceedings of the Fifth

The Chronicle of

S KI N & AL LE RG Y

Supplement to

The Chronicle of Skin & Allergy, February 2020

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February 2020

From the

SKIN SPECTRUM SUMMIT

CURRUCULUM CHAIRS

Will you join us in supporting diversity and inclusiveness in dermatologic care?

Dear Colleague:

Published annually as a supplement to The Chronicle of Skin & Allergy by Chronicle Information 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: health@ chronicle.ca

We welcome you to this annual edition of the Proceedings of Skin Spectrum Summit.

As these Proceedings are being distributed, we are preparing the sixth annual iteration of the Summit, a live Continuing Medical Education event. This year’s conference will be national in scope and will be held at the Chestnut Conference Centre in Toronto on Saturday, April 18. You are encouraged to register and attend this accredited session.

It strikes us that several things have changed since the first Summit was held in 2014. Interest in the clinical subject of Ethnodermatology has grown demonstrably over these years, and we are gratified to have played a role in raising awareness. Practitioners and researchers are gaining practical therapeutic knowledge, through observation, trials, and genomic research, about the traits shared across our differ- Contents © Chronicle Information ent lineages -- as well as some factors that may somewhat distinguish us.

Resources Ltd, 2020, except where Our primary goal has been to facilitate better care for our Canadian communities. noted. All rights reThe celebration of diversity and inclusiveness are key to the Canadian character, and the provision served worldwide. of access to care for all has become the principle that in several ways defines who we are as a nation. Yet, The Publisher prohibits reproduction we note with concern from watching the evening newscasts that there is by no means universal acceptin any form, including print, broadcast, ance of these humanitarian values; moreover, in certain jurisdictions there are controversies affixed to and electronic, providing clinical care to immigrants and refugees. without written perAs we have stated in previous editions of this publication: as physicians, we know that levels of mission. Printed in melanin may represent in several meaningful ways the least of our differences. We are all ethnic, and we Canada.

Single copies: $47.95 are all continuously learning from, and teaching each other. per issue. Single We hope you will join our eminent faculty for the 2020 Skin Spectrum Summit in Toronto for a copies are subject to 13% HST. lively and rewarding exploration and exchange of knowledge concerning the treatment of cutaCanada Post Cananeous disorders in different populations, particularly those with Fitzpatrick skin types III through dian Publications IV. Mail Sales Product Please enjoy this monograph, and do consider attending this year’s national Skin Spectrum Summit. Agreement Number 40016917.

You may register at the conference website, www.skinspectrum.ca www.derm.city

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DR. AFSANEH AlAvi ..............................................................................................................4

Topical clindamycin-tretinoin an effective Tx option for acne DR. MONiCA K. li ........................................................................................4 Treating hormonal acne in women DR. RENiTA AHluwAliA ................................................................................5 Conveying the rationale of acne Tx to patients DR. ANDREw F. AlExiS ..................................................................................6 Topical scar management DR. JERRY TAN ............................................................................................7 Mitigate acne scarring by treating it immediately DR. CATHERiNE MAARi ..................................................................................7 intermediate systemic acne treatment DR. JERRY TAN ............................................................................................8 Choosing appropriate acne therapy DR. JERRY TAN ............................................................................................9 ATOPIC DERMATITIS Clinical presentation of AD in children with skin of colour

DR. DANiEllE MARCOux ..................................................................................................10

Myths and misconceptions in AD

DR. KEviN PEHR..................................................................................................................10

Skin barrier function plays an important role in AD

DR. AFSANEH AlAvi ..........................................................................................................11

Optimizing topical therapy in AD

DR. MAHA DuTil ................................................................................................................12

Steroid sparing and reducing flares in AD

DR. KATiE BElEzNAY..........................................................................................................12

Morphologic variants of AD in skin of colour

DR. MARiSSA JOSEPH ........................................................................................................13

Patients with AD are genetically predisposed

DR. iSABEllE DElORME ....................................................................................................14

Educating patients about AD, complications

DR. MARCiE ulMER............................................................................................................14

AESTHETICS & HAIR Safe, effective aesthetic Tx in skin of colour

DR. HANEEF AHiBHAi ........................................................................................................16

How does skin aging differ among races?

DR. MARiSSA JOSEPH ........................................................................................................16

Grooming practices for Afro-textured hair

DR. RENéE A. BEACH ..........................................................................................................17

Traction alopecia in men wearing turbans

DR. RENéE A. BEACH ..........................................................................................................17

Diagnostic dilemmas and treatment options in Afro-textured hair

DR. RENéE A. BEACH ..........................................................................................................18

HYPO- & HYPERPIGMENTATION Diagnosing and Tx options for hyperpigmentation

DR. JAGGi RAO ....................................................................................................................20

Hyperpigmentation and scarring

DR. KATiE BElEzNAY..........................................................................................................21

light patches on the trunk may turn out to be progressive macular hypomelanosis

CONTENTS

ACNE Acne management

DR. ANDREw F. AlExiS ......................................................................................................21

Tyrosinase is a contributing factor to hyperpigmentation

DR. RENéE A. BEACH..........................................................................................................22

Scleroderma has a similar presentation to vitiligo in patients with skin of colour

DR. ANDREw F. AlExiS ......................................................................................................22

KELOIDS & MYCOSIS Controlling onychomycosis and toe web bacteria

DR. GARY SiBBAlD ............................................................................................................24

Treatment of keloids

DR. RENéE A. BEACH..........................................................................................................25

PSORIASIS How to spot psoriasis in Fitzpatrick skin types v and vi

DR. ANDREw F. AlExiS ......................................................................................................26 Common areas, modalities of treatment and subtypes of Pso DR. GARY SiBBAlD ....................................................................................26 Treating mild, moderate and severe psoriasis DR. CATHERiNE MAARi ..............................................................................27 Clearing of psoriasis plaques may not mean the end of treatment for patients with skin of colour DR. ANDREw F. AlExiS ..............................................................................28 Signs of psoriasis DR. JAGGi RAO ..........................................................................................28 Treating scalp Pso in women of African ancestry DR. ANDREw AlExiS ..................................................................................29

ROSACEA Treatment options for rosacea

DR. KEviN PEHR..................................................................................................................30 Rosacea management: Early Dx reduces morbidities DR. MAHA DuTil ......................................................................................30 Rosacea underreported, underdiagnosed in patients with skin of colour DR. MONiCA K. li ......................................................................................31

MELANOMA, SUN PROTECTION when brown patches are not melasma

DR. ANDREw F. AlExiS ......................................................................................................32 The three basic methods for sun protection DR. SuNil KAliA ........................................................................................33

WOUND MANAGEMENT Sickle cell disease may complicate ulcers in patients of colour

DR. BRiAN KuNiMOTO ......................................................................................................34 Risk factors for diabetic foot ulcers and what to look for in an initial foot exam MARiAM BOTROS ....................................................................................35

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Acne management

A

Dr. Afsaneh Alavi

ACNE

ccording to Dr. Afsaneh Alavi, the key to determining the best course of action for acne treatment and management is consulting with patients on how they feel and their perception of their condition. Dr. Alavi discussed acne management strategies at Skin Spectrum Summit in Toronto.

Acne has four pathogenic factors: an alteration in the keratinization process, sebum production by the sebaceous gland, release of inflammatory mediators into the skin and P. acnes follicular colonization.

Studies have shown that a certain phenotype of acne responds better to topical treatment. Dr. Alavi suggests a combination of retinoids and benzoyl peroxide as a single agent for the first line of therapy for comedonal and inflammatory acne.

During her presentation, Dr. Alavi alluded to a survey of 3,000 to 4,000 dermatologists and non-dermatologists, which showed that only 50% of dermatologists use retinoids in the management of acne. For non-dermatologists, fewer than 30% were using retinoids as a treatment option.

“Retinoids are a great treatment in the management of acne,” she said. “What may be the barrier for treatment using retinoids is dryness of the skin and irritation that coun-

4 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

selling and using moisturizer can resolve.”

For pregnant women, azelaic acid, either 15% gel or 20% cream, is an option when treating post-inflammatory hyperpigmentation.

Topical and systemic antibiotics should not be used as a monotherapy in the management of acne, said Dr. Alavi.

“Experts use neither topical [nor] systemic antibiotics as a single agent as a treatment for a patient with acne,” Dr. Alavi said, “because of resistance.”

Isotretinoin is the first line of therapy for very severe acne, such as cystic and conglobate acne.

“The recommendation is that if you have a patient [who] at the end of treatment … still has acne, you proceed [with isotretinoin] until the final clearance,” said Dr. Alavi.

Acne flares can also be eliminated by initiation of a low dose of isotretinoin.

For maintenance, Dr. Alavi recommends topical retinoids with or without benzoyl peroxide. Topical antibiotics should not be used as acne maintenance therapy.

Laser, intense pulsed light and photodynamic therapy should not be considered first-line therapy for inflammatory acne.

“If other treatments fail, [these therapies are] an option,” she added.

Topical clindamycintretinoin an effective Tx option for acne

T

Dr. Monica K. Li

opical combination treatment options are now being recommended in North America and Europe as one of the first-line therapies for patients with acne, said Dr. Monica K. Li during her presentation at Skin Spectrum Summit in Vancouver.

“There are different synergistic and additive mechanisms of action when using a topical combination approach, which will then target multiple pathogenic factors underlying the progression of the acne,” said Dr. Li. “The topical combination approach allows for better patient compliance because there are less ingredients and less products that they have to use as part of their skin care and acne management,” stated Dr. Li. A topical combination treatment can also help practitioners achieve desired treatment outcomes, according to Dr. Li, because of a higher likelihood of increased patient compliance.

One of the most effective topical combination treatment options is a

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Treating hormonal acne in women

T

Dr. Renita Ahluwalia

clindamycin-tretinoin gel (Biacna, Bausch Health).

During her presentation, Dr. Li discussed a clinical study that looked at the safety, efficacy and tolerability of clindamycin-tretinoin as a treatment option for acne. After a 12-week period, patients saw a significant reduction in papules and pustules, with results seen as early as two weeks.

Compared to tretinoin alone, the combination treatment had a faster onset of action by six weeks.

“Studies have shown that clindamycin can improve the effectiveness of retinoids,” said Dr. Li. “Topical retinoids can improve the penetration of other active agents, allowing for better concentration and penetration into the pilosebaceous unit, where the formation of the microcomedone first starts.”

Dr. Li also talked about how the combination of a topical clindamycintretinoin gel with a benzoyl peroxide wash was an effective treatment option for a patient who was uncomfortable with systemic treatment options.

The patient was a 43-year-old fe-

Dr. Monica K. Li

male with severe papulopustular acne on her face and upper back.

“The severity of her presentation warranted a course of isotretinoin....

This patient declined all of the systemic options because she was not comfortable with their potential side-effect profiles,” said Dr. Li. After four months, the patient had some papules and pustules but also showed significant improvement. According to Dr. Li, the takehome point from this case is that “benzoyl peroxide can be added to the combination of a topical clindamycin-tretinoin for a triple-modality approach where we are targeting different pathogenic factors underlying acne development.”

“If we look at phase III studies on the effectiveness of the combination of clindamycin with tretinoin across all skin types, we can see that not only are fairer-skinned patients doing very well with this medication, but also those with skin types IV to VI,” said Dr. Li. Dr. Li’s presentation was supported through an unrestricted educational grant from Bausch Health.

he prevalence of acne in females is on the rise, Dr. Renita Ahluwalia reported during her presentation at Skin Spectrum Summit in Toronto.

“Fifty per cent of women in their 20s and 35 per cent of women in their 30s experience acne,” said Dr. Ahluwalia. “The main age of referral for women with acne has increased by eight years over the last decade, from 18.5 to 26.5.”

During her talk on acne in the female patient, Dr. Ahluwalia spoke about how it is important to consider hormonal factors when treating female patients with acne. “Up to 85 per cent of adult women complain that their acne flares a week before their period, with hormonal flares higher in women over age 30 compared to younger women.”

When treating hormonal acne, it can be helpful to consider the etiology of the acne. Prior to a woman’s menstrual period, a woman experiences an increase in her progesterone and estrogen, which can stimulate the premenstrual acne flare.

Dr. Ahulwalia talked about how a combination topical regimen of clindamycin phosphate 1.2%/tretinoin 0.025% [Biacna, Bausch Health] and topical dapsone 5% [Aczone, Bausch Health], along with an over-the-counter benzoyl peroxide cleanser and supported with the hormonal birth control spironolactone, was an effective treatment for a patient with severe hormonal acne.

“What is really unique about the tretinoin in this [topical combination product] is that there are two forms of it: one that is immediately available and one that solubilizes slowly by going into the skin and into the follicle to increase penetration,” said Dr. Ahluwalia. “Another key point about the tretinoin in this product is that it is not degraded by sunlight or benzoyl peroxide.... The delayed release of the second form [of tretinoin] and its small particle size [allow] it to enter into the pilosebaceous unit and target those resistant P. acnes.”

In a three-week head-to-head trial, patients treated with the clindamycin/tretinoin combination product had less stinging, scaling and erythema compared to those receiving a combined product of adapalene and benzoyl peroxide. There was also a 50 to 60% decrease in both inflammatory and non-inflammatory lesions after 12 weeks. “[Topical dapsone 5%] works better in female patients,” said Dr. Ahluwalia.

“Studies have shown that 48.6 per cent of women achieve clearer skin [compared

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to] 34.4 per cent of men.” Dr. Ahluwalia also stated that this product works on both inflammatory and noninflammatory lesions and patients are sustaining treatment results for over a year.

A Canadian study on topical dapsone 5% treatment in 101 female patients showed very effective results. Using the global acne grading score as a measuring tool, 69% of patients achieved success.

After three months of the topical combination regimen, Dr. Ahluwalia's patient had noticeably improved skin but was not completely clear of acne. It was to further target the hormonal component of her patient’s acne that Dr. Ahluwalia prescribed 100 mg daily of spironolactone.

“When there is a hormonal component, we have to address that.”

Dr. Ahluwalia’s presentation was supported through an unrestricted educational grant from Bausch Health.

Dr. Renita Ahluwalia

Conveying the rationale of acne Tx to patients

E

Dr. Andrew F. Alexis

xplaining the rationale behind choices in a therapeutic regimen for acne can help patients be more confident in a doctor’s recommendations and encourage better adherence to treatment, said Dr. Andrew F. Alexis in a presentation at Skin Spectrum Summit in Montreal.

“It helps to very briefly tell the patient that acne is caused by four key factors, including overproduction of sebum — oil, in layman’s terms for the patient; follicular hyperkeratinization, which to the patient you can describe as blocked follicles; overgrowth of bacteria — P. acnes or the new name, C. acnes; and inflammation,” said Dr. Alexis.

That then allows a practitioner to explain to patients how their particular presentation of acne is being driven by those factors and how the combination of recommended treatments works to correct the situation.

He noted that benzoyl peroxide (BPO) is frequently used in acne treatments because not only is it antimicrobial — without encouraging antimicrobial resistance — it also has some comedolytic effects. BPO also works well in conjunction with other agents, allowing for fixed-dose combination products that simplify

6 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

administration while addressing multiple pathogenic factors of acne at the same time.

“Topical dapsone, one of the recent additions to our topical acne armamentarium, has a range of anti-inflammatory effects and is available as an aqueous gel. It tends to be very well tolerated,” Dr. Alexis said. He noted that studies have looked at the efficacy of combining topical dapsone with BPO or with a fixed-dose combination of BPO and the retinoid adapalene.

“When we do it like this, we use [topical dapsone] once a day — offlabel instead of … twice a day — and use the retinoid formulation in the evening, typically,” he said.

“One word of caution is when you combine topical dapsone directly with a benzoyl peroxide,” Dr. Alexis said. “You want to do that at separate times, not in the same place and time. Otherwise, you can get a tan-brown discolouration.”

Topical retinoids are one of the most important classes of medication in managing acne, said Dr. Alexis. “They help to normalize follicular desquamation but also have the added benefit of reducing hyperpigmentation, which, of course, is very relevant to patients with skin of colour.”

This class of medications is also

valuable as a maintenance therapy, used in conjunction with another therapy, such as an oral antibiotic, to bring acne under control and then used alone after the antibiotic is stopped to prevent acne flares, he said.

Antibiotics, although they are effective at reducing microbial overgrowth and have anti-inflammatory properties, should not be used as monotherapy due to the risk of encouraging antimicrobial resistance, he said. As well, the choice of antibiotic — based on efficacy, safety and cost — should be explained to the patient. Minocycline, for example, is extremely efficacious and has a low risk of inducing photosensitivity but can potentially induce some unusual side effects, including drug hypersensitivity syndrome and pigmentation of scars and mucous membranes.

“There is even evidence from a French study that patients of African ancestry were more likely to develop this drug hypersensitivity syndrome from minocycline,” Dr. Alexis said.

“So when thinking about patients of colour, this, coupled with the pigmentation concern, makes this a second-line agent. So we depend more on doxycycline [in darkerskinned patients].”

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Topical scar management

F

Dr. Jerry Tan

acial scars have a strong negative impact on quality of life and can be frequent after inflammatory acne, noted Dr. Jerry Tan in a presentation at Skin Spectrum Summit in Toronto.

Fortunately, there are a growing range of treatments, including topical approaches, for not only reducing the appearance of scars but also helping to prevent their formation.

For atrophic scars, one treatment that has been investigated in a study of patients with acne scars but no active acne is adapalene 0.3% gel.

“The vast majority of patients had moderate or greater improvement in terms of overall scar severity,” said Dr. Tan of that study. “What we saw is that the patients also had increased deposition of collagen and procollagen, which is what we expect if this product is going to be able to enhance repair.”

For hypertrophic scars, which are more common in reactive, darker skin, there are more options.

Treatments for hypertrophic scars that have already formed include silicone sheets and sometimes intralesional triamcinolone acetonide injections, said Dr. Tan. “And there are a lot of other options now, including some of the vascular lasers..”

However, when a lesion is progressing from macular erythema into the beginnings of hypertrophy, only a few options are available for which there is level 1 or 2 scientific evidence, he said.

These include silicone sheets and onion extract, the latter of which has been shown to produce good results on surgical scars.

Dr. Jerry Tan Another new option is a topical for-

mulation of putrescine. It has been studied in all sorts of hypertrophic scars in a cosmetic surgery clinic, as well as in the prevention of hypertrophic scars post-breast reduction, said Dr. Tan. “This product reduces the activation of tissue transglutaminase, an enzyme that enhances cross-linking of collagen,” he said. Excess cross-linking of collagen can make the tissue very hard, forming a lump, hypertrophic scar or keloidm which is undesirable.

“You want the soft [collagen] that helps to elevate and gives you tissue structure, but you do not want excessive cross-linking. And this agent seems to help with that.”

Crucial to preventing acne scars is getting inflammation under control quickly, Dr. Tan said. “In acne, the analoyg is that of a forest fire: as long as the fire is burning, you are going to get stumps in the forest. So put out the fire quickly.”

It is also valuable to think about the nature of an individual patient’s scar risk. If it is mostly atrophic, there is evidence for topical retinoids. If there is concern about hypertrophic scars and the patient already has some, still has active acne and is receiving surgery on areas at high risk of hypertrophic scars — particularly a patient of colour — “then you may really want to consider some of these topical options to help mitigate [the] risk of scar formation.”

Mitigate acne scarring by treating it immediately

I

Dr. Catherine Maari

t is important to treat acne immediately to mitigate potential scarring. This was a point made

by Dr. Catherine Maari during her presentation at Skin Spectrum Summit in Montreal.

“Why do we treat acne? We treat acne so it does not scar,” stated Dr. Maari. “Even if the acne is not severe, we need to intervene and treat aggressively because once there are scars, it is very difficult, if not impossible, to treat.”

During her presentation, Dr. Maari described the case of a patient she was not initially seeing for acne but who had acne with scarring that had not been treated. The patient was initially resistant to treatment. However, after completing a course of isotretinoin, his acne cleared, but he was still left with scars. “I wish I had seen this patient earlier,” said Dr. Maari. “Any time you see severe acne scarring but are not comfortable prescribing isotretinoin, make sure to refer the patient [to a dermatologist] right away.”

It is also important to treat punch-out scars aggressively, according to Dr. Maari, especially in patients

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with skin of colour. “In patients with darker skin, punch-out scars can cause hyperpigmentation,” she stated.

“Even if the scars are not punch-out, hyperpigmentation, once there, can last for months or even years.”

In addition, the importance of treating acne in skin that is prone to hyperpigmentation, regardless of the severity, was emphasized by Dr. Maari. “If the patient has one to two papules or pustules, it leaves a hyperpigmented scar. This is something that we want to treat earlier to try and control the acne better. I will be more aggressive with these patients to try and control pigmentation.”

Dr. Maari outlined potential treatment options for various types of acne. For comedonal lesions, she recommended the use of topical retinoid. For inflammatory lesions, she suggested either antibiotics or benzoyl peroxide. Patients who have sebum secretion should be treated with isotretinoin, and patients who have a mixed acne can be treated with a combination treatment, such as clindamycin-tretinoin (Biacna, Bausch Health).

“Do not underestimate the impact of acne. I always ask my teenage patients, ‘On a scale of one to 10, how much are you bothered by your acne?’ The answer is often eight or nine. I tailor my treatment according to the needs of the patient,” she said.

Dr. Maari’s presentation was supported through an unrestricted educational grant from Bausch Health.

Intermediate systemic acne treatment

S

Dr. Jerry Tan

ystemic therapy for acne represents an array of effective treatments beyond antibiotics and retinoids, but some of the “common wisdom” regarding their use is incorrect, according to Dr. Jerry Tan, who spoke at Skin Spectrum Summit in Toronto.

During an intermediate overview on acne, Dr. Tan talked about systemic treatments, including oral antibiotics and isotretinoin, but also spironolactone oral contraceptive pills for female patients, antihistamines and lifestyle changes.

Regarding oral antibiotics, he suggested avoiding minocycline in favour of tetracycline or doxycycline. “The problem with minocycline [is that] it is one of the only … cyclines that has been associated with a high risk of [issues such as autoimmune hepatitis and drug-induced lupus]….

Of the different moieties of cyclines, this seems to be the most allergenic of them all. So if you can avoid it, why not?”

Avoiding this antibiotic is also supported by a lack of evidence that it works any better than the other cyclines, Dr. Tan said.

“If you are looking to reduce the risk of antibiotic resistance, add BPO washes, add BPO gels. Limit [antibiotic] use to three months.”

For female patients, spironolactone-based oral contraceptives are another effective option, he said.

“The overall quality of evidence we have for spironolactone in acne is low,” said Dr. Tan. “But I have to tell you, based on the sessions with other acne experts and people who treat a lot of acne, this is one of those unheralded heroes in our toolkit. And the reason is it works so well; it is so smooth and has so few side-effects.”

He mentioned a hybrid systematic review that found spironolactone 100 to 200 mg/day reduces inflammation and inflammatory lesion counts. Higher dosing was associated with an increased risk of side–effects — breast tenderness and irregular menstrual periods — so Dr. Tan

8 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

recommended starting patients at 50 mg/day, slowly increasing to 200 mg and then slowly lowering the dose if the acne comes under control.

Contrary to common thought, routine potassium monitoring is largely unnecessary when treating acne with spironolactone, he said, except in patients with diabetes or kidney disease, such as type 4 renal tubular acidosis.

A Korean study from 2014 showed that adding the antihistamine desloratadine to oral isotretinoin improves results, Dr. Tan said. “It makes the isotretinoin work faster, it makes it work more thoroughly and when you actually evaluate the effect of the desloratadine, it reduces inflammation and sebum secretion.”

As desloratadine is available over the counter in Canada, practitioners can feel confident that it is reasonably safe. This is particularly true for patients with premenstrual acne flares, who would only need to take it for a week or two at a time, he said. It could also be used to augment another treatment for patients on topicals who do not want to move to other systemics or for patients concerned about antibiotic resistance.

Oral isotretinoin has a bit of a bad reputation, Dr. Tan said, in part because some patients develop severe cheilitis. But the frequency and severity of cheilitis are partly due to outdated ideas about dosing the medication, he said. Recommendations to treat to a total cumulative dose of 120 to 150 mg/kg are a legacy of an era when isotretinoin treatment was limited to four months, he said.

As that is no longer the case, it makes more sense to treat to clearance rather than to a fixed total dose.

Starting a patient at a 10 mg dose and gradually increasing it to achieve clearance, and using lower maintenance dosing such as 0.1 to 0.5 mg/kg, can avoid or reduce many side-effects, including cheilitis.

“It is still going to get you there. It is still going to get the patient where they want to go.”

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Choosing appropriate acne therapy

“A

Dr. Jerry Tan

t the end of the road, all you want is to maximize outcomes, so it starts with appropriate selection of treatment,” said Dr. Jerry Tan in his presentation on acne at Skin Spectrum Summit in Vancouver.

Dr. Tan believes that successful treatment begins with providing patients with anticipated timelines so that their mindset can be “based on practical reality.” Then it is important to select a type of treatment that is available to each patient and follow through with the proper application.

Dr. Tan noted that acne starts with hormonal triggers. Some of these hormonal triggers may include a Western diet, dairy intake and changes in pubertal sensitivities.

These triggers can influence sebocytes in terms of the amount and quality of sebum that is made. In fact, Dr. Tan reported that “sebum by itself can trigger acne.” Sebum has the ability to activate inflammatory mechanisms, leading to increased inflammation. However, in other cases, hormones can increase sebum, which increases proliferation of P. acnes, which generates lipases.

After identifying acne and its triggers, Dr. Tan suggested the use of a combination of treatments that have already been proven to be successful. Retinoids are one of the only products that stop the development of microcomedones. Dr. Tan emphasized that “comedones are technically inflammatory, and when

biopsied, inflammatory infiltrates can be found.” To treat these, he advised the use of a combination of topical retinoids and benzoyl peroxide, both of which have been known to work against the proliferation of comedones. However, Dr. Tan described the importance of certifying that the treatment is both available and affordable to the patient.

Dr. Tan related the application of a topical treatment to playing a sport: “When you are thinking about topical treatments, I want you to think about defence. You have to cover the field. You don’t know where the next spots might come from.” He emphasized the need to engage with patients through positive reinforcement as adherence to the treatment requires reminders.

Dr. Tan discussed a study that discovered that the first week after prescription, only 60% of patients are opening the tube; however, when they are reminded by their doctor, the percentage increases to 100%.

Even when the treatment has been stabilized, Dr. Tan recommends that patients continue with persistent treatment as trials have shown that maximum improvement plateaus only at 20 weeks, after which patients should move forward with healthy lifestyles.

TORONTO

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Clinical presentation of AD Myths and in children with skin of colour misconceptions in AD Dr. Danielle Marcoux

A

ATOPIC DERMATITIS

topic dermatitis (AD) is more prevalent in children with skin of colour, specifically children who are of African-American, Asian or Pacific Islander decent, compared to children with Caucasian skin, noted Dr. Danielle Marcoux during her presentation at Skin Spectrum Summit in Montreal.

“Right now, around the world, one in five children have some manifestation of atopic dermatitis. Fortunately, less than 10 per cent have moderate-severe,” said Dr. Marcoux.

The clinical presentation of AD is different in both children and adults with skin of colour compared to patients with Caucasian skin, she said. Different clinical characteristics include erythema that is more grey, violet or brown in colour; dyschromia; follicular accentuation, particularly in AfricanAmericans; and lichenification in Asians, and there is often extensor involvement.

Erythema is an important factor when using the SCORing Atopic Dermatitis (SCORAD) scale to rate the severity of a child’s AD, said Dr. Marcoux. “If you adjust the erythema score ... the child could be six times more likely to be rated as having severe AD.” For example, “if you say there is no erythema, you lower the score of the child.”

Dyschromia is “a source of anxiety for parents because they see changes in colour on their children’s skin,” said Dr. Marcoux. “It is all the post-inflammatory hyperpigmentation. When it is more round and white, we label it pruritus alba, which [means] white scales.”

“As far as phenotypes, Asians have more well-demarcated lesions with increased scaling and lichenification,” she noted. However, “in African Americans, there is more extensor involvement; there is also more perifollicular accentuation and scattered distinct papules on the extensors and trunk.”

Dr. Marcoux went on to point out the importance of education: “Therapeutic education, in all chronic disease, is fundamental; you don’t just hand out a prescription. [Atopic dermatitis] is disturbing to parents; they are worried. They really need reinforcement and education.”

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Dr. Kevin Pehr

here are a number of ideas about atopic dermatitis (AD) that are outdated but are still being referenced in practices.

Some of these were described by Dr. Kevin Pehr at Skin Spectrum Summit in Montreal.

“We used to say, ‘Don’t worry; the child will outgrow [AD] when he is a teenager’ or ‘Don’t worry; she will outgrow it when she is an adult,’” said Dr. Pehr. In truth, he said, 40% of pediatric AD cases persist into adulthood.

With as many as 10% of children experiencing AD, that means 4% of all people could have the condition last through their whole childhood.

Another idea Dr. Pehr would like abandoned is the use of antihistamines to treat itching in AD and to help children sleep.

“I will probably get arguments on this. Every textbook will tell you ‘antihistamines’! No, no, no.”

“There is no histamine release involved [in AD],” he said. “Yes, if you give [children] enough at bedtime, they will fall asleep because you drugged them with the anti-

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histamine.... It will not stop them from scratching. If you put somebody to sleep with whatever, and if you do infrared cinematography, you will see them scratching in their sleep.”

AD often flares in the winter in Canada due to how dry the air gets, but practitioners should not assume this is the season when patients’ AD will be the worst. “The air has zero per cent humidity; it is functionally a desert here in winter. On the other hand, for some people, it is the excessive heat. So you have to ask your patient: Is it the hot? Is it the cold? Is it the dry? Is it the wet?” said Dr. Pehr.

A misconception many parents have is that being conservative in their use of medications such as topical steroids will help address their children’s AD while using less medication, he said. However, treating to clearance is the better choice.

“The reason I will go back to ‘treat to clear’ is they will use less medicine overall in the long run.

Most parents—especially parents of young children—will treat until the child is sorta-kinda-almostmaybe-sorta clear or perhaps a little bit better, which means they are constantly on and off treatment.

Treat them hard, treat them until they are completely clear; you will use less medicine. Even if you have to wait until the lichenification goes down.”

Skin barrier function plays an important role in AD

I

Dr. Afsaneh Alavi

mpairment to the barrier function of the skin plays an important role in the pathophysiology of atopic dermatitis (AD), Dr. Afsaneh Alavi reported during her presentation at Skin Spectrum Summit in Toronto.

“If you look at the pathophysiology of the disease, even in non-lesional skin, there is an impairment in barrier function,” said Dr. Alavi.

“The first line of treatment for atopic dermatitis ... is emollients,” said Dr. Alavi. “Emollients help the barrier to function.”

During her intermediate AD overview presentation, Dr. Alavi

posed two questions to the delegates in attendance: “If barrier function is that important in terms of [the] pathophysiology of atopic dermatitis, could [we] prevent atopic dermatitis if we help the barrier function of the skin? Could we help our patients to have less severe disease?” She answered these questions by discussing the findings of the Horimukai, et al. study published in The Journal of Allergy and Clinical Immunology (2014; 134(4):824–830).

During the study, 59 neonates who were considered at high risk for AD had an emollient moisturizer applied twice daily for the first 32

Dr. Afsaneh Alavi

weeks of life. The results showed that approximately 32% fewer neonates developed AD when compared to the control group. “If we can help maintain the barrier function, we can prevent some degree of AD. That is why [barrier function] is so important,” said Dr. Alavi.

Current AD guidelines suggest using an emollient moisturizer and avoiding triggering factors as the first line of AD management. Dr. Alavi stressed the importance of proper moisturization: “Lots of times, patients come and say, ‘I use moisturizer, but it doesn’t get better.’ In most cases, [moisturizers] are underused.” In adults, the recommended amount of moisturizer per week is 250 grams; however, according to Dr. Alavi, most patients are not using this amount.

The two moisturizers that are typically prescribed to patients are hydrophilic moisturizers and lipophilic emollients. Both should be fragrance free. “Lipophilic emollients are suggested to be applied after [active disease] to maintain moisture,” stated Dr. Alavi.

Dr. Alavi also discussed other treatment options for AD, including topical anti-inflammatory agents such as steroids and calcineurin inhibitors, phototherapy, PDE4 inhibitors and topical JAK inhibitors.

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Optimizing topical therapy in AD

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Dr. Maha Dutil

opical treatment of atopic dermatitis (AD) involves a multi-angle approach for both managing flares and ongoing maintenance, but there are both well-established therapies and new agents for this condition that can produce improvement.

That was one message Dr. Maha Dutil included in her presentation on AD at Skin Spectrum Summit in Toronto.

The basis of any care regimen is emollient use, Dr. Dutil said, noting that studies have shown that moisturizing alone can improve the eczema score. Bathing habits, too, are a non-medical factor that can impact AD symptoms, she said, recommending that patients with AD only bathe once every two to three days to reduce the drying effect.

Topical treatments for AD include topical steroids, topical calcineurin inhibitors (CNIs) and PDE4 inhibitors.

Steroid phobia is common even though, when used properly, steroids are very valuable, she said.

“If you counsel the patient and use low- to mediumpotency steroids, you do not really have many side effects,” Dr. Dutil said. “There is a long history of safety when used correctly, and they are very effective at cooling inflammation down quickly. They relieve the itch, and they are inexpensive.”

She recommends prescribing low-potency steroids for the face and folds and mid-potency steroids for the body, arms and legs. “I leave the high-potency [steroids] … for the palms and soles.”

For patients who do not respond to a topical steroid, have developed a side-effect or an intolerance or have become dependent due to overuse, Dr. Dutil says switching to a topical CNI or a PDE inhibitor could be a good choice.

Topical steroids should also be avoided in adolescents or preadolescents. “If you happen to hit them during their growth spurt with a topical steroid, you increase

12 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

the risk of sideeffects,” she said.

CNIs “suppress inflammation by inhibiting calcineurin-dependent T-cell activation. They are anti-inflammatory without being antiproliferative.

They improve skin barrier function, and they reduce Staph. carriage.” With these products, patients should be counselled that approximately 20% of patients experience a transient burning sensation on application, lasting roughly 10 minutes, for the first few days of treatment. Although there is a safety warning in the monographs of these products, Dr. Dutil noted that in 20 years of clinical experience with topical CNIs, no link has been found between use of these products and skin cancers or lymphomas.

The newest option is PDE4 inhibitors, one of which, crisaborole, was approved in Canada in late 2018. “Phosphodiesterase degrades cyclic AMP and is overactive in patients with atopic dermatitis. So by decreasing phosphodiesterase, cyclic AMP goes up in the cell, and it reduces inflammation,” said Dr. Dutil.

She mentioned a four-week study of PDE4 inhibitor treatment in patients aged 2 and older with mild-to-moderate AD. In that study, by day 29, a third of patients were clear or almost clear, with a two-grade improvement. “It helps the itch within a week. It is probably because cyclic AMP goes up in all the cells, not just the skin cells. It also goes up in nerve cells. That may be an effect.”

Steroid sparing an

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Dr. Katie Beleznay

ndividuals with very dark skin may be at elevated risk of developing atopic dermatitis (AD). That, combined with the chronic nature of AD and the tendency for darker skin to develop difficult-to-treat post-inflammatory pigment changes, suggests that encouraging treatment adherence and reducing the frequency and severity of AD flares are particularly important in this population.

This was a point brought up by Dr. Katie Beleznay in a talk at Skin Spectrum Summit in Vancouver.

Dr. Beleznay said that on presentation many patients expect she will be able to cure their eczema.

“And I say, This is a chronic condition, similar to high blood pressure or diabetes,’” she said. “Some conditions, some people get them despite everything you do. What we are going to do is try to help you manage it better.”

She said she often illustrates the cycle of AD to patients by drawing a sinusoidal curve, explaining that the peaks of the curve represent AD flares. She tells patients, “Our goals with treatment [are] to reduce the peaks—the severity of the flares— and … increase the time between the flares.”

The cornerstone of any treat-

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nd reducing flares in AD ment program, however, is adherence, Dr. Beleznay said.

“I … ask people about vehicle preference because the best cream is the one that a patient will actually use. If I give them an ointment, but they are never going to use it because it is too greasy, even though it may be a little bit more potent [than a cream] or might work a bit better in a specific area, it is not going to do any good if it sits on their shelf.”

Another factor impacting patient adherence is fears—warranted or not—patients have regarding some active ingredients.

“In my practice, I mention steroids, and people sometimes say, ‘No, there is no way I am using that.

It is terrible; it thins the skin,’” she said.

One way to address this concern is to use a topical calcineurin inhibitor (TCI) for milder AD or for maintenance between flares, Dr. Beleznay said.

“With the flare, when things are quite bad, at that stage a physician may want to consider using a corticosteroid to calm things down. Put the fire out, per se. Then at the first sign a new flare is starting, that is when a physician might want to use pimecrolimus ... to try and stop the flare before it gets

too extreme and harder to control.”

TCIs such as pimecrolimus and tacrolimus have equivalent anti-inflammatory potency to a low- to mid-potency steroid, she said.

They can also be safely used on the eyelids as they do not present a risk of skin thinning the way steroids do.

AD frequently occurs on very visible parts of the body, such as the face. This is particularly bothersome in patients with skin of colour, Dr. Beleznay said, because even if the flares can be controlled, they may have induced post-inflammatory pigment changes that can persist for a significant amount of time.

Dr. Beleznay cautiously suggested that there may be a lower risk of pigment changes with TCIs. “There are some studies that say that steroids themselves can contribute to hypopigmentation. Most commonly, I think that is actually related to the dermatitis itself not being treated.”

“But we do use the calcineurin inhibitors for treating some conditions where there may be some hypopigmentation or depigmentation, so that is a consideration.

Dr. Beleznay’s talk was sponsored by Bausch Health.

Morphologic variants of AD in skin of colour

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Dr. Marissa Joseph

topic dermatitis (AD) has different morphologic variants in patients with skin of colour in comparison with individuals with Caucasian skin.

This was the key message from Dr. Marissa Joseph’s presentation on AD in skin of colour at Skin Spectrum Summit in Toronto.

According to Dr. Joseph, it is important to be aware of how AD presents itself in skin of colour patients. “Sixty per cent of Canadians are visible minorities, and we have the highest per capita immigration rate in the world. You really have to think about disease processes in unique patient populations that are becoming, to be honest, not that unique,” stated Dr. Joseph.

She described a case of a three-year-old girl who was referred to her with a rash. Dr. Joseph said the rash had very little to no red and was more of a “dusky grey.” She went on to say that her patient had follicular accentuation and a lichenoid presentation. In addition, the rash was present on her extensor surfaces.

In darker skin types, “less erythema, violaceous-greyish hue [and] hypo- or hyperpigmentation may actually be the main indicators of severity. Follicular accentuation is quite common,” said Dr. Joseph. “Classically, we are taught that [AD] will occur on flexor surfaces, but very commonly in darker skin types, it is prevalent on extensors, … so that makes it a little bit difficult to differentiate it from psoriasis.”

Another case Dr. Joseph described was of a young girl referred to her for acne. “When we look very carefully, those aren’t comedones; those are just little follicular bumps.” According to Dr. Joseph, eliciting specific information from the patient was extremely important, especially in this case. “This was super itchy for her. Very, very itchy. She was scratching, making it difficult for her to concentrate. This would represent more of a follicular variant,” said Dr. Joseph. She prescribed a calcineurin inhibitor, which cleared the rash, something that would not likely happen if it was simple acne.

In another case, Dr. Joseph saw a young man with no acutely visible rash but very itchy skin. Upon inspection, the patient had very fine flat-topped little bumps. “This would represent a lichenoid sort of presentation,” said Dr. Joseph.

“It is not just the usual suspect of an ill-defined eruption on the flexor areas,” said Dr. Joseph. In patients with skin of colour, AD can have “perifollicu-

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lar presentations, [and there can be] dyspigmentation in the presentation, a lack of erythema, lichenoid presentations and the presence [of AD] on extensor surfaces,” said Dr. Joseph.

Patients with AD are genetically predisposed to it

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Dr. Isabelle Delorme

atients with atopic dermatitis (AD) are genetically predisposed to the disease, reported Dr. Isabelle Delorme during her talk at Skin Spectrum Summit in Montreal.

“Atopy is when people have a predisposition with hyperreactivity,” said Dr. Delorme.

AD is the first manifestation of diseases in the atopic march, followed in order by food allergies, asthma and rhinitis, said Dr. Delorme. However, not all people with atopy will have all of the diseases.

“Some people will have one; others will have all of them. But, in general, there is a link that exists between the diseases,” said Dr. Delorme.

“It appears that the skin barrier plays a role, not only in atopic dermatitis but also in the development of food and airborne allergies,” said Dr. Delorme. “There is a sensitization through

the skin barrier, which is defective, and that is where the sensitivity to food allergens, such as peanuts or eggs, for example, would appear to pass through the defective skin barrier.”

AD and the remaining diseases in the atopic march are more likely to develop at a young age, according to Dr. Delorme. Children who develop food allergies are also at risk of developing more diseases in the atopic march. Current treatment

guidelines recommend applying an emollient to the skin if a child has food allergies, regardless of AD development, in order to protect the barrier function.

Dr. Delorme also discussed the role of diet in AD. “There is still a lot of conflicting data. Currently, there is not enough evidence to recommend a specific diet to patients as a form of prevention for atopic dermatitis,” she said. However, some foods

might aggravate or exacerbate AD, such as fast food, fruit and fish.

Dr. Delorme stressed the importance of providing patients not only with information but also a treatment plan for AD. “We give patients a lot of information, but it is good to provide them with a treatment plan with things clearly written down to help them treat themselves [or their children] properly,” noted Dr. Delorme.

Educating patients about AD, complications

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Dr. Marcie Ulmer

roviding patients with atopic dermatitis (AD), or a family history of the condition, with good information can help them prevent flares and identify signs of complications.

This was part of the message Dr. Marcie Ulmer presented during a talk at Skin Spectrum Summit in Vancouver.

“I have had a lot of patients come into my practice very frustrated that they still have their condition,” said Dr. Ulmer. “They will say, ‘When I was a child, my doctor told me I would grow out of it.’ So I think it is important we do not tell our patients that they will grow out of it because a lot of them do not.... Up to 25 per cent of pediatric patients have symptoms into adulthood.”

Educating patients about how vital emollient use is in managing AD is important. Dr. Ulmer described a randomized controlled trial of emollient use from birth in infants with a family history of AD, which showed that daily full-body moisturization could reduce the cumulative risk of AD by 50% by six months.

“The conclusion was that the skin barrier enhancement from birth is really a feasible strategy for reducing the incidence of atopic dermatitis in high-risk neonates,” she said. “I do recommend it to families.”

“In general, moisturizers are really the cornerstone of

atopic dermatitis treatment. If you only recommend one thing, this is a very good thing to recommend. They help prevent itch, … help reduce flare frequency and help restore the lipid balance and skin barrier integrity. They are shown to have a steroid-sparing effect.”

Sometimes treatment-resistant eczema may not just be AD, Dr. Ulmer said, describing one of her own patients with both AD and acne who presented with a tight cluster of inflamed lesions on her chin. The lesions turned out to be due to a herpesvirus infection. “[Patients with AD] are prone to secondary infections because they have reduced immunity and impaired skin barrier function,” she said. “Staph is what we will most commonly see. It can be methicillin sensitive or methicillin resistant.”

Herpes infections can become disseminated— eczema herpeticum—which can be very serious and require hospitalization, said Dr. Ulmer. “But if caught early, it can usually be treated orally with [valacyclovir].”

The molluscum contagiosum and human papilloma viruses can also be easily spread by individuals scratching their itchy AD. Fungal infections such as dermatophytes and yeasts can also be spread this way. They are all harder to treat in patients with AD, she said.

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Safe, effective aesthetic Tx in skin of colour

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Dr. Haneef Alibhai

AESTHETICS & HAIR

sing the correct tools and techniques for aesthetic dermatology in darker skin can produce good results while minimizing the risk of inducing unwanted pigment changes, explained Dr. Haneef Alibhai at Skin Spectrum Summit in Vancouver.

One technology Dr. Alibhai advocated for skin rejuvenation in Fitzpatrick skin types IV through VI was picosecond pulsed lasers.

“The beauty of the picosecond laser is it does not work photothermally, as other lasers do. Picosecond lasers work photoacoustically, creating a pressure wave to break down pigment,” he said.

Rather than heating a target point, these devices cause a phenomenon known as laser-induced optical breakdown, which causes a pressure wave that spreads through the tissue, reaching deeper into the dermis than the lasers could themselves, Dr. Alibhai said. The pressure waves temporarily alter the permeability of the cell membranes, which increases production of elastin and collagen.

This process leads to very little downtime, “and there is no risk of hyperpigmentation because these laser-induced optical breakdowns are located below the dermal-epidermal junction,” he said.

“This is a very good device to lighten unwanted pigment. It has become my go-to to treat pigmentation on skin types IV, V, and VI, such as your typical solar lentigines, very safely.”

Of the picosecond lasers, Dr. Alibhai said he prefers a 755 nm device as energy at that wavelength is much more preferentially absorbed by melanin rather than oxyhemoglobin. “If you compare it to 532 nm, where the melanin-toblood ratio is about 2.5, or 1,064 nm, where melanin-to-blood absorption is about 16 times, at 755 nm, the difference between melanin and oxyhemoglobin absorption is actually 50 times.”

This results in very limited risk of pinpoint bleeding, minimal side-effects and less downtime while lightening pigment and increasing collagen, he said.

Dr. Alibhai and his colleagues have begun pre-treating darker-skinned patients with hydroquinone compounds for the four weeks prior to their picosecond laser appointments, he said. “That is just for our comfort and safety, so we can sleep well at night. Just to minimize the risk of [postinflammatory hyperpigmentation].

Many patients with darker skin have also asked about correcting dark circles under their eyes, he said. For those patients, particularly those with hollows under their eyes, Dr. Alibhai has been treating them with very fine, low-cohesivity, low-viscosity hyaluronic acid fillers, administered using a cannula.

“You have to choose the right patient,” he noted, saying that only three of every 10 patients are a candidate for treating this way. “If you have the right patient, the right product and the right technique, you get great results.”

How does skin aging differ among races?

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Dr. Marissa Joseph

r. Marissa Joseph began her talk at Skin Spectrum Summit in Toronto by examining the belief that there is a difference in how individuals of

16 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

different races age.

“Is that really true?” she asked before going on to contrast the features of aging seen in different skin types.

Thinking about mechanisms of

aging is important across all skin types, she said.

She spoke about intrinsic aging and extrinsic aging, making note of the extrinsic causes of aging, such as UV

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Dr. Marissa Joseph exposure and smoking.

But, she said, when comparing Fitzpatrick skin types, darker skin types tend to experience facial aging at a decreased rate due to intrinsic factors.

According to a survey of women aged 18 to 75, “African-American women reported advanced signs of facial aging on average 10 to 20 years later than their Caucasian counterparts,” she said.

Forehead lines in African-American women were reported in their 50s, tear troughs did not appear until their 60s and crow’s feet finally appeared in their 70s, she said.

Approximately 70% of AfricanAmerican women aged 70 to 79 reported that they still had not observed lines around their mouths.

“There really is a delayed onset of things like wrinkles,” she said.

Dr. Joseph went on to rank the rate of wrinkle onset by race: black patients experienced the slowest onset,

followed by Hispanic patients, Asian patients and, finally, white patients.

The reason that darker-skinned patients experience a decreased rate of onset may be due to “a protective effect of increased fibroblast activity,” she said.

This may also explain the increased risk of keloids in darkerskinned patients, she said.

This does not mean that patients with darker skin tones don’t seek or require treatments or improvements for anti-aging, she said.

Dermatosis papulosa nigra, small dark keratoses that appear on the face and neck, was one of the examples she gave of an aging condition specific to people with darker skin.

“There are nuances to addressing their specific aging concerns,” she said.

have patients [be] careful with regards to styling practices,” explained Dr. Beach. “The hair growth is generally less than other hair types, and this can be approximately half or three-quarters of the rate of other hair types.”

Patients in this cohort prefer to use conditioners over shampoos mainly because some of the slipping agents in conditioners help Afro-textured hair be more manageable after it is shampooed.

As a result of the decreased growth rate in patients with Afro-

textured hair, trimming frequency should be reduced to twice a year on average, according to Dr. Beach.

Additionally, the bedtime routine for patients with Afro-textured hair is significant for two reasons: first, to preserve a certain hairstyle, and second, to minimize trauma to the existing hair. Some patients will apply moisturizing products but will also protect the hair with something silky or satiny, such as a bonnet or particular wrap, to minimize friction.

Grooming practices for Afro-textured hair

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Dr. Renée A. Beach

hen it comes to grooming practices for those with Afro-textured hair, you are considering another type of normal, according to Dr. Renée Beach, who presented on hair and scalp disorders at Skin Spectrum Summit in Montreal.

Whereas non-Afro-textured hair types may require washing two to three times a week, with Afro-textured hair, weekly washing is generally adequate enough.

“The hair can be quite fragile for manipulation, so you really want to

Traction alopecia in men with turbans

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Dr. Renée A. Beach

raction alopecia is a scalp disorder that occurs commonly in women. But as Dr. Renée A. Beach discussed during her presentation on hair and scalp disorders at Skin Spectrum Summit in Vancouver, a minority of men, particularly men who wear turbans, report symptoms of the condition.

“As a dermatologist, we often look before we ask, and when we look, we see that there is loss of the frontal hairline, with a fringe pattern [of hair] remaining at the edge of the front,” Dr. Beach said, describing the symptoms of traction alopecia.

Female patients will show signs of gradual hair loss as a result of a history of wearing swept-back hairstyles, sleek ponytails and top knots.

According to Dr. Beach, when you question these patients, they will admit that when the hairstyles go in, they are painful. But both female and male patients often accept the pain as part of the styling process.

Signs of traction alopecia include the fringe hair loss along the edge of the frontal scalp. There is retained vellus or small terminal hairs that simply do not get swept up into

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the style. A trichoscopy can show specific features, but this is a clinical, bedside diagnosis that doesn’t require further investigation.

Male patients, who are observing Sikhs wearing turbans, are at a greater risk for traction alopecia.

During her talk, Dr. Beach showed examples of a dermatologist based in India using the process of inserting hair grafts and hair plugs in an attempt to cure a case of traction alopecia in male patients.

Dr. Renée A. Beach

To avoid further hair loss, patients need to undergo significant modification to the way they wear the turban so that the condition does not recur.

“Patients who are wearing turbans or hijabs are encouraged not to pull them tightly along the hair,” said Dr. Beach. “Hairstyle modification is paramount, but there is offlabel use of minoxidil 5 per cent foam, which can certainly help in a subacute situation.”

Traction alopecia is a reversible form of hair loss; however, at later stages, a hair transplant may be the only option for patients.

Diagnostic dilemmas and treatment options in Afro-textured hair

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Dr. Renée A. Beach

atients with Afro-textured (AT) hair can have a variety of issues, including seborrheic dermatitis, traction alopecia and androgenetic alopecia.

During a talk on hair and scalp disorders at Skin Spectrum Summit in Toronto, Dr. Beach discussed diagnostic and treatment options for patients with conditions related to AT hair.

Seborrheic dermatitis mainly affects the scalp, causing scaly patches, red skin and dandruff. For treatment, Dr. Beach recommends the use of a triple-threat therapy including an anti-yeast, anti-inflammatory medication and, in some cases, debris removal.

“I have a discussion with [patients] about increased washing, at least temporarily. I ask them to wash their scalp twice a week, which I know is really a lot for Afrotextured hair types,” she said. “Also, [I ask them to] consider the use of ciclopirox lotion, if they need to, a few nights a week.”

Mometasone lotion is an option to aid with itching, and scaling can be done with a 2% salicylic acid compound.

Although the recurrence of seborrheic dermatitis can be limited by washing and rinsing the scalp, traction alopecia requires patients to modify their hairstyle.

Traction alopecia is the gradual receding of the hairline. There is hair at the front of the hairline and then there are patches of hair with a noticeable regression.

The condition can be caused by wearing the hair in slicked-back updos and top-knot buns.

“Patients will admit, sometimes reluctantly, to headaches, tenderness, sometimes broken hairs with certain hairstyles. And typically, they get a fringe sign [of hair loss]. Patches of hair along the hairline [are] a dead

18 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

ringer for traction alopecia,” said Dr. Beach.

In addition to hairstyle modifications to reduce tension on the scalp, Dr. Beach recommends the off-label use of a 5% minoxidil foam. Traction alopecia is reversible if diagnosed and treated in the early stages.

Weathering and trichorrhexis nodosa—defects in the hair shaft—occur when there is a lack of hair growth. Hair strands appear like broomstick hair. Patients also have broken shafts, simple knots and complex knots throughout the scalp. The hair has been weathered, which is caused by heating the hair strands with a blow dryer or ceramic straightener.

“When we heat the hair strands, they literally get air bubbles in the shaft, and the air bubbles are tied to breakage,” said Dr. Beach. “When patients with Afro-textured hair dry comb their hair without any sort of product on their hair, it can amount to a daily haircut in terms of the breakage that they sustain.”

She suggests air-drying the hair and minimizing the friction with a seamless comb. Products with “slip” that contain ingredients such as glycerine, as well as trimming off dead ends, can be helpful in treatment.

Androgenetic alopecia is a type of hair loss common in middle age. Affecting 40% of females and 50% of males, androgenetic alopecia is gradual and progressive and can be described as follicular miniaturization. Thicker hairs turn into vellus hairs and whisk away.

This type of hair loss is a combination of genetics, heritage and androgen activity.

Dr. Beach suggests a 5% minoxidil foam for treatment and notes that if spironolactone is prescribed to patients, there is a dosage difference between men and women.

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SKIN SPECTRUM SUMMIT

CHAIRS & FACULTY

Dr. Renita Ahluwalia is a staff dermatologist at Women’s College Hospital in Toronto.

Dr. Afsaneh Alavi is a dermatologist at York Dermatology Clinic and Research Centre in Richmond Hill, Ont., and is the Past President of the Canadian Hidradenitis Suppurativa Foundation.

Dr. Andrew F. Alexis is Chair of the Department of Dermatology at Mount Sinai West in New York, and Director of the Skin of Color Center at Mount Sinai St. Luke’s. He is also an associate professor of Dermatology at the Icahn School of Medicine at Mount Sinai.

Dr. Haneef 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.

Dr. Renée A. Beach is Head of the Alopecia Clinic at Women’s College Hospital in Toronto.

Dr. Katie Beleznay is Director of the Vancouver Acne & Rosacea Clinic and a dermatologist at Carruthers & Humprey Cosmetic Dermatology and Seymour Health Centre in Vancouver.

Mariam Botros is the Chief Executive officer of Wounds Canada (formerly known as the Canadian Association of Wound Care).

Dr. Isabelle Delorme is a dermatologist based in Drummondville, Que. In addition to her clinical activities, she devotes time to Continuing Medical Education and operates her own research centre dedicated to clinical research in inflammatory diseases.

Dr. Maha Dutil is a dermatologist in private practice, a consultant at

Women’s College Hospital in Toronto, and Assistant Professor of Medicine in the Dermatology Department at the University of Toronto.

Dr. Marissa Joseph is a pediatrician and dermatologist and is the Medical Director of the Ricky Kanee Schachter Dermatology Centre at Women’s College Hospital in Toronto. She also works at the Hospital for Sick Children where she manages children with complex dermatologic disease.

Dr. Sunil Kalia is a dermatologist and the Co-Director of the Clinical Trials Unit at the Skin Care Centre in Vancouver.

Dr. Brian Kunimoto is the founding Director of the Vancouver General Hospital Wound Healing Clinic from 1990 to present. He has a special interest in wound bacteriology.

Dr. Monica K/ Li is a dermatologist practicing at City Medical Aesthetics Center in Vancouver and at The Skin Doctor/Enverus Medical in Surrey, B.C. Dr. Catherine Maari is Associate Professor at the Faculty of Medicine at the University of Montreal and practices dermatology at the CHUM (University of Montreal teaching hospital) and Saint-Justine Hospital in that city.

Dr. Danielle Marcoux is a Clinical Associate Professor at the University of Montreal and dermatologist at CHU Sainte-Justine in Montreal.

She is a founder and past-president of the Camp Liberte Society, a camp for children with dermatologic disorders.

Dr. Kevin Pehr teaches at Jewish Gen-

eral Hospital/McGill University in Montreal, where he is Chief of Cutaneous Lymphoma, and operates a private practice that encompasses medical, surgical and aesthetic dermatology.

Dr. Shafiq Qaadri is a Toronto-based family physician, Continuing Medical Education (CME) lecturer, medical writer and broadcaster.

Dr. Jaggo Rao is founder of the Rao Dermatology Centre in Edmonton and a full Clinical Professor of Medicine at the University of Alberta.

Dr. Jason Rivers is a Clinical Professor of Dermatology at the University of British Columbia. He practices medical and cosmetic dermatology at Pacific Derm in Vancouver, and is President of the Acne and Rosacea Society of Canada.

Dr. Gary 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 wound care key opinion leader (educator, clinician and clinical researcher).

Dr. Jerry Tan is an Adjunct Professor at Western University, Windsor campus and practices general dermatology in Windsor, Ont. He is the Medical Director of Healthy Image Centre for Aesthetic Dermatology and Windsor Clinical Research Inc. Dr. Marcie Ulmer is a dermatologist at Pacific Derm in Vancouver where she has a comprehensive medical and aesthetic dermatology practice. She is a Clinical Instructor in the Department of Dermatology and Skin Science at UBC.

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Diagnosing and Tx options for hyperpigmentation

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Dr. Jaggi Rao

HYPO- & HYPERPIGMENTATION

hen dealing with patients suffering from hyperpigmentation, Dr. Jaggi Rao recommends that practitioners start by looking at why the skin is hyperpigmented. Dr. Rao discussed the consultation process and treatment options for patients with hyperpigmentation during his presentation at Skin Spectrum Summit in Vancouver.

There are two different categories of hyperpigmentation: melanotic or melanocytotic, according to Dr. Rao. Melanotic hyperpigmented conditions have too many melanosomes compared to the baseline, whereas melanocytotic hyperpigmentation occurs when there are excess melanocytes.

Melanotic conditions include freckles, melasma and facultative pigmentation. Melanocytotic symptoms include different types of

Dr. Jaggi Rao

20 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

moles, nevus of Ota and Ito, blue nevus and lentigines.

Using the Fitzpatrick skin phototype, Dr. Rao suggests that doctors begin the consultation process by assessing the patient’s baseline pigment, the level of pigmentation without the disorder.

“This is reflective of the constitutive epidermal pigmentation that a person would have,” Dr. Rao explained. “People who have darker skin types … have more labile melanocytes, and if you are too aggressive with the treatment, you can cause more pigmentation or post-inflammatory hyperpigmentation. Typically, this will happen for Fitzpatrick skin type III to VI.” To achieve synergy in treatment, Dr. Rao suggests a multiproduct approach to effectively treat hyperpigmented skin.

“If you can go ahead and both prevent further pigment gain and promote loss and do it in multiple levels, then we will be able to have better and safer therapy,” Dr. Rao said.

Multi-layer therapy is another treatment option for hyperpigmentation Dr. Rao discussed.

Utilizing enzyme inhibitors of the melanin pathway as well as melanin transfer, exfoliants and antioxidants can treat the pigments that are excess not only in the epidermis but also in the dermis.

“We now know that infrared radiation can also cause free-radical accumulation, and that might contribute to damage,” said Dr. Rao. Although Dr. Rao focused his presentation on topical agents for the treatment of hyperpigmentation, he acknowledged that different types of sunscreens as well as multimodality therapy can be used to treat the disorder.

“You can use a lot of this with other modalities, such as laser therapies, peels and so forth, as long as you know how to do it properly, you’re well trained and you have that comfort level,” suggested Dr. Rao. Dr. Rao’s presentation was supported through an unrestricted educational grant from Vivier Pharma.

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Hyperpigmentation and scarring Light patches on the trunk Dr. Katie Beleznay may turn out to be progressive macular hypomelanosis

“P

ost-inflammatory hyperpigmentation is one of the top reasons that skin of colour patients seek dermatological care,” said Dr. Katie Beleznay in a presentation at Skin Spectrum Summit in Vancouver.

Dr. Beleznay emphasized how early and effective intervention is essential to prevent pigmentary issues and scarring. Specifically, she discussed how keloid scarring is more common in skin of colour. In addition, for skin of colour patients, some hair-grooming products may cause or worsen acne, leading to what Dr. Beleznay described as “pomade acne.”

After inflammatory wounds, the pigmentation of skin can occur. Post-inflammatory hyperpigmentation is more common in darker-skinned patients, whereas post-inflammatory erythema is more common in patients with lighter skin types. Dr. Beleznay stressed that these skin discolourations, although they are not true scars as the skin is not pitted or depressed, can last for years. Therefore, “it is important to set up expectations, how to treat this, when will it fade, so [patients] are not thinking it is going to be gone the next day,” said Dr. Beleznay.

Epidermal lesions may persist for up to six to 12 months, but dermal hyperpigmentation can last for years and may be more disconcerting than acne. Facial acne scarring occurs in 95% of patients and develops within 12 weeks. Dr. Beleznay described how facial acne scars can manipulate the perception of an individual, presenting a survey that found that people with clear skin are more often associated with positive traits.

Dr. Beleznay suggested the use of oral antibiotics, which can be less irritating to the skin than topical therapies. She named isotretinoin as a potentially remissive treatment for acne, which was found to be safe and effective in African-American, Middle Eastern, Asian and Asian-Indian populations.

Isotretinoin reduces sebum production by 70%, reverses follicular hyperkeratosis to normalize epidermal differentiation, reduces P. acnes and inhibits the inflammatory reaction, which reduces the amount of neutrophils attracted to the troubled site.

In terms of scarring with the use of isotretinoin, Dr. Beleznay advised that “less scarring develops in those receiving isotretinoin early in their disease process.”

Dr. Beleznay stressed that it is important to be clear with patients as treating acne and acne scarring can be an expensive and lengthy endeavour.

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Dr. Andrew F. Alexis

n his presentation titled “Diagnoses Not to Miss” at Skin Spectrum Summit in Montreal, Dr. Andrew F. Alexis provided information on several tricky skin conditions that can easily be mistaken for something else.

Many of these conditions, he said, are not “everyday” conditions that dermatologists encounter in their practice. However, one of the more common, although often misdiagnosed, conditions he spoke about was progressive macular hypomelanosis (PMH).

This condition usually appears as white or light-coloured patches on the patient’s trunk.

“Usually, when we see these little hypopigmented macules that coalesce to patches on the trunk, the diagnosis is pretty straightforward: we think tinea versicolor,” said Dr. Alexis.

But not all of these types of patches on the trunk are tinea versicolor, he said.

PMH also presents as hypopigmented macules that coalesce to patches that appear on the chest and back.

“You often try to treat it as tinea versicolor. You give [patients] every

antifungal known to man, and it just doesn’t go away,” he said.

With tinea versicolor, fine scales are often observed, but not with PMH. In cases where no scale is observed and antifungals are ineffective, it’s often PMH, he said.

Unlike tinea versicolor, the condition is not caused by yeast, which triggers a fungal infection. Instead, PMH is a bacterial infection, which he said is thought to be mediated by the bacteria P. acnes, also known as C. acnes.

The P. acnes bacteria can be found using a Wood’s lamp, under which it fluoresces.

According to Dr. Alexis, treatment should be directed at the P. acnes bacteria, which means using either a topical benzoyl peroxide wash or topical clindamycin formulations.

Resolution should happen in approximately 12 weeks, he said.

For best results, Dr. Alexis recommends phototherapy, such as narrowband UVB, in addition to topical antimicrobial therapy.

“With that I hope that I have helped to broaden the differential of common presentation of dark spots and light spots and patients of colour,” he said.

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Tyrosinase is a contributing factor to hyperpigmentation

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Dr. Renée A. Beach

ncreased activity of the tyrosinase enzyme is a contributing factor to skin dyspigmentation according to Dr. Renée A. Beach, who spoke at Skin Spectrum Summit in Montreal.

“When we think about hyperpigmentation, what we are really thinking about is the enzyme tyrosinase,” said Dr. Beach. If a person’s trigger is ultraviolet light, for example, this “activates the tyrosinase enzyme to enhance or increase melanin production.... Our bodies are actually doing this as a means of trying to protect our skin; however, what happens is we tend to overdo it or overcompensate, which leads to dyspigmentation.”

Dr. Beach spoke about ways to inhibit tyrosinase, resulting in an overall more even skin tone.

According to Dr. Beach, benzene-1,4 diol (hydroquinone) is the most effective treatment option for improving dyspigmentation. “It is used for a variety of conditions,” she said. “I use it in practice for

post-inflammatory hyperpigmentation; it is also being more commonly used for melasma.” Benzene-1,4-diol is an aromatic organic compound, and when used in the range of 2 to 4%, it inhibits the activity of tyrosinase.

“Two per cent [benzene-1,4-diol] can be used on all skin types to help prevent and treat hyperpigmentation,” stated Dr. Beach. She emphasized the importance of educating patients on the process of benzene-1,4-diol treatment, stating that patients need to understand that the effects are gradual and it can take anywhere from three to four months to produce results.

Dr. Beach also said that “patients with olive, brown or black skin will probably notice a greater benefit because they are generally starting off from a higher level of dyspigmentation in many cases because their skin depigments more readily.”

She also mentioned the importance of properly

Scleroderma has a similar presentation to vitiligo in patients with skin of colour

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Dr. Andrew F. Alexis

itiligo is not the only cause of hypopigmentation in patients with skin of colour, said Dr. Andrew F. Alexis in a presentation at Skin Spectrum Summit in Vancouver.

“When there is a striking contrast of normal and involved skin and it has that sort of milk-white appearance, it is usually vitiligo. However, not all depigmented patches on the skin are vitiligo. We have to keep an open mind and consider other diagnoses,” he said.

“Light patches, loss of pigment on the face, [are] a pretty common scenario

22 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

using sunscreen to both prevent further damage and to inhibit tyrosinase. “When we use something like sunscreen or sunblock, tyrosinase activity is alleviated or decreased. You get a decreased melanin production; you get skin protection and an overall more even skin tone,” said Dr. Beach.

Dr. Beach recommends that patients use at least a broad-spectrum SPF 45 sunscreen because she feels most people do not apply their sunscreen thickly enough. “My rule is SPF 30 does not really manifest as an SPF 30,” said Dr. Beach, meaning that a higher SPF is needed.

“We want to help [a patient’s] pigmentation, but part of the issue is making sure we prevent further dyspigmentation, which is why sunscreen is an important element,” said Dr. Beach.

Dr. Beach’s presentation was supported through an unrestricted educational grant from Vivier Pharma.

when treating patients with skin of colour,” noted Dr. Alexis. “While vitiligo can certainly affect the periorificial areas of the face, ... you have to look at the whole patient,” not just the affected areas.

During his presentation, Dr. Alexis described the case of a patient who was referred to him with a diagnosis of vitiligo; however, further evaluation revealed that she actually had scleroderma.

The patient, an African-American woman, had patches of hypopigmentation on her face and trunk, but, most importantly, she had taut, bound-down skin and a tapering of her digits.

Noted Dr. Alexis: “When scleroderma presents in darker skin, it often presents with an associated pigment change, which might be the first thing the patient notices, and the thing that would drive the patient to a physician or, specifically, a dermatologist.”

Systemic sclerosis has a higher rate of prevalence in women of African-American ancestry, usually with a worse prognosis compared to other groups, said Dr. Alexis.

Dr. Alexis provided another example of a patient who was also diagnosed

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Dr. Andrew F. Alexis

Dr. Danielle Marcoux

Dr. Isabelle Delorme

with vitiligo prior to seeing him, but clinical examination, biopsies and a serological workup were consistent with scleroderma.

After looking at the whole patient, he saw “areas with some hyperpigmentation and hypopigmentation.... In the area with the loss of pigmentation, there is some follicular sparing, creating a salt-and-pepper appearance,” said Dr. Alexis. According to Dr. Alexis, “this salt-and-pepper appearance, especially involving the trunk, is a very striking and common presentation of scleroderma in darker-skin patients.”

Dr. Alexis also stressed palpating the skin. “Don’t forget the importance of palpation. Don’t just stand at the edge of the bedside or doorway when diagnosing what seems to be a pigmentary concern.”

Dr. Marcie Ulmer

Dr. Katie Beleznay

Dr. Kevin Pehr

Dr. Haneef Alibhai

Dr. Shafiq Qaadri

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Controlling onychomycosis and toe web bacteria

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Dr. Gary Sibbald

KELOIDS, MYCOSIS

n his presentation at Skin Spectrum Summit in Toronto, Dr. Gary Sibbald spoke about preventing diabetic foot ulcers by first outlining treatment for onychomycosis and toe web bacteria.

“The average wear and tear in the foot for someone who lives an average lifespan is the equivalent of walking 115 thousand miles,” said Dr. Sibbald.

It is no surprise, then, that 75% of the population experiences foot pain at some point, said Dr. Sibbald.

Many other physical ailments can first manifest in the foot, he said. Those ailments include arthritis, peripheral vascular disease, cardiac disease and diabetes.

“A foot out of alignment results in discomfort and pain in the ankle, the knee, the hip and the back,” he said.

For patients with diabetes, 85% of amputations begin with a foot ulcer, said Dr. Sibbald. For this population, an onychomycosis infection can be especially concerning.

“In a population of persons with diabetes, 1 per cent of them have gangrene,” said Dr. Sibbald. For those with diabetes and onychomycosis, 5% have gangrene, he said.

He noted that 2% of persons with diabetes and a foot ulcer will develop gangrene. If they have diabetes, a foot ulcer and onychomycosis, the incidence goes up to 6%.

When taking a nail clipping for culture, the most important part is to get the subungual debris, said Dr. Sibbald.

“This is really where most of the fungus is. About 30 per cent can be falsely negative on culture, so you may need three cultures. But if we see a KOH [test] with fungal filaments, that’s enough,” he said.

There are 22 different conditions that can mimic fungus, Dr. Sibbald said. He offered a piece of advice for identifying tricky cases.

“The most important pattern is distal streaking where it’s wider distally than proximally,” he said.

If unsure about the diagnosis, he recommends 1% hydrocortisone powder and antifungal cream.

Dr. Sibbald also talked briefly about bacteria between the toes. The tightest toe web is typically between the fourth and the fifth toe, he said.

In patients with diabetes, this can become a problem area for bacterial and

24 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

fungal infections, so he recommends checking in this area first before going proximally to check the others.

“Bacteria, specifically Staph and Strep, can get in. That causes lymphangitis and subsequent cellulitis, and these people end up in emergency departments,” he said.

He recommends using 10% povidone-iodine on this area by applying it with a cotton applicator.

“It’ll control gram-positive, gramnegative and anaerobic bacteria; it will treat dermatophyte fungus, yeast and viruses. This is a way to keep that space clean,” he said. He also recommends breathable footwear for patients with this condition

Dr. Gary Sibbald

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Treatment of keloids

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Dr. Renée A. Beach

he best treatment for keloids is to try to avoid them altogether, according to Dr. Renée A. Beach, who presented on scarring at Skin Spectrum Summit in Montreal.

“The problem with keloids is that we do not have great treatments,” Dr. Beach explained. “We have treatments that help and treatments that work for a subacute period, whether that is three to six months, but I always tell people prevent it so that we do not have to have this conversation.

“If you know it is in your family or you know you have a tendency, try to prevent it or avoid practices that are going to help form keloids.”

On top of there being no permanent removal of the scar, it is also difficult to find surgeons who will excise keloids because they can recur in some capacity.

For a cost-effective treatment option, Dr. Beach suggests using clobetasol.

She prescribed twice-daily applications of clobetasol cream to a 19-year-old female patient without extended health benefits.

“This is an instance where you want to use your side-effects as your therapeutic effect,” Dr. Beach said. “Often times you will hear a patient say, ‘Oh, I don’t want to use a steroid because it is going to thin my skin.’ This is the time we say, ‘Exactly; this is what we are hoping for.’”

Patients using this regimen for three to five months will not improve the colour of the scar. A Caucasian patient will end up with a flat, red scar but will not have a keloid anymore. A patient with brown, olive or black skin can experience hypopigmentation, according to Dr. Beach.

“Clobetasol treatment is certainly OK, as long as your patient understands you are not doing anything to improve the colour of the keloid, and that is across skin colours,” she said.

For a patient with an unlimited budget, Dr. Beach suggests consulting a plastic surgeon to see if the keloid can be removed cosmetically. Therapy with pulsed dye laser can be used to mitigate some of the redness. CO2 ablation is also an option.

Additionally, for a patient not concerned with costs, Dr. Beach recommends a three- to six-month course of imiquimod.

“I usually ask them to use it about four to five days a week and see them back in about four to six weeks,” she said. “The patient needs to understand it is going to look worse before it starts to look better. [The prescription] will need a couple of refills; depending on their drug plan, that can get expensive.”

Dr. Jason Rivers

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How to spot psoriasis in Fitzpatrick skin types V and VI

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Dr. Andrew F. Alexis

PSORIASIS

s part of his talk on psoriasis in skin of colour at Skin Spectrum Summit in Toronto, Dr. Andrew F. Alexis detailed a number of ways that the skin condition can present differently in darker skin.

This was part of a larger talk debunking myths surrounding the prevalence of psoriasis in darker skin and comparing the disease’s colour presentation and shape across skin shades.

He began his talk by discussing how psoriasis in darker skin has come to be understood better over the years. Although it was once considered a “rare” skin condition in people of colour, Dr. Alexis debunked that myth.

“This was due to underreporting,” he said. “Thankfully, more recent stud-

Common areas, modalities of treatment and subtypes of Pso Dr. Gary Sibbald

26 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

ies have shown that the prevalence of psoriasis in darker skin is far from rare; in fact, these studies have shown the prevalence rate [to be] in the one to two per cent range.”

As far as psoriasis in darker skin types goes, Dr. Alexis said that sometimes the presentation is classic; it is usually sharply demarcated, brick red or pink, and can have plaques with silvery scales.

“However, once we get into the more darkly pigmented ranges of the spectrum, including Fitzpatrick type V and type VI, the redness may be masked by melanin and may start to look a little more purple or violaceous than red,” he said.

The sharp lines of demarcation and characteristic scale will still be present, he said, but because of the purplish hue, it can be difficult to dis-

I

n his presentation at Skin Spectrum Summit in Toronto, Dr. Gary Sibbald spoke about topical treatments for psoriasis. He discussed the “many faces of psoriasis,” including the subtypes; the different modalities of treatment; and the common areas at which psoriasis tends to manifest itself.

tinguish from lichen planus, another papulosquamous disorder.

One factor that can help differentiate the two disorders is the location on the body where it is found.

“Lichen planus tends to favour the flexural side of extremities, including the wrist and forearm, while psoriasis will be more extensor,” he said.

The shapes of the lesions of the two disorders differ as well, he said.

“In lichen planus, plaques tend to be more flat topped and polygonal.”

Hyperpigmented lesions ranging from dark brown to red brown may appear on darker skin as opposed to red lesions on lighter skin.

Certain skincare practices may also hide the character of the scale. In his presentation, Dr. Alexis gave the example of a patient who had a nightly routine of applying petrolatum ointment on his scaly plaques and scraping off the scales with a kitchen knife.

“This is a lesson to be learned as far as asking about what patients are doing and considering how that might impact the clinical appearance of the plaques in front of us,” he said.

Psoriasis subtypes include plaque psoriasis, guttate psoriasis, pustular psoriasis and erythrodermic psoriasis, said Dr. Sibbald. He went on to point out that there is “‘A’ evidence for most of what we do in psoriasis,” referring to randomized controlled trials.

He said that for any patient with 5% or less psoriasis coverage, he would recommend starting with

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Treating mild, moderate and severe psoriasis

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Dr. Catherine Maari

n her presentation at Skin Spectrum Summit in Montreal, Dr. Catherine Maari spoke about treating psoriasis in its different forms: mild, moderate and severe.

Topical treatments can work best for mild psoriasis, whereas moderate psoriasis can respond well to phototherapy, she said. For severe psoriasis, she recommends biologics.

She outlined a few topical treatment options.

“Corticosteroids are still the gold standard,” she said.

She also mentioned a topical vitamin D analogue, calcipotriene. “[Calcipotriene] cream does not exist anymore; there is only the ointment.

For the patient who does not like greasy treatment but says, ‘I do not want a cortisone,’ this is the only thing you can offer,” she said.

She also said that doctors can try a mix of betamethasone dipropionate topical corticosteroids.

“They only work for a very short period of time,” said Dr. Sibbald. Salicylic acid increases penetration, and he even recommended using petrolatum, which he said has an antipsoriatic effect.

He also suggested that additional supplemental treatments should include local physical modalities, ultraviolet light, biologics and systemic agents.

and calcipotriol.

For hands and feet, she recommended using a “very strong” cortisone, such as halobetasol propionate, clobetasol or betamethasone dipropionate.

She also emphasized that doctors should tell their patients to pay no attention to the percentages listed on the prescription packaging as the potency of the individual corticosteroid matters more.

“They will see .05 per cent [of a high-potency corticosteroid] and think it must be weak and apply that on their face. Or they will see 1 per cent hydrocortisone and … will think that is stronger and apply that on their body, and it does not work.”

Be very clear about which topical is to be used on which part of the body, she said.

That said, Dr. Maari expressed her frustration with topical psoriasis treatments in general.

“We have not had any great topi-

In his list of treatments, he also mentioned methotrexate, although he noted it has B rather than A evidence.

Dr. Sibbald went on to describe the differences between the various topical treatment vehicles for psoriasis: lotions, creams, ointments, patches, pastes and gels.

“We always talk about these terms, but do we really know what

cal treatments … come on the market in the last 20 years,” she said.

Dr. Maari said that for her, the unmet need in psoriasis is more in the mild to moderate range.

“For extensive psoriasis patients, we have great treatment,” she said.

For scale psoriasis, which she said can be difficult to treat, she has found good results with fluocinolone in oil form, although she noted that it is a very greasy treatment.

Finally, she touched on biologic treatments for more extensive cases.

Biologics are very effective treatments with minimal side-effects, she said. The downside is that they are very expensive.

“The problem is they cost $20,000 a year, and the patient needs to be on the treatment forever,” she said.

Despite the cost, biologics can almost completely clear severe psoriasis, she said.

they mean?” he asked the audience.

A lotion is a powder in water, a cream is composed of oil in a continuous water base, an ointment is water with a continuous oil base, a patch is occlusive delivery, a paste is a powder in an ointment and a gel is a powder in a lattice, said Dr. Sibbald.

Ointment vehicles do have an antipsoriatic effect, he noted. He also

Dr. Catherine Maari

warned against compounding a gel.

“A gel is an unstable modality that must not be compounded,” he said.

Common sites where psoriasis manifests or “areas of trauma,” said Dr. Sibbald, include the elbows, knees, scalp and torso. Less common sites include the genitals and the nails. If the nails are involved, he said, be aware that this could point to psoriatic arthritis.

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Clearing of psoriasis plaques may not mean the end of treatment for patients with skin of colour

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Dr. Andrew F. Alexis

n a presentation on psoriasis in pigmented skin delivered at Skin Spectrum Summit in Montreal, Dr. Andrew F. Alexis asked his audience to keep an open mind while diagnosing the skin disorder and to take into account the patient’s concerns about hyperpigmentation.

“You need to really look head to toe at the patient and, if it just does not fit, have a low threshold for biopsy,” he said while referring to a patient with sarcoidosis, which he called “one of the great imitators” of psoriasis in darker-skinned patients.

The quality of life impact of psoriasis can be greater in people with skin of colour, he said, which makes it even more important for a dermatologist to get the diagnosis right the first time and to take into account some cultural and aesthetic concerns as well.

Dr. Alexis explained why the quality of life is impacted more so in people with skin of colour.

Signs of psoriasis

“N

Dr. Jaggi Rao

ail changes may indicate psoriatic arthritis as nails are an extension of the skin itself,” said Dr. Jaggi Rao in a presentation at Skin Spectrum Summit in Vancouver.

Dr. Rao described psoriasis as an immune-mediated chronic in-

“It is probably that the associated pigmentary alterations contribute to a greater quality of life impact,” he said.

Some cultural aspects to perceiving the disease may also play a role, he explained.

To demonstrate this, he showed an example of a patient whose psoriatic scaling had improved with treatment, along with redness and other symptoms, but who was left with hyperpigmented patches on her legs.

“In a research study, she might be considered a treatment success, but in real life, she doesn’t think the treatment is even working because functionally she still can’t comfortably expose her skin.”

Clearing up both plaques and pigment alteration can become part of the treatment in darkerskinned patients, he said. This persistent pigment alteration may lead to a much longer treatment period for patients with skin of colour.

flammatory skin condition that impairs the physical and emotional aspects of an individual’s life. He states that “nothing is destroying or attacking the skin; it has to do with the influence of the immune system to create the reaction we see.” Dr. Rao lists the five main types of psoriasis

28 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

He stated that after clearing the psoriasis, he will start working on the hyperpigmentation with topical bleaching agents.

When it comes to data on the treatment of psoriasis in skin of colour, Dr. Alexis said they are quite limited.

“When you look at all of the studies, there is one consistent theme: the demographics hover around 90 per cent Caucasians.”

For this reason, there are fewer data for patients with skin of colour.

Dr. Alexis said has worked with the data that do exist and has not found any safety or efficacy differences in any of the treatments for psoriasis.

Regarding his clinical impression of treating hyperpigmentation before it becomes a problem, Dr. Alexis said this: “Early and appropriately aggressive treatment might reduce the impact of the severity and duration of hyperpigmentation.”

as psoriasis vulgaris, guttate psoriasis, pustular psoriasis, inverse psoriasis and erythrodermic psoriasis.

Psoriasis vulgaris is the most common as it is seen in 80 to 90% of all psoriasis cases. Guttate psoriasis is caused by the presence of group A streptococcus. Pustular psoriasis, identified through the studded pustules commonly found on palms and soles, and erythrodermic psoriasis, which involves blood vessel dilation (which can change thermal regula-

tion), are both types that require emergency urgent care.

Psoriatic arthritis can be identified through the change in appearance of the nails. Dr. Rao explained that nails “do not have blood vessels but have keratin and different forms of skin cells.” Some changes that occur can be pits and grooves, white-yellow discolouration, separation of the nail from the nail bed, a thickened plate, scales of the nail bed, splinter hemorrhages, pustules

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and more fungal infections. He reported that these symptoms are usually not unilateral and would be visible on the hands and feet.

With psoriatic arthritis, Dr. Rao advised that topical treatments do not work particularly well as the nail functions as a barrier to the treatment. Instead, Dr. Rao suggested injection-based or oral treatments.

Dr. Rao said that in the past, psoriasis would be treated with a series of topical, systemic and phototherapy treatments; however, he now believes in using more aggressive therapies earlier, as long as they’re safe. He cautioned that patients need to qualify for these more extreme treatments, which he does by first using systemic treatments plus light therapy. “If that fails, they qualify to move on to the more intensive treatments,” said Dr. Rao. As with any treatment process and plan, Dr. Rao emphasized that the main goal is patient satisfaction.

Treating scalp Pso in women of African ancestry

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Dr. Andrew F. Alexis

hen treating a woman of African ancestry with psoriasis of the scalp, Dr. Andrew F. Alexis recommends that doctors take into account differences in hair structure and in hair-care practices.

“When prescribing topical therapy in particular, we have got to go an extra step and think about prescribing something that will be compatible with this patient’s hair type and hair-care regimen, especially hair-washing frequency,” said Dr. Alexis in a presentation at Skin Spectrum Summit in Vancouver.

Generally, he said, hair-washing frequency is lower in women of

African ancestry, for a variety of practical and cultural reasons.

Once-weekly or once-everyother-week washing is common, he said.

“To prescribe something that involves washing the hair every single day would not be aligned with this patient’s normal hair-care practices, so we have to come up with a regimen that involves a good compromise.”

He said that this compromise could be something such as onceweekly washing with a medicated shampoo and using potent topical leave-on products on the scalp for the rest of the week.

It is best to get the patient’s feedback on what they would prefer as far as dosing regimen and

Dr. Alexis

vehicle, whether they prefer a water-based, an oil-based or some other formulation, said Dr. Alexis.

“Breaking down the various options and getting the patient’s own input on the selection goes a long way for adherence and better outcomes,” he said.

One product that is particularly well suited for treating scalp psoriasis in this population, he said, is a fixed-combination formulation of calcipotriene and betamethasone.

Among its advantages are that it does not dry out the hair and is easy to leave in without washing.

“However, particularly in more severe cases of scalp psoriasis, we may need to consider non-topical therapies,” he said.

One treatment that is particularly effective against scalp psoriasis is secukinumab, he noted.

In summary, Dr. Alexis said that he advises doctors not to forget to convey to the patient that “you are in with them for the long haul” and to give them realistic timelines.

“Take into account hair-care practices and query patients about traditional cultural practices that may influence the presentation of their disease,” he said.

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Treatment options for rosacea

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Dr. Kevin Pehr

ROSACEA

lthough there is no lab test to diagnose rosacea, there are several treatment options, which Dr. Kevin Pehr discussed during his talk at Skin Spectrum Summit in Montreal.

“If the patient understands therapy-quality conditions, they’re not expecting cure,” Dr. Pehr said.

“It is chronic. It is not adult acne.”

To begin with, Dr. Pehr recommends asking questions to gain an understanding of what is most worrisome to the patient.

“Ask, ‘What aspect bothers you?

Is it the flushing? Is it the broken blood vessels? Is it the itchy feel? Is it the papules and pustules? Is it the eyelids?’ Maybe they all bother the patient, but find out what bothers them the most and focus the treatment on that to start,” he said.

When treating the nose area, Dr. Pehr recommends spraying oxymetazoline nasal spray on the skin twice a day. The relatively inexpensive treatment works about a third of the time, according to Dr. Pehr. Additionally, patients can use brimonidine gel, an alpha-2 agonist, which is applied in the morning and works roughly 80% of the time. The gel lasts about 12 to 13 hours before wearing off.

For erythrotelangiectatic and background erythema, Dr. Pehr sug-

30 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

gests laser therapy or intense pulsed light, but cautions that this treatment is expensive and is not permanent.

There are various options when it comes to treating papules and pustules, including ivermectin, which is expensive but effective.

Azelaic acid can be used for treatment and is also good for post-inflammatory hyperpigmentation but can be a little irritating.

Although, in theory, low doses of systemic antibiotics, such as tretinoin or benzoyl peroxide, will work for the treatment of papules and pustules, Dr. Pehr avoids these treatment options because they are irritating for the patient.

With phyma, or bulging nose, Dr. Pehr says isotretinoin may work as a treatment option, but surgery may be required.

When it comes to ocular rosacea, Dr. Pehr says often patients won’t think to ask their dermatologist about the condition.

“Ask them about it,” he said.

“The patient will not volunteer. They do not feel it is their business, especially in my case. They say, ‘Well, you’re a skin doctor; this is my eye problem. Why say something to you?’”

Dr. Pehr suggests that with “good, hard treatment,” the patient

should see a response within the first two months, but it could take up to six months. It is important that patients understand that the treatment could clear their rosacea symptoms for the rest of their life but that they could also relapse once the treatment stops.

Rosacea management: Early Dx reduces morbidities

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Dr. Maha Dutil

ducation and open dialogue are crucial for doctors helping their patient manage rosacea symptoms, according to Dr. Maha Dutil, who discussed treatment options and things to avoid during her talk on rosacea management at Skin Spectrum Summit in Toronto.

“Early diagnosis and treatment will reduce morbidities,” Dr. Dutil said. “Counsel on skin care, sun protection and [avoiding] triggers. It takes a lot of time, but unless [patients] do all these things, your therapeutic options do not work well.”

There are many topical treatments available to patients, such as metronidazole gel and 1% cream

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and azelaic acid gel 15%, which can be used for both acne and rosacea.

Ivermectin 1% cream and brimonidine gel, which restricts the blood vessels to help reduce redness, can also be used. Benzoyl peroxide, an acne medication, helps papulo, pustular rosacea.

When the disease is more severe, Dr. Dutil suggests using systemic antibiotics. To avoid altering the microbiomes, she says to use only anti-inflammatory doses of doxycycline. Isotretinoin can also be used in treatment. For phymatous rosacea and vascular lesions, lasers can be used. Surgical interventions are also an option for phymatous rosacea.

Dr. Dutil says to avoid using an acne wash with salicylic or glycolic acid as it will aggravate rosacea symptoms. Instead, use a gentle cream. Additionally, sun protection is important. Dr. Dutil suggests using chemical-free sunscreens as chemical sunscreens tend to aggravate rosacea. Also, makeup can help cover the redness of rosacea symptoms.

There is a study showing that an antimicrobial dose of doxycycline can produce similar efficacy and safety in skin types IV to VI as well as skin types I to III. “Prescribe effective treatments, topically and systemically, if needed,” said Dr. Dutil. “Let’s reduce the disparities in rosacea management.”

Rosacea underreported, underdiagnosed in patients with skin of colour

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Dr. Monica K. Li

he management of rosacea in light and dark skin types is very similar according to Dr. Monica K. Li, who presented on strategies to manage rosacea symptoms at Skin Spectrum Summit in Vancouver.

“Unfortunately, because the entity itself is underreported and underdiagnosed in those with skin of colour, there is not a lot of data specifically looking at management, and the efficacy of management strategies for this patient population,” Dr. Li explained.

With the increased risk of post-inflammatory hyperpigmentation in darker-skinned patients, physicians and clinicians need to be vigilant when implementing lasers and light-based therapies to ensure that this patient population does not experience potential adverse effects as much as possible.

The goal of rosacea management is to reduce papules and pustules in patients, which can reduce the chronic inflammation occurring on the face, leading to potential scarring and post-inflammatory hyperpigmentation.

When using laser and light therapies, the goal is to reduce superficial capillaries and to resurface the possible phymatous changes that can result as rosacea progresses.

Dr. Li cautions practitioners to be careful when choosing laser and light therapies for darker skin phototypes because there is an increased risk of post-inflammatory hyperpigmentation that can result as a sequela of these interventions.

“I use a long-pulse 1064 nm laser, Nd:YAG. We can also use a 595 nm pulsed dye laser to reduce the diffused redness that can be seen on the face,” said Dr. Li.

“Because of the chronic nature of rosacea, usually a series of treatments are required every one to two years to improve some of the facial redness and symptoms experienced by darker-skinned patients.”

For supportive measures to help both fair- and dark-skinned patients, it is important to avoid triggers such as spicy foods, alcohol and sun exposure when possible.

Additionally, dermatologists should be advising and helping patients to use photoprotection, particularly with physical agents containing zinc oxide and titanium dioxide, consistently. The use of bland emollients and moisturizers is important because essentially all patients with rosacea have hypersensitive skin.

When using a new skin-care product, patients should apply the product to a test-spot area for a week to determine tolerance prior to more generalized application of the product on the entire face.

Patients should be counselled to use physical blockers as opposed to chemical blockers. Chemical blockers can be more irritating to rosacea patients with sensitive skin. Also, patients should avoid alcohol-based exfoliating products (astringents), which can further drive the redness and irritation on facial skin.

Established options for rosacea management include an oral 40 mg subantimicrobial-dose doxycycline taken once daily. Studies show that this treatment method has similar efficacy and safety for skin phototypes I to III, as well as those with phototypes IV to VI. In the U.S., a topical oxymetazoline cream is available for the treatment of facial redness in both lighter and darker skin phototypes.

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When brown patches are not melasma

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Dr. Andrew F. Alexis

MELANOMA, SUN PROTECTION

n a presentation titled “Diagnoses Not to Miss” at Skin Spectrum Summit in Toronto, Dr. Andrew F. Alexis sorted through a number of cases in which his patients exhibited pigmentation symptoms that could easily be misinterpreted as more common diseases at first glance due to their fairly standard appearance.

In some cases, skin hyperpigmentation can be brought on by unusual skin-care regimens or reactions to other therapies, he said.

“When one is presented with symmetrical brown patches on the face, the diagnosis is usually melasma, but not always.”

He outlined a number of cases in which these brown patches turned out to be something different than expected.

Dr. Alexis proceeded to discuss a

32 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

case involving a 53-year-old AfricanAmerican woman with brown patches on her face, which he said is a very common complaint. He described her patches, which appeared on the cheek and temple, as being brown with a purplish-grey hue. She also had a past medical history of hypertension, for which she was prescribed diltiazem.

“What else can it be?” he asked the audience.

It turns out that diltiazem triggered a photodistributed lichenoid drug eruption, he said.

“After identifying the causative agent — diltiazem in this case — discontinuing it and switching to a chemically unrelated antihypertensive, she got better,” he said.

He noted that this purplish-grey photodistributed lichenoid drug eruption could also be caused by therapies such as antimalarials, thiazide diuret-

ics, furosemide, ethambutol and tetracycline.

“When you see dark patches on the face that aren’t quite brown but [are] more greyish blue or lichenoid looking, consider photodistributed lichenoid drug eruption,” he said.

He used other examples to give an idea of the process he went through to find the correct diagnosis.

One case involved a woman with post-inflammatory hyperpigmentation brought on by months of harsh scrubbing of her facial area “in an effort to even her skin tone,” said Dr. Alexis.

“She was trying to treat hyperpigmentation but induced hyperpigmentation from her very irritating skin-care regimen,” he said.

A second case he noted was a patient with lichen planus pigmentosus, which tends to be in a photodistributed area, he said. Characteristics include bluish-grey pigmentation on the face, head and neck.

He used these cases as a lesson to the audience to be thorough in their investigation of the causes of a patient’s symptoms.

“When thinking about the common things we see in patients of colour, it is easy to get into a little bit of a rut. Not every brown patch on the face is melasma, and not every white patch is vitiligo,” he said.

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The three basic methods for sun protection

T

Dr. Sunil Kalia

he three basic forms of sun protection are seeking shade, wearing protective clothing and using sunscreen, but it is not always that simple, according to Dr. Sunil Kalia.

In his presentation at Skin Spectrum Summit in Vancouver, Dr. Kalia went over the finer details of each form of protection.

Since the ozone layer protects from UVC, UVB and UVA are the most worrying because they can cause skin cancer, he said.

“UVB can cause direct DNA damage, and UVA can cause indirect DNA damage,” said Dr. Kalia.

Moreover, unlike infrared light, UV light is not warm, so it cannot be felt. UVB peaks around the noon hours, so much of the key messaging for skin protection centres around avoiding sun exposure between 10 a.m. and 3 p.m., he said.

According to Dr. Kalia, simply avoiding the sun during these times is the most effective way to protect against damage. But if that is not possible, wearing protective clothing and sunglasses and using sunscreen are the next best options, in that order.

“Clothing gives good protection, but what is the protection factor of something like a thin white Tshirt? It’s equivalent to an SPF of about five,” he said.

Although that is not adequate, the T-shirt cannot be wiped off and does not have to be reapplied, he said. For clothing, he recommends darker shades, heavier fabrics and tighter weaves. The type of fabric matters too.

“Polyester, wool, then cotton,” he said. “For a pair of jeans, the protection factor on that is 200 SPF, which is amazing, but, of course, it is hard to wear that thick pair of jeans when it is really hot.”

Although it is more expensive, UV protection factor clothing also exists. This brought him to the sub-

Dr. Sunil Kalia

You are invited to join us at the 2020 Summit and receive a discount on registration fees.

ject of sunscreens.

“When you see the sunscreen bottle, what are you looking for?” he asked.

Most people look for SPF, but that is not the only factor to consider, he said. UVA protection is also another important factor to consider.

Although many sunscreen bottles will tell you to apply 15 to 30 minutes before sun exposure, Dr. Kalia said that is not necessary. Applying just before going out will still work.

He also said that most sunscreens recommend that the user reapply them every two hours, but that is just an arbitrary number. It is better to reapply sunscreen based on perspiration, if or when it is wiped off or after swimming, he said.

It is also not necessary to rub it in deeply, he said. A light application is sufficient.

Finally, he recommends using two tablespoons of sunscreen for the full body and half of one teaspoon for the face.

“That’s quite a bit of sunscreen,” he said. “You could be going through a whole bottle of sunscreen in one day if you’re doing it properly.”

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Sickle cell disease may complicate ulcers in patients of colour

I

Dr. Brian Kunimoto

WOUND MANAGEMENT

that cells pile up. n his presentation at Skin Spectrum Summit in “They get very sticky,” he said. “Red blood cells stick toVancouver, Dr. Brian Kunimoto spoke about sickle gether, they stick to platelets, they stick to white cells and cell disease and its complicating effects on venous they stick to the walls of the vessels.” leg ulcers or livedoid vasculopathy in patients of This causes an increase in blood viscosity, which can colour. trigger thrombotic events.

“Clinically, in dermatology, we see patients who have ex“Thrombosis in the vessels becomes a real problem tremely painful venous ulcers,” he said. with plugging and potentially something known as vascuThese ulcers can lead to a drastic decrease in quality of lopathy,” he said. life. A person with venous insufficiency can develop hypoxia Because of all this, ischemic injury can occur, which can around the ankles, and this can trigger a sickle cell crisis, he lead to reperfusion injury and a severe stimulation of insaid. flammation, he said.

“Which really is a vicious circle because you get the hyA patient with ischemic changes may develop livedoid poxia, you get the ulceration and then you get the sickle cell vasculopathy, which Dr. Kunimoto said is less common. crisis, which causes more hypoxia, and it just goes around Livedoid vasculopathy looks very different, he said. The and around,” he said. ulcers can look irregular in shape. When they heal, they heal Dr. Kunimoto explained the difference between sickle with atrophie blanche, which is associated with dilated cell trait and sickle cell disease. blood vessels and pigmentation, he said.

“Sickle cell trait is when the situation is heterozygous, In managing a venous leg ulcer, he said first rule out arand it is an autosomal recessive inheritance of a single terial disease by doing an arterial Doppler ultrasound. Then amino acid substitution in the beta globin protein as part of concentrate on local wound care, which involves periwound hemoglobin,” he said. protection.

Patients who are heterozygous “A lot of them drain a lot of have sickle cell trait. Patients who are fluid, so you have to select a good homozygous have sickle cell disease, moisture balance dressing,” he he said. said. He also emphasized the use Approximately 300,000 infants of compression bandaging. worldwide are born with sickle cell “If your patient has sickle cell disease each year, he said, the majordisease, make sure you consult ity coming from central Africa. with a hematologist because all of “This is truly a genetic disorder the conditions are comorbidities that affects people of colour,” he said. that a hematologist can really help According to Dr. Kunimoto, one with,” he said. of the effects of sickle cell disease is Dr. Brian Kunimoto

34 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

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Risk factors for diabetic foot ulcers and what to look for in an initial foot exam

I

Mariam Botros

n her presentation in Montreal at Skin Spectrum Summit, Mariam Botros outlined some risk factors for diabetic foot ulcers and amputation, as well as what doctors should be looking for in their initial diabetic foot exam.

According to Diabetes Canada, 11 million Canadians live with diabetes and prediabetes, she said.

Foot ulcers are also costly to treat, she said, so doctors should concentrate on trying to prevent it.

According to Botros, 85% of diabetic foot ulcers and amputations are preventable.

“If we can’t prevent it, we want to manage it appropriately,” she said.

Neuropathy is the “key permissive factor” for the development of diabetic foot ulcers, she said. This is because once patients lose the ability to sense pain in their feet, the skin breaks down quickly.

In searching for a systematic approach to preventing foot ulcers, she said that doctors need to start by going back to assess the patient.

One alarming symptom to take note of would be pain in a neuropathic foot, which means an infection is quite advanced, she said.

Another red flag is finding exhibited inflammatory signs, which could indicate that the infection is progressing.

Other risk factors for ulcers and amputation are a history of amputation or ulcers, she said. In addition, Dr. Botros mentioned peripheral neuropathy, foot deformity, peripheral arterial disease, diabetic nephropathy, diabetic retinopathy, poor glycemic control, smoking, inappropriate footwear and other psychosocial considerations.

When doing a diabetic foot exam, she recom-

Miriam Botros

mends looking at a few key categories: skin and nails, peripheral neuropathy, peripheral arterial disease, bone deformity and footwear.

“These are the categories that we want to see addressed in a diabetic foot exam,” she said.

Callouses increase pressure on the foot, so debriding the callous is always a good idea, she said.

They’re not there to protect the wound, contrary to some misconceptions, she said. Deformity can also increase the pressure rate.

Investigating for fungal infection is also a key part of the diabetic foot exam, she said, emphasizing that doctors check first between the fourth and fifth toe web space.

A vascular examination is also recommended, as well as checking for loss of sensory perception in the foot.

Botros also recommends that doctors make sure their patients are wearing appropriately supportive footwear. Whether the footwear is too large or too small, it can cause friction, which could result in a diabetic foot ulcer, she said.

Once the foot exam is complete, she said that the attending doctor must categorize the risk level. If the risk is urgent, the doctor must address patients by either treating them themselves or referring them to a multidisciplinary team.

Patients who have undergone lower limb amputations have lower quality of life, high rates of depression and loss of productivity, she noted. For this reason, she said, preventive measures and noting red flags early are keys to preventing amputation and ensuring a higher quality of life.

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Improve diagno $GRSW VWUDWHJLHV DQG WRROV WR EHWWHU PDQDJH SDWLHQWV ZLWK VNLQ RI FRORXU DQG WKH SRWHQWLDO XQLTXH challenges that they may face in their treatment. eatment.

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