The Chronicle of Skin & Allergy - Dec 2024

RACTICAL T HERAPEUTICS and C LINICAL N EWS from the W ORLD of D ERMATOLOGY n D ECEMBER 2024

2024: Year in r eview

? Topicals and oral therapies advancing the specialty in 2024 see page 4

Clinical practice

Diagnosing and treating AKs in 2024

n Transplant recipients require a higher degree of clinical suspicion

by LOUISE GAGNON, Correspondent, The Chronicle

Identifying patients at greatest risk of squamous cell carcinomas (SCCs) after developing an actinic keratosis (AK), effective treatment of AKs, attention to diagnosis and treatment of AKs in patients with skin of colour, and the newest form of photodynamic therapy (PDT) are all topics that are top of mind for Canadian dermatologists who regularly diagnose and manage AKs.

“For every one [AK] that we see on the surface, there are five

Acne therapy

Hormonal

or so that are subclinical and present in the background,” said Dr. Ilya Shoimer, a dermatologist and Mohs micrographic surgeon and Clinical Assistant Professor at the University of Calgary. “I think when we have a solitary lesion, the first thing we need to do is get the correct diagnosis.”

A thin AK is managed differently from a hypertrophic AK, managed differently

and

antibiotic agents vs. oral isotretinoin

n Anti-hormonal Tx should be considered

by LOUISE GAGNON, Correspondent, The Chronicle

Isotretinoin is one of the most effective oral therapies for severe or resistant acne as it addresses most of the pathogenic factors, Dr. Jaggi Rao told the 2024 Acne Summit. However, it does not address the effect of hormones, and so needs to be supplemented with an anti-hormonal therapy.

from a squamous cell carcinoma (SCC) in situ, and managed differently from an invasive SCC. “We need to know if it is actually an actinic keratosis or something more sinister,” said Dr. Shoimer, noting a biopsy may be warranted to rule out the presence of an invasive SCC

In terms of treating AKs, Dr. Shoimer noted options include 5fluorouracil or various concentrations of imiquimod (5% and 3.75%) or use of 5-fluorouracil with a Vitamin D analog.

“That is a good option [fluorouracil and a Vitamin D analog]

by LOUISE GAGNON Correspondent, The Chronicle

The use of topical roflumilast cream 0.3% in the treatment of psoriasis provides relief from symptoms and eases distress for patients with the chronic condition, according to data from a study presented in poster format at the annual meeting of the American Academy of Dermatology in San Diego.

“The advantage of roflumilast cream is that it has an excellent tolerability profile,” said Dr. Irina Turchin.

“There is no or very minimal application site burning [in the majority of patients], even on the genital area or in the skin folds, so patients are able to apply the cream with no concerns about discomfort.” She is Medical Director, Brunswick Dermatology Center, Fredericton, N.B.

Poster outlined Dr. Turchin was one of the investigators and co-author of the poster presented, which captured patientrelated outcomes in patients who had plaque psoriasis that affected anywhere from two to 20% of their body surface area. The research was sponsored by Arcutis Biotherapeutics, Inc.

Dr. Ilya Shoimer

Dr. Irina Turchin

Pr CABTREO

THE FIRST + ONLY TRIPLE COMBINATION TREATMENT

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CABTREO (clindamycin phosphate, adapalene, and benzoyl peroxide) is indicated for the topical treatment of acne vulgaris in patients 12 years of age and older.

CLINDAMYCIN

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Consult the Product Monograph for complete details on recommended dosing and administration.

Scan here to learn more about CABTREO

Consult the Product Monograph at https://bauschhealth.ca/wp-content/uploads/2024/08/CABTREO-PM-E-2024-08-01. pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use. The Product Monograph is also available by calling 1-800-361-4261.

TOP of the MONT H

Hormonal and antibiotic agents vs. oral isotretinoin

During the 2024 Acne Summit, Dr. Jaggi Rao discussed hormonal and antibiotic agents as compared to oral isotretinoin. .

2024: Year in review

. . 1

A Message from the Medical Editor

IResearch

Skin of colour diagnosis by medical students remains poor, study shows

4

Canadian dermatologists highlight therapies approved in 2024, noting that the past year will be remembered for approvals of therapies that addressed multiple dermatologic conditions

Vender on PsO:

Biologic treatment sequences in moderate-to-severe PsO

Also, a study examined switching between biologic and targeted synthetic disease-modifying antirheumatic drugs. It was found that switching between b/tsDMARDs is common over time in PsA patients 8

Chronicle Postgraduate Educational Supplement

Findings from a survey (Skin Health and Disease (Sept. 3, 2024)) show a need for changes in the preclinical dermatology curriculum to improve diagnostic ability and representation of skin of colour (SOC) images in educational resources.

swers 61.73% and 66.20% (p=0.28)). There was no statistically significant differences between the White and the SOC image surveys for students who identified as persons of colour (POC) versus those who did not.

n this issue of THE CHRONICLE OF SKIN & ALLERGY, we’re focusing on the many highlights of this historic era in dermatology. The lifechanging advances in therapeutic innovations we are witnessing are impacting our daily practice and bringing much needed treatment to our patients with unmet needs.

In this issue’s postgraduate educational supplement, American researchers assess dermatology residents' comfort level in recognizing and treating various common hair conditions with a focus on those specific to Skin of Colour (SOC). Researchers found that there are knowledge gaps in understanding hair-related care for patients with SOC.

First- and second-year medical students at the University of Arizona College of Medicine-Phoenix (UACOMP) completed a quiz including 15 multiple-choice questions assessing dermatologic diagnostic ability and three Likert scale questions asking participants to rate their confidence level in identifying dermatologic conditions in SOC and the diversity of dermatologic resources. Only 15% of the total images in UACOMP’s preclinical lectures represent SOC.

19

The students performed similarly well on the White and SOC image surveys (mean correct an-

December 2024 • Vol.

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Students were more likely to identify psoriasis (p=0.004), varicella zoster (p=0.004), and melanoma (p=0.01) on White skin and neurofibroma (p=0.004) and tinea versicolour (p=0.004) on SOC.

Second-year medical students scored better overall (p=0.01) and on the White image survey scores (p=0.02) but not on POC image survey scores (p=0.09)

The students were more comfortable identifying diagnoses on White skin (Likert scale=4.05) and agreed more opportunities to identify common skin lesions on SOC would enhance their medical education (Likert scale=4.56).

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“We have to really stay on top of things and treat the actinic keratosis more aggressively in order to prevent progression to squamous cell carcinoma.”

Dr. Ilya Shoimer, a dermatologist and Mohs micrographic surgeon and Clinical Assistant Professor at the University of Calgary.

Since its introduction, roflumilast has been a game-changer for our patients with psoriasis. Now, with the new foam formulation and an indication for eczema, roflumilast will be a go-to therapeutic in our clinical armamentarium (see page 1).

The new JAK inhibitors that are on the way for hand eczema, eczema, and vitiligo are gaining traction as well. Getting the therapies to patients has not been as seamless as for roflumilast but progress is being made. When it comes to alopecia areata, baricitinib has been a game-changer as well. To date, the majority of my AA patients are very pleased with the outcome. Topical JAKs, especially

Medical Editor Wayne Gulliver, MD, FRCPC

John P. Arlette, MD, FRCPC

Benjamin Barankin, MD, FRCPC

Marc Bourcier, MD, FRCPC

Eric Goldstein, MD, FRCPC

Peter Hull, MD, FRCPC

Richard Langley, MD, FRCPC

Danielle Marcoux, MD, FRCPC

Editor, Cosmetic Dermatology Sheldon V. Pollack, MD, FRCPC

Kim Papp, MD, FRCPC

Yves Poulin, MD, FRCPC

Melanie D. Pratt, MD, FRCPC

Denis Sasseville, MD, FRCPC

Jerry Tan, MD, FRCPC

Ronald B. Vender, MD, FRCPC

R.A.W. Miller, MD, FRCPC H. Eileen Murray, MD, FRCPC

Founding Editor Colin A. Ramsay, MD, FRCPC (1936-2003)

Associate Editor Mitchell Shannon

Editorial Director R. Allan Ryan

Senior Editor John Evans

Assistant Editor Darren Stallman, Jeremy Visser

Client Engagment Cristela Tello Ruiz

Please turn to Message page 6→ Assistant

Publisher

Joyce Pitters-Hinds

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Clinical practice 2024: Ye a r i n r e v i e w

? Topicals and oral therapies advancing the specialty in 2024

by LOUISE GAGNON, Correspondent The Chronicle

Canadian dermatologists agree that 2024 will be remembered as a year in which there were approvals for therapies that can be used for more than one condition, such as ruxolitinib to treat vitiligo and mild atopic dermatitis (AD), and roflumilast foam 0.3% to treat seborrheic dermatitis and scalp psoriasis.

First treatment indicated for vitiligo doubles as AD therapy Dermatologists are encouraged by the approval of the topical Janus kinase (JAK) inhibitor ruxolitinib, because it is the first on-label treatment for non-segmental vitiligo.

Toronto dermatologist Dr. Sam Hanna, Medical Director of Dermatology on Bloor in Toronto, noted the

approval of the non-steroidal topical has been garnering a lot of interest among the dermatology community.

“This has really caught people’s attention,” said Dr. Hanna. “It is the first thing ever that’s been approved for vitiligo. That marks quite a revolution [in vitiligo treatment].”

Dr. Hanna added that this therapy will also meet an unmet need in AD.

“It was shown to be effective and well-tolerated in atopic dermatitis, and it is nice to have options for limited disease,” said Dr. Hanna. “You are not necessarily going to use this for somebody with 80 per cent body surface area coverage [with AD], but you would for somebody with more limited disease, or disease in places where you

may want to avoid using steroids, like the face and folds.”

Fiona Lovegrove, MD, PhD, Medical Director at Lovegrove Dermatology in London, Ont., noted that her patients with vitiligo are very excited about the availability of ruxolitinib as a treatment.

“I have a list of patients who want to use it [ruxolitinib],” said Dr. Lovegrove. “Everything else we use is off-label. We usually cycle between topical corticosteroids and topical calcineurin inhibitors, and those are all off-label treatments. People who have access to it will do phototherapy, but we don't have much phototherapy in our [geographic] area.”

Yuka Asai, MD, PhD, a dermatol-

Dr. Sam Hanna

Dr. Yuka Asai

Dr. Fiona Lovegrove

Dr. Benjamin Barankin

When your patient presents with moderate-to-severe plaque psoriasis,

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TREMFYA® is also indicated for the treatment of adult patients with active psoriatic arthritis. TREMFYA® can be used alone or in combination with a conventional disease-modifying antirheumatic drug (cDMARD) (e.g., methotrexate).1

TREMFYA® provincial funding is now available in most provinces for patients with PsO or PsA.1,2-10 * Restrictions may apply. Refer to the respective provincial listings for full coverage details and restrictions. 2-10 *

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The Product Monograph is also available by calling 1-800-567-3331.

PsO=psoriasis; PsA=psoriatic arthritis.

* Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario (EAP or Limited Use code required), Prince Edward Island, Saskatchewan. Please refer to the respective listings for coverage information and restrictions.2-10

References: 1. TREMFYA®/TREMFYA ONE-PRESS® (guselkumab

The image depicted contains models and is being used for illustrative purposes only.

2024: JAK inhibitors for alopecia and acne

Continued from page 4

ogist and Associate Professor, Division of Dermatology, Department of Medicine, Queen’s University in Kingston, Ont., pointed out the benefit of having a non-steroidal option to treat vitiligo as well as mild-to-moderate AD.

“It’s really nice to have a drug that is effective and on-label for that disease [vitiligo],” said Dr. Asai. “We have had nothing until now. I think it is great, and both vitiligo and AD tend to affect the face. Having a product where you don't have to worry about [eye pressure and] glaucoma or skin atrophy in locations such as the face is reassuring.”

Toronto dermatologist, Medical Director and Founder of Toronto Dermatology Centre, Dr. Benjamin Barankin noted that clinical study of the topical agent has been encouraging. “This has actually been properly studied, and it works and it is safe,” he said.

Elegant option for seborrheic dermatitis and scalp psoriasis

The approval of roflumilast foam 0.3% in Oct. 2024 signals a breakthrough in the treatment of

seborrheic dermatitis, a condition for which there were no on-label treatments, while also offering relief for patients with scalp psoriasis.

“I have been looking forward to it for quite some time,” said Dr. Hanna. “For somebody with a significant seborrhea or psoriasis in a hair-bearing area like the scalp, this is a very elegant foam with an effective molecule that we're now familiar with. [Roflumilast] is well-tolerated and safe.”

A foam provides ease of application that is very appealing and using a non-steroidal treatment does not introduce concerns around possible adverse events, according to Dr. Barankin.

“It is once a day, and it is elegant,” said Dr. Barankin. “You can use it on your face and your scalp. It is not a steroid, so you are not worried about possibly affecting [patients’] eye pressures and conditions like glaucoma.”

There is overlap between seborrheic dermatitis and psoriasis, and the conditions can cooccur, a phenomenon that dermatologists refer to as sebopsoriasis.

“They overlap so much that we have the term sebopsoriasis,” explained Dr. Asai, stressing

Message from the Medical Editor

Continued from page 3

delgocitinib, the hand eczema product from LEO, may have promise for challenging eruptions such as frontal fibrosing alopecia.

Two other articles I would like to bring to your attention to is a report by Dr. Jaggi Rao at Chronicle’s Acne Summit earlier this year where he reviews current approaches to acne (see page 1). Newer products such as clascoterone are helping, while older standbys such as isotretinoin, doxycycline, spironolactone, and oral contraceptives continue to play an important role.

The other article of importance in this issue is related to the management of AKs (see page 1). As we know there is a skin cancer epidemic now afflicting Canada. I’ve never seen so many

aggressive SCCs in the transplant and nontransplant population. It seems we are fighting a losing battle but it is always very important to revisit the diagnosis of treatment of AKs in 2024 so that we are armed with the best tools to fight this epidemic

I’d like to wish the Chronicle’s readership health and happiness in 2025. Stay tuned for even more excitement to come in 2025 on both the research and therapeutic fronts. Also, THE CHRONICLE OF SKIN & ALLERGY will be marking its 30th year of continuous publication, and we’ll have some special topics in store.

As always, THE CHRONICLE team invites and welcomes your comments on this issue, or any other topic in dermatology, at www.derm.city.

—Wayne P. Gulliver, MD, FRCPC, Medical Editor

roflumilast foam is the first on-label treatment for seborrheic dermatitis. “Foam as a delivery method is a lot better [than cream], particularly for hair-bearing areas. It is a nice type of delivery because we will be able to get to the scalp. This foam will work for both seborrheic dermatitis and scalp psoriasis.”

Clinicians have used therapies such as calcineurin inhibitors off-label for seborrheic dermatitis, making the addition of roflumilast foam a welcome new tool.

“Like vitiligo, seborrheic dermatitis is another chronic condition where we have not had any approved therapies to date,” said Dr. Lovegrove. JAK inhibitors for alopecia and a new treatment for acne

Patients with severe alopecia areata now have oral therapies, such as baricitinib and ritlecitinib, that are indicated for their condition, according to Dr. Barankin.

“These are the first approved agents that actually offer meaningful benefit,” said Dr. Barankin. “The current therapies we offer really had significant gaps in benefit and efficacy.”

A new addition to the acne tool box is a triple therapy topical combination that includes an antibiotic (clindamcyin phosphate), adapalene (a retinoid), and benzoyl (an antibacterial agent), which was approved by Health Canada in Sept. 2024.

“We have had numerous dual therapies for years,” said Dr. Barankin. “It is the first-ever triple therapy, and it appears to be well-tolerated and superior to the dual therapies. It is probably the most potent topical therapy for acne that we have ever had.”

Non-proprietary and brand names of therapies: ruxolitinib (OPZELURA, Incyte Biosciences Canada); roflumilast foam/cream 0.3% (ZORYVE, Arcutis Biotherapeutics); baricitinib (OLUMIANT, Eli Lilly Canada); ritlecitinib (LITFULO, Pfizer Canada); topical clindamycin phosphate/adapalene/benzoyl peroxide (CABTREO Topical Gel 1.2%/0.15%/3.1%, Bausch Health, Canada Inc.).

In moderate to severe plaque psoriasis

H I S S I G H T S

A R E S E T O N SKIN CLEARANCE*

PrBIMZELX® (bimekizumab injection) is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.1

SUPERIOR SKIN CLEARANCE (PASI 100) DEMONSTRATED VS. SECUKINUMAB AT WEEK 16

In the BE RADIANT trial, BIMZELX achieved both non-inferiority and superiority for percentage of patients achieving complete skin clearance (PASI 100) at Week 16 vs. secukinumab†,2

• 62.0% (230/373) of BIMZELX patients achieved a PASI 100 vs. 49.0% (181/370) of secukinumab patients (adjusted risk difference: 12.7%; 95% CI: 5.8–19.6; p<0.001)

In the BIMZELX arm, patients were treated with Q4W dosing up to Week 16, before being initiated with Q8W maintenance dosing.

DISCOVER BIMZELX

NOW INDICATED IN PSORIATIC ARTHRITIS

PrBIMZELX® (bimekizumab injection) is indicated for the treatment of adult patients with active psoriatic arthritis. BIMZELX can be used alone or in combination with a conventional non-biologic disease-modifying antirheumatic drug (cDMARD) (e.g. methotrexate).

CI: confidence interval; PASI 100: 100% improvement from baseline in Psoriasis Area and Severity Index; Q1W: every week; Q4W: every four weeks; Q8W: every eight weeks

*Fictional patient. May not be representative of the general population.

†BE RADIANT: A phase IIIb multicentre, randomized, double-blind, active comparator-controlled study comparing the efficacy and safety of BIMZELX vs. secukinumab in adult patients with moderate to severe plaque psoriasis (N=743). Patients were randomized 1:1 to BIMZELX 320 mg Q4W through Week 16 (n=373), or secukinumab 300 mg Q1W through Week 4 followed by secukinumab 300 mg Q4W through Week 48. Patients who completed the 48-week double-blind period could enrol in an ongoing 96-week open-label extension period. At Week 16, patients receiving BIMZELX 320 mg Q4W were re-randomized 1:2 to receive either BIMZELX 320 mg Q4W (off-label maintenance arm) or 320 mg Q8W through Week 48. The primary endpoint was 100% reduction from baseline in the PASI score at Week 16.

Conditions of clinical use:

• Not authorized for use in pediatrics (< 18 years of age)

Relevant warnings and precautions:

• Inflammatory bowel disease

• Serious hypersensitivity reactions

• Vaccinations

• Infections, including tuberculosis

• Pregnant or nursing women

• Women of childbearing potential

For more information:

Please consult the Product Monograph at https://www.ucbcanada.ca/en/bimzelx for important information relating to adverse reactions, drug interactions, and dosing information that has not been discussed in this piece. The Product Monograph is also available by calling 1-866-709-8444.

References: 1. BIMZELX Product Monograph. UCB Canada Inc. March 11, 2024. 2. Reich K, Warren RB, Lebwohl M, et al. Bimekizumab versus secukinumab in plaque psoriasis. N Engl J Med. 2021;385(2):142–152.

Vender on Psoriasis

Ronald B. Vender, MD, FRCPC comments on recent findings and developments, and answers clinicians’ questions

Biologic treatment sequences in moderate-to-severe PsO

This retrospective study examined biologic treatment sequences in moderate-to-severe psoriasis across two tertiary centers in Australia from 2006 to 2020 (Australas J Dermatol). The researchers analyzed 440 treatment courses from 263 patients, investigating patterns of biologic switching, reasons for switching, and treatment efficacy

Ustekinumab and adalimumab were the most frequently prescribed first-line biologics overall. However, after 2015, there was a shift toward increased use of IL-12/23 and IL-17 inhibitors as first-line treatments. TNF-α inhibitors showed the highest rate of switching (63.8%), while IL-23 inhibitors had the lowest attrition rates.

The study revealed that patients who did not switch biologics had lower BMI (mean 29.8 vs. 32.7) and lower rates of psoriatic arthritis (24.4% vs. 47.7%) compared to those who switched. The median PASI score at discontinuation generally exceeded 3.0, while it was below 1.2 for patients continuing treatment, suggesting these as potential thresholds for considering biologic switches.

IL-17 inhibitors demonstrated the most rapid treatment response, achieving PASI-90 and PASI-100 faster than other biologic classes. Biologic-experienced patients on IL-17 inhibitors who continued treatment had the lowest median absolute PASI of 0.0.

The main reasons for switching biologics were loss of efficacy (36.0%) and lack of efficacy (31.4%). Patients with higher BMI were more likely to switch due to efficacy issues or psoriatic arthritis flares. Adverse events were most common with TNF-α inhibitors.

This study provides valuable insights into real-world biologic treatment patterns in Australia, highlighting the increasing use of newer biologics like IL-17 and IL-23 inhibitors due to their rapid onset of action and efficacy. It also identifies factors associated with biologic switching, such as BMI and psoriatic arthritis, which can guide clinical decision-making.

Limitations include the small sample size, limited data on newer biologics, and potential variability in switching practices. The authors suggest that larger-scale, long-term studies are needed to further elucidate optimal treatment sequencing for clinical guidelines.

This retrospective study provides valuable insights into biologic treatment patterns for moderate-to-severe psoriasis in Australia from 2006 to 2020. It highlights a shift toward using IL-17 and IL-23 inhibitors as first-line treatments due to their rapid efficacy and lower switching rates compared to TNF-α inhibitors. The study also found that patients who did not switch biologics had lower BMI and less psoriatic arthritis, indicating these factors may predict better treatment outcomes.

IL-17 inhibitors stood out for their quick achievement of PASI-90 and PASI-100 and sustained low PASI scores in biologic-experienced patients. The main reasons for switching biologics were loss or lack of efficacy, particularly among patients with higher BMI or psoriatic arthritis.

While the study offers important real-world data, its limitations—such as the small sample size and limited data on newer biologics—highlight the need for further largescale studies to refine treatment sequencing and improve clinical guidelines.

Switching related to inefficacy in biologics and targeted synthetic therapies for PsA

This retrospective observational study (Therapeutic Advances in Musculoskeletal Disease) examined switching between biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) due to inefficacy in patients with psoriatic arthritis (PsA). The study included 141 PsA patients treated with b/tsDMARDs at a rheumatology outpatient clinic in Madrid from 2007 to 2022.

A total of 56 patients (40%) experienced 121 switches between b/tsDMARDs, with 103 switches due to inefficacy. The researchers found that:

The incidence rate of switching due to inefficacy was 11.53 per 100 patient-years.

• 20% switched due to inefficacy in the first year, increasing to 32% by the second year. Median drug sur-

• vival was almost five years.

In bivariate analysis, all b/tsDMARDs had higher risk of switching compared to TNF inhibitors. However,

this was no longer significant in multivariate analysis after adjusting for confounders.

The researchers noted that factors associated with increased risk of switching due to inefficacy in multivariate analysis included: female sex, calendar time (increased risk from 2019 onward), presence of inflammatory back pain; concomitant use of glucocorticoids or sulfasalazine; and higher number of previous b/tsDMARD courses.

According to the study, TNF inhibitors and IL17 inhibitors showed similar efficacy in real-world use.

The authors conclude that switching between b/tsDMARDs is common over time in PsA patients, with inefficacy being the primary reason. They found no significant differences in switching risk between different b/tsDMARD groups after adjusting for confounders. Clinical factors such as inflammatory back pain, female sex, and number of previous treatments were stronger predictors of switching than the specific b/tsDMARD used.

The study provides valuable real-world data on long-term b/tsDMARD use and switching patterns in PsA. Limitations of the study include the retrospective design and lack of standardized disease activity measures. Strengths include the long follow-up period and ability to adjust for multiple confounders. The findings may help guide treatment decisions and expectations regarding b/tsDMARD efficacy and durability in clinical practice.

A study published in Therapeutic Advances in Musculoskeletal Disease (2024) examined switching between b/tsDMARDs in psoriatic arthritis (PsA) patients due to inefficacy. Among 141 patients, 40% switched treatments, with inefficacy being the main reason. The risk of switching was higher in the first two years, with factors like female sex, inflammatory back pain, and prior treatments increasing the likelihood. TNF inhibitors showed similar efficacy to IL-17 inhibitors. The study provides real-world insights into the long-term use of b/tsDMARDs in PsA, although limitations such as its retrospective design and lack of standardized disease activity measures were noted. These findings could help inform treatment decisions and expectations for b/tsDMARD efficacy and durability in clinical settings.

• We invite your comments and questions about this feature at www.derm.city. Dr. Ron Vender is a certified dermatologist with more than 30 years of clinical practice experience and over 100 clinical trials in psoriasis. He is founder and director of Venderm Innovations in Psoriasis, a center of excellence for Psoriasis offering a comprehensive management solution for individuals with psoriasis. www.psoriasis.vip

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Topical: Roflumilast minimizes risk of irritation

Continued from page 1

Investigators used the Worst-Itch-Numeric Rating Scale (WI-NRS), where 0 denotes no itch and 10 denotes the worst itch imaginable. WINRS success was defined as at least a four-point improvement in patients who had a baseline score of at least four. Other tools used include the 16-item Psoriasis Symptom Diary (PSD), which assesses the severity and impact of symptoms and how bothersome and how embarrassing they have been, and the Dermatology Life Quality Index (DLQI), a 10-question questionnaire used to measure the impact of skin disease on quality of life and where the score ranges from 0, denoting no impact on quality of life to 30, meaning maximum impact on quality of life. All of these outcomes were measured every two weeks from baseline out to week 8.

The authors found 68.5% of roflumilast patients achieved WI-NRS success at week 8 while 31.3% of placebo patients achieved it, a difference that was statistically significant, p<0.0001. They also observed a statistically significant greater decrease from baseline in DLQI total score that favoured roflumilast over placebo: -4.6 vs. -1.69, p<0.0001. In addition, there were significant differences in PSD total score between roflumilast-treated patients and those treated with placebo at weeks 2, 4, and 8.

“

W e think of psoriasis as a chronic condition, so we expect to treat it long term.”

Dr. Irina Turchin

“We think of psoriasis as a chronic condition, so we expect to treat it long term,” explained Dr. Turchin, noting patients are provided with instructions on how to apply roflumilast. “In the [INTEGUMENT open-label] long-term extension trial, the patients were using the cream until they had clear or almost clear skin and then could take a break until disease recurrence and use it again. We expect that this would also happen in real life. Because it is a non-steroidal preparation, I have no concerns about its use on special sites such as skin folds, the face or genital area and/or about using it long term.”

Still another benefit of roflumilast is its formulation minimizes the risk of irritation or contact dermatitis because it does not contain fragrance or propylene glycol, according to Dr. Turchin. “Another advantage of roflumilast cream vehicle is

the emulsifier (Crodafos) that maintains skin integrity of the lipid bilayer while facilitating delivery of the roflumilast.”

The pooled baseline demographics from DERMIS-1 and -2 trials reveal that patients with skin of colour were more than 10% of the study population, with roflumilast being well-tolerated in these patients.

“Roflumilast is a great option for patients with skin of colour,” said Dr. Turchin. “It is a nonsteroidal preparation, so we do not see hypopigmentation that we sometimes would see with the use of topical steroids. It gets absorbed nicely and does not leave a white layer on the skin. Patients really like it.”

Non-proprietary and brand names of therapy: roflumilast (ZORYVE, Arcutis Biotherapeutics).

Plant-based adaptogen serum effective for management of erythema

Findings from a clinical trial show a new non ­prescription topical serum comprised of plant­based adaptogens supports skin homeostasis. The serum is highly effective at managing background erythema when used as an adjunct therapy.

THE CHRONICLE OF COSMETIC MEDICINE + SURGERY spoke with Canadian dermatologists, Dr. Nathan Rosen and Dr. Channy Muhn who have used the serum in their practice. The topical is marketed as Mystro Active Balance Serum by skinbetter science.

Drs. Rosen and Muhn are co­founders of the Dermetics cosmetic dermatology clinic in Burlington, Ont.

The new serum is composed of plant adaptogens intended to support homeostasis in the skin, said Dr. Rosen. The developers of the serum call the technology PATH (Plant Adaptogens Targeting Homeostasis). In addition to the adaptogens, the serum contains antioxidants and ingredients that enhance the skin barrier and hydration in the skin.

Sources for the adaptogens include Panax notoginseng root extract, cocoa leaf cell extract, hops extract, Echinacea purpurea extract, Matricaria flower extract, turmeric root extract, Magnolia officinalis bark extract, Balsam copaiba resin, and Sophora japonica bud extract.

A study of Mystro in a human skin model1 that examined the impact of the serum on biomarkers of stress and aging showed improvements in most of the markers.

In particular, the study examined found an 85% increase in expression of Aryl hydrocarbon receptor vs. control occurred following exposure to the serum, which indicates enhanced support of cellular and epidermal homeostasis, and the skin barrier’s response to stress. There were also statistically significant increases in expression with thioredoxin reductase 1 (293%), metallothionein 1A (307%), metallothionein 1F (529%), and metallothionein 1G (163%) vs. control, which indicates support of the

skin’s adaptive response to stress and immune homeostasis.

Significantly decreased levels of chloride channel accessory 2 (69%) indicates inhibition of oxidative stress­induced senescence.

Drs. Rosen and Muhn said their experience using Mystro in their clinic matches what has been seen in a clinical trial.2 Findings from the study at week 12 include:

• 23% mean reduction in pore size

50% mean improvement from baseline in erythema

• 44% mean improvement in skin dullness

• 52% mean improvement in texture

• 21% mean improvement in uneven pigmentation

• 82% of patients reported using less makeup

• 87% of patients reported friends and family had noticed or commented on

• their skin improvement.

•

98% of patients reported they felt more confident in the appearance of their skin

Dr. Muhn said these high patient­reported outcome measures are valuable for communicating the benefits of the serum to patients in a way they can quickly grasp.

Dr. Rosen noted that one of the plant extracts in Mystro is turmeric, and some patients may experience a bit of yellow or orange colour on their skin when using the serum. He said that lighter­skinned patients might notice this colouration, but simply reducing the amount applied to half a pump a day would avoid this issue.

1. Draelos ZD, Grimes PE, Watchmaker J, Nelson DB: Gene expression analysis of a topical serum comprised of plant­based adaptogens developed to support homeostasis and skin quality. J Clin Aesthet Dermatol 2024; 17(2):43–46.

2. Draelos ZD, Grimes PE, Watchmaker J, Nelson DB: A multi­center trial evaluating a serum comprised of plant­based adaptogens targeting skin quality. J Clin Aesthet Dermatol 2024;17(2):15–19.

Dr. Rosen

Dr. Muhn

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Acne: Use oral antibiotics for at least six months

Continued from page 1

Dr. Rao is a clinical professor in the faculty of medicine and dentistry and director of the dermatology program at the University of Alberta, and the founder and team lead of ConsultDerm, a national teledermatology project.

There are four pathogenic factors that cause acne, said Dr. Rao. One of these is alteration in keratinization. The hair follicle normally undergoes keratinization, but in acne, the keratin becomes adhesive, sticking to the skin. Instead of flaking away, it develops into a keratin plug. The second factor is increased sebum production, from the oil gland adjacent to the hair follicle in the pilosebaceous unit. The third factor is the presence of Cutibacterium acnes, which will digest the oil and release substances that irritate the skin, leading to the fourth factor, inflammation.

Two of these factors, the alteration in keratinization and sebum production, are directly related to hormones, particularly androgens, said Dr. Rao. Androgens include progesterone, testosterone, dihydrotestosterone, and even dehydroepiandrosterone sulfate.

Treating acne early is key

It is important to treat acne early to prevent scarring, said Dr. Rao. Physicians should also treat as many pathogenic factors as possible. Systemic agents should be used if topical agents alone are not successful. Systemics should also be used if the

Which of the following topical retinoids has the highest efficacy in treating acne but also the highest potential for irritation?

A. Adapalene

B. Tretinoin

C. Tazarotene

D. Trifarotene

acne is moderate to severe. Examples of moderate to severe acne include: if the acne is in widespread anatomic locations; if there is the presence of red swollen papules or pustules, as well as cysts and nodules; if there are intense psychosocial sequelae; and if there is high scarring potential. Darker skin tones are often associated with more fibrosis and scarring, and even hyperpigmentation.

Acne can be assessed as having non-inflammatory lesions or inflammatory lesions, said Dr. Rao. Non-inflammatory lesions include comedones, which are either whiteheads or blackheads. Those alone are considered mild acne. Inflammatory acne can be papular, pustular, or nodulocystic. Intense inflammation will lead to acne scarring

Among oral anti-acne therapies, isotretinoin is one of the most effective as it addresses most of the factors causing acne, said Dr. Rao. However, it does not address hormones, and so needs to be supplemented with a therapy that addresses the effect of hormones.

The treatment algorithm for inflammatory acne that is either papular or pustular includes topical agents plus an oral antibiotic, said Dr. Rao. This will usually include topical anti-inflammatory combination therapy, such as retinoids plus benzoyl peroxide, and perhaps topical antibiotics. But it is recommended to use an oral antibiotic as well, he said.

Oral antibiotics that work well for acne include those in the tetracycline group, such as tetracycline, minocycline, and doxycycline, said Dr. Rao. There are also those in the macrolides group, such as azithromycin and erythromycin. But he cautioned that these no longer work well for acne as patients have become resistant to them. Clindamycin works well for acne, but there is an increased risk of pseudomembranous colitis from C. difficile overgrowth in the gut. The sulfa medication trimethoprim-sulfamethoxazole also is effective for acne, but some patients have sensitivities or allergies to it.

Oral antibiotics should be used for at least six weeks but should not be used for longer than six months, said Dr. Rao. If the medication has not worked within that time, it is unlikely to be successful, and using it for too long can encourage development of resistance.

Hormonal acne primarily seen in females Hormonal acne is primarily seen in female patients, said Dr. Rao. It is most likely to be seen on the lower face, such as the chin, cheeks, or jawline, or on the neck or submental regions, areas which have more hormone receptors. Hormonal acne is characterized by monomorphic inflammatory papules that are deep-seated and tender and may be cystic.

The treatment algorithm for hormonal acne is similar to that for inflammatory acne, but also includes anti-hormonal agents, said Dr. Rao. In addition to anti-inflammatory agents, physicians may also prescribe an oral anti-hormonal agent such as spironolactone or an oral contraceptive. If the patient is under 35 years of age and there

are no contraindications, oral contraceptives can work well to mitigate hormonal sensitivity by reducing the hormone or by preventing it from reaching the hormone receptor. Dr. Rao recommended using the contraceptive desogestrel and ethinyl estradiol for one year and then reassessing the patient’s improvement. Spironolactone, in doses of between 50 and 150 mg/day, also works well at blocking the effects of hormones. It should be used for at least 12 months in patients over the ago of 35 years, he said.

Severe, or nodulocystic acne, may also have papules or inflammatory pustules, and comedones said Dr. Rao. Severe acne almost always results in scarring, particularly indented atrophic scarring. It is important to treat severe acne as quickly as possible. One treatment option is using oral antibiotics in combination with topical therapy, but oral isotretinoin is faster and more predictable. There are now two lipid-encapsulated isotretinoin formulations on the market in Canada. Because of the lipid encapsulation, these medications do not have to be taken with a meal. Dr. Rao recommended using these medications for two to four months. Once the acne has cleared, the therapy can be stopped or can be changed to a topical retinoid to help keep the skin clear.

When using isotretinoin, Dr. Rao said it is highly recommended to do bloodwork at baseline and one month into treatment, including a complete blood count post-differential, an alanine transaminase liver test, and a complete lipid profile. He also recommended doing these tests if the dosage is increased. If the patient is a woman of childbearing potential, it is important to check for pregnancy before starting treatment as well as through the treatment period. A urine pregnancy screen should be done at baseline and monthly, as isotretinoin is teratogenic. As an extra precaution, physicians could also prescribe an oral contraceptive.

Non-proprietary and brand names of therapies: desogestrel and ethinyl estradiol (Linessa, Aspen); spironolactone (Aldactone, Pfizer); isotretinoin (Accutane, Roche; Clarus, Mylan), lipid-encapsulated isotretinoin (Epuris, Cipher; Absorica LD, Sun Pharma).

Bottom Line: Isotretinoin is one of the most effective oral anti-acne therapies as it addresses most of the factors causing severe or resistant acne, but can be supplemented with anti-hormonal therapy. The treatment algorithm for inflammatory acne that is either papular or pustular includes topical agents plus an oral antibiotic. The treatment algorithm for hormonal acne is similar to that for inflammatory acne, possibly including an oral anti-hormonal agent such as spironolactone or an oral contraceptive. It is important to do bloodwork when prescribing isotretinoin, including a complete blood count post-differential, an alanine transaminase liver test, and a complete lipid profile. It is critical to avoid pregnancy because isotretinoin is teratogenic.

Dr. Jaggi Rao

A c ne D x Qu i z

Correct answer C.Tazarotene.

Photo courtesy of Adobe Stock Images

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Cost, availability of sunscreens for dark skin remain barriers

ERecently come across something from the peer-review literature that you consider to be interesting or impactful? Share it with your colleagues. E-mail your clippings, along with your comments, to: health@chronicle.org

FFORTS ARE NEEDED TO ENHANCE THE AVAILABILITY AND AFFORDABILITY OF SUNSCREENS CATERING TO PEOPLE WITH DARKER skin tones. That’s the conclusion of a study published in Dialogues in Health (Sept. 23, 2024; 5:100194). For this study, the researchers recorded the number of products on the shelf, SPF level, application, colouration, and cost at three beauty supply chain stores and three pharmacy, health, and wellness stores in or near Harlem in New York City in the spring of 2023. They then visually matched the number of skin tones for tinted sunscreen to the Fitzpatrick skin phototypes scale.

Of 385 sunscreen products identified, the investigators found 78.7% were traditional white sunscreen, followed by sheer (15.3%) and tinted (6.0%) products. Beauty supply stores offered more tinted sunscreen options than pharmacy, health, and wellness stores (n=17,15.3% vs. n=6, 2.2%, p<0.001). Of the tinted sunscreen products, 19 brands offered only a single tone. Tinted sunscreen was significantly more expensive, with an average cost of US$24.59 [standard deviation $14.71] per ounce vs. $6.85 [SD 8.66] for traditional and $9.38 [SD 8.92] for sheer sunscreen.

In their conclusion, the authors note that sunscreens traditionally contain sun-reflective ingredients that create a white cast, which is undesirable for individuals with darker skin types. They write that the findings of this study show a need to increase the availability and affordability of sheer sunscreens or sunscreens that are available in a wide variety of tones.

—For more information visit https://tinyurl.com/55cmbrusx

Factors influencing psoriasis Tx decisions in women of childbearing age identified

SYSTEMIC THERAPIES HAVE TRANSFORMED PSORIASIS TREATMENT OVER THE PAST TWO DECADES, BUT THEIR SAFETY DURING pregnancy remains a concern, note the authors of a study in the International Journal of Women’s Dermatology (Dec. 2024; 10(4):p e187). Investigators examined the disease burden and treatment approaches. They shared decision-making indicators in women of childbearing age with moderate-to-severe psoriasis, both with and without a current desire for pregnancy. The researchers determined that treatment decisions for women of childbearing age with moderate-to-severe psoriasis were influenced by childbearing wishes, with shared decision-making improving therapeutic alignment with patient preferences.

For this study, conducted at the University Medical Center Hamburg-Eppendorf, the authors surveyed 145 women of childbearing age with psoriasis. Exclusion criteria included age over 45, early menopause, and comorbidities that posed risks. The participants were divided into two groups: those wishing to conceive (CB+) and those not planning to have children (CB ). Patients without childbearing wishes were older and often had children already. They were assessed on disease severity, quality of life, and treatment choices.

The study’s key findings showed differences in treatment choices between the CB+ and CB groups but no significant differences for most clinical characteristics. As for treatment options, the CB+ group was more likely to be prescribed tumour necrosis factor (TNF) alpha-blockers, such as certolizumab pegol, a medication considered safer in pregnancy. The CB group was more frequently prescribed non-biologic systemic treatments such as fumaric acid esters. The results also revealed that the desire to have children was significantly associated with the likelihood of receiving TNF alpha blockers, whereas clinical characteristics were not.

Regarding the indicators of shared decision-making for the current treatment, the authors note that less than 50% of patients acknowledged shared therapy goals despite physicians reporting collaborative goal setting. Additionally, patients with pregnancy plans were more likely to report that their childbearing wishes were considered in treatment decisions, and family planning discussions were more frequent in the CB+ group. The study identified effective, shared decision-making as critical for aligning treatment with patient needs and ensuring safe therapy for women of childbearing age with psoriasis.

—For more information visit https://tinyurl.com/yck94tkk

Potentially improved results for

FINDINGS FROM A RECENT STUDY PUBLISHED ONLINE AHEAD OF PRINT IN Clinical and Experimental Dermatology (Oct. 16, 2024) suggest potential benefits for adding 17α-estradiol as an adjunct to minoxidil as a treatment for female pattern hair loss (FPHL), though with increased risk of menstrual irregularities.

For this study, 43 women with FPHL applied either a combination of topical 17α-estradiol 0.01% with minoxidil 2% or topical minoxidil 2% alone twice daily for six months. Researchers evaluated progress through clinical and trichoscopic assessments at baseline and the end of the treatment.

The results showed both groups experienced hair improvement after treatment. Although improvements appeared slightly better in the 17α-estradiol-minoxidil group, the differences were insignificant. Notably, more women using the combined treatment reported menstrual irregularities.

The authors concluded that while combining 17α-estradiol with minoxidil may offer minor advantages, it doesn’t seem significantly more effective than minoxidil alone and could increase the risks of menstrual irregularities. However, the study’s limitations, including small sample size, brief follow-up, and lack of cellular-level examination or assessment of systemic absorption of the treatments, could impact the accuracy of comparing the treatments’ efficacy and safety. Further research with larger samples and in-depth cellular analysis is needed to understand better the potential benefits and risks of adding 17α-estradiol to minoxidil for FPHL treatment.

—For more information visit https://tinyurl.com/36ea773z

by DARREN STALLMAN Assistant Editor The Chronicle

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AKs: Photoprotection important for patients with AKs

because the Vitamin D helps the 5-FU to better penetrate,” said Dr. Shoimer. “As a result, treatment can be more effective, and it’s a shorter course [of treatment].”

Dr. Michael Stevens, a dermatologist and Mohs micrographic surgeon at Precision Dermatology & Skin Surgery in Bedford, N.S., noted he may use a combination to help clear AKs. “My mainstay would be liquid nitrogen plus or minus field therapy,” said Dr. Stevens.

Considerations for specific populations

Clinicians need to be very alert with respect to the development of AKs in patients who are organ transplant recipients, stressed Dr. Shoimer. “You have to have a much higher degree of suspicion for squamous cell skin cancer because their immune system is so weakened, and the tumour cells proliferate quite quickly and grow,” he said. “We have to really stay on top of things and treat the actinic keratosis more aggressively in order to prevent progression to squamous cell carcinoma.”

Identifying AKs in patients with skin of colour can also be problematic if clinicians are only using visual cues, said Dr. Shoimer. “The challenge would be the morphology may be a little bit different. We often see with actinic keratoses, a surrounding redness which is more evident on lighter skin but may be a little bit more challenging to see in darker skin,” he said. “We can use our tactile senses for AKs, so we can still feel those hyperkeratotic characteristics or those crested papules. Even in skin of colour, you would still be able to palpate or feel an AK.”

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With regard to treatment of AKs in patients with skin of colour, clinicians need to be wary of potential visible discolouration and aim to minimize the risk of this, cautioned Dr. Mark Lupin, a dermatologist in Victoria, B.C.

“One concern with the use of imiquimod [as treatment for AKs] is that there have been cases of apparent permanent whitening, especially on areas like the chest,” said Dr. Lupin. “In someone with darker skin pigment, we have to be more careful not to induce hyperpigmentation or hypopigmentation.”

Approaches to enhanced AK clearance with PDT and identifying risk of SCCs Photodynamic therapy (PDT) has been used to treat AKs, but clinicians acknowledge that poor tolerability can be a restrictive factor in the widespread use of PDT with blue light. But daylight PDT also has its limits.

“Daylight PDT is a good alternative in terms of less pain, as the activation of the light with standard PDT is quite painful,” explained Dr. Shoimer. “The downside of daylight PDT is the lack of predictability. In Calgary, we are quite fortunate to have a lot of sunny days, but if there is cloudy weather, you are not going to get that reliable activation from sunlight. The main challenge of daylight PDT is the reliability of the light source.”

Dr. Stevens agreed that standard PDT is not a comfortable treatment for patients while daylight PDT is not a reliable management option because it is weather-dependent. “I find that the indoor [PDT] is painful for patients and the outdoor/daylight PDT can be tricky unless you are doing it in warmer months,” said Dr. Stevens.

A modification to PDT that is being practiced by some clinicians is synchronous PDT, where 5aminolevulinic acid (ALA) is applied to the skin and blue light is applied immediately following, explained Dr. Lupin (Photodiagnosis and Photodynamic Therapy Feb. 2024; 45:103838).

“The trend is to use synchronous PDT, which means you apply ALA and then straight away apply blue light for 30 minutes,” said Dr. Lupin. “It is much less painful and has been found to be equally effective in at least a couple of studies.”

In terms of optimizing PDT if it is employed, Dr. Lupin noted supplementation with oral Vitamin D3 favours an improved outcome.

“Another pearl is that if you pretreat for two weeks with 10,000 units of oral Vitamin D3, you may get better clearance rates using PDT on the AKs,” said Dr. Lupin. “This applies for people who are deficient in vitamin D, but even people who are not deficient in Vitamin D seem to have a better clearance rate [of AKs].”

Results from a non-randomized trial demonstrated that the use of Vitamin D3 enhanced response to PDT in patients who had AKs (J Am Acad Dermatol 2022 Jul; 87(1):80-86).

Clinicians should be aware of which patients

are at elevated risk of developing SCCs, pointed out Dr. Lupin, citing data that recognized patient characteristics associated with an elevated risk of SCCs. This meta-analysis involving 220,236 patients with AKs and 220,236 control subjects, looked at the cumulative incidence of AKs over a 10-year period and found risk factors for the development of cutaneous SCCs in patients with AKs included older age, white race, a history of basal cell carcinoma, and male sex (JAMA Dermatol 2021 May 1; 157(5):559-565).

Photoprotection

Increased photoprotection is something to keep in mind for patients who have had actinic damage, according to Dr. Stevens. “I find that I usually recommend for patients who have had AKs and a lot of sun damage, that they use a sunscreen with an SPF [sun protection factor] number of 45 or 60,” said Dr. Stevens. “I also suggest sun avoidance if possible and wearing clothing such as a broad-brimmed hat.”

Dr. Shoimer agreed that photoprotection through avoiding the sun during peak hours, wearing protective clothing and even taking oral supplementation are wise measures for patients who have had AKs, as these patients are at enhanced risk of developing forms of skin cancer like basal cell carcinoma and melanoma.

“We advise avoiding [being out in] peak hours, using sunscreens, and we now recommend polypodium leucotomos extract pills because they can help prevent sunburns,” said Dr. Shoimer.

Chronicle Companies is pleased to support Camp Liberté with monetary and in­kind donations through Sandi’s Fund, established to honour our late friend and colleague, Sandra Gail Leckie, RN. Sandi was a nurse, pharmaceutical industry executive and health educator who had a life long affinity for children and children’s charities.

Chronicle Companies contributes profits from the annual National Pharmaceutical Congress (www.pharmacongress.info) to Sandi’s Fund for Camp Liberté, and has partnered with Camp Liberté to provide communications assistance for this valuable philanthropic undertaking.

Dr. Michael Stevens

Dr. Mark Lupin

Camp Liberté was created by a group of dermatologists dedicated to offering children with moderate to severe skin conditions an opportunity to enjoy a summer camp experience. With locations in eastern and western Canada, Camp Liberté hosts more than 40 children per summer at no cost to parents, thanks to the support of generous donors.

Our camps are fully equipped with volunteer dermatologists, residents and nurses to care for children with a wide range of skin conditions, including atopic dermatitis, epidermolysis bullosa, and alopecia areata.

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A gift to Camp Liberté provides Canadian children with skin conditions an opportunity to grow in confidence and self-esteem through a multi-cultural outdoor camping experience in a fun, safe, bilingual, environment.

Donate Now! / Faites un don dès maintenant! campliberte.ca

Le Camp Liberté a été créé par un groupe de dermatologues déterminés à offrir à des enfants qui ont des problèmes de peau variant de modérés à graves la possibilité de vivre l’expérience d’un camp d’été. Avec ses emplacements dans l’est et l’ouest du Canada, le Camp Liberté accueille plus de 40 enfants par été sans qu’il en coûte quoi que ce soit aux parents, grâce à l’appui de généreux donateurs.

Nos camps bénéficient des services complets de dermatologues, de médecins résidents et d’infirmières bénévoles qui s’occupent d’enfants aux prises avec un vaste éventail de problèmes de peau, y compris la dermatite atopique, l’épidermolyse bulleuse et la pelade.

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Un don au Camp Liberté permet à des enfants canadiens qui ont des problèmes de peau d’accroître leur confiance en soi et leur estime de soi en vivant une expérience multiculturelle de camping en plein air offerte dans un environnement bilingue, sécuritaire et amusant.

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Dr. Yvette Miller-Monthrope is a Toronto based dermatologist and dermatopathologist. She is an assistant professor of medicine at the University of Toronto and the medical director of the pigmentation disorders clinic at Women's College Hospital. She has special interests in diverse skin types, inflammatory dermatoses, curriculum development and clinical-pathological correlation.

P O S TG R A D UAT E EDUCATIONAL SUPPLEMENT

Dermatology resident comfort level treating hair conditions related to patients with skin of colour

Starling

Tolliver,1 Camilla Cascardo,2 Nikita Wong,3 Yasmine Abushukur,2 Geoffrey Potts1,*

1Department of Dermatology, Wayne State University, Detroit

2Oakland University William Beaumont School of Medicine, Rochester, Mich.

3Wayne State University School of Medicine, Detroit

* Corresponding author. E-mail address: gpotts@med.wayne.edu (G. A. Potts).

ABSTRACT

Background: Although recent studies demonstrated resident satisfaction in the treatment of skin of colour (SOC) related disease, comfort levels treating hair specific to populations within the SOC spectrum is unclear.

Objective: The purpose of this study is to assess dermatology residents comfort level in recognizing and treating various common hair conditions with a focus on those specific to SOC

Methods: An Institutional Review Board-approved survey was distributed to United States residents of Accreditation Council for Graduate Medical Educationaccredited dermatology programs. Data pertaining to hair care knowledge and treatment comfort levels were collected. Analysis was completed using equal variance 2-sample t tests and analysis of variance F tests, p<0.05.

Results: Dermatology residents were relatively comfortable with common conditions such as androgenetic alopecia and alopecia areata, but uncomfortable with creating healthy hair regimens, discussing natural hair care products, and treating trichorrhexis nodosa. Resident self-identification as underrepresented in medicine significantly impacted resident knowledge of hair care and treatment in patients with SOC.

Limitations: This study was limited due to small sample size and potential recall bias. Conclusions: This study highlights knowledge gaps in understanding hair-related care for patients with SOC, affirming the continued importance of diversifying dermatology programs as well as hair-specific training for residents.

INTRODUCTION

Nearly half of the U.S. population will be made up of individuals with skin of colour (SOC) by the end of the century.1,2 Despite the rapid increase in this population, coverage of issues pertinent to SOC, especially those of African ancestry in dermatologic educational resources, remains variable. In addition, much of the current literature emphasizes disease processes related to skin alone.3 Research is limited on the prevalence of characteristic hair disease in patients with afro-textured hair compared to patients with non-afro-textured hair, however, studies have shown high rates of breakage, traction alopecia (TA), central centrifugal cicatricial alopecia in Black women.4,5 As many as 50 to 90% of Black women experience hair loss6,7 and they

often have increased morbidity such as severe permanent scarring and deep psychological impact associated with these illnesses.8

Despite recent studies demonstrating a majority of dermatology residents being satisfied with their knowledge of disease primarily seen in patients with SOC,9 many patients with SOC attribute their dissatisfaction with their dermatologic care due to the inadequate training of dermatologists on these conditions.10 Moreover, to our knowledge no studies have focused on hair alone. This underscores the importance of exploring and understanding the gaps present in dermatology resident training as it pertains to individuals of varying hair types. Together, this signifies an underlying importance of both skin and hair mastery in all skin types. This study intends to assess dermatology residents’ level of knowledge and

comfort treating various hair-related conditions and those specific to SOC patients.

METHODS

Data collection

An institutional review board-approved Qualtrics survey was generated and distributed via e-mail to the Association of Professors of Dermatology membership list on February 24, 2022. Program directors and academic dermatologists were encouraged to distribute the survey to residents within their institution. Participation eligibility was limited to residents of an Accreditation Council for Graduate Medical Education-accredited U.S. dermatology residency program. All residents consented to participation prior to providing responses.

Hair-related conditions assessed included, tinea capitis, TA, alopecia areata, androgenetic alopecia, lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia (CCCA), discoid lupus erythematosus, dissecting cellulitis, folliculitis decalvans, trichotillomania, and trichorrhexis nodosa (TN). Residents reported how frequently they treated patients with each of these conditions. Frequencies ranged from 1 to 6 respectively, (never or 1 time per year, once every 6–12 months, once a month to once every 6 months, once a week to once a month, every day to once a week, or multiple times per day).

Residents were asked to rank their comfort level with recognizing and treating each of these conditions. Comfort levels ranged from 1 to 5 respectively (extremely uncomfortable, somewhat uncomfortable, neither comfortable nor uncomfortable, somewhat comfortable, or extremely comfortable). Using the same scale, residents were asked to describe their comfort level with understanding the basic hair morphology of SOC patients as well as their comfort counseling individuals with SOC on proper hair practices, best hair products, and healthy hair regimens. Demographic data pertaining to residents’ dermatology program, residency location (reported as state and coded by geographic region), year of residency (PGY-2, PGY-3, and PGY-4), clinical setting (urban, suburban, rural, and mixed), and access to a hair-specific clinic within each residency program were collected. Residents were also asked whether or

not they identify as underrepresented in medicine and various clinical interests.

Statistical analysis

Responses were extracted using Microsoft Excel and coded within a spreadsheet before statistical analyses were run using Windows SAS/STAT software (Version 9.4, SAS Institute Inc., Cary, N.C.). Summary statistics were calculated for all available data. Equal variance 2-sample t tests were used to compare the means for numerical variables of normally distributed data. Analysis of variance tests were run when comparing resident comfort treating various hair-related conditions in the general population versus in SOC patients. Results were considered statistically significant if p<0.05. Qualitative analysis was conducted through openended questions. The Wayne State University Institutional Review Board deemed this study exempt.

RESULTS

A total of 45 US-accredited dermatology programs across 146 residency total programs (30% response rate) were included in our analysis. Each class was represented fairly equally with varied geographical locations and practice types. Our study reported 24% of participants from underrepresented backgrounds and 10.7% of the total residents had an interest in SOC. Of the 121 total residents in our survey, 45.5% noted a hair-specific clinic at their residency program (Supplementary Table S1, https://links.lww.com/IJWD/A42). The residents were asked to report how often they observed each hair condition, their comfort recognizing each, and their comfort level treating each. Residents reported seeing most hair conditions at least once a month to once every 6 months except for folliculitis decalvans, trichotillomania, and TN (2, 2, and 2, respectively). When comparing all non-SOC hair-related conditions residents felt overall “either somewhat comfortable” or “extremely comfortable” regarding recognition and treatment of these diseases (Supplementary Table S2, https://links.lww.com/IJWD/A43). When considering comfort with afro-textured hair conditions dermatology residents as a whole felt “neither comfortable nor uncomfortable” or

Reprinted with permission © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Women’s Dermatologic Society. This is an open access article distributed under the terms of the Creative Commons Attribution Licence CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Content has been edited to conform with the Canadian Press Publication Style Guide Chronicle.Academy develops bespoke structured learning programs for clinicians providing in-depth education to professionals in the healthcare industry.

“somewhat uncomfortable” (Table 1). Resident comfort in counselling patients on protective hair practices differed significantly depending on their background (p=0.0034), as did their comfort in counseling patients on hair product recommendations for natural hair care (p=0.0006). Comfort level also differed significantly in relation to understanding the basic science of hair morphology in SOC individuals and its unique characteristics (p=0.0011) and their comfort developing a healthy hair regimen (p=0.0016) with residents underrepresented in medicine having higher degrees of comfort. At the same time, however, the reported comfort

levels were respectively “neither comfortable nor somewhat comfortable” versus “somewhat uncomfortable” in all categories except counseling on protective styles and prescribing treatments for TA. Here, residents felt “somewhat comfortable” versus “neither comfortable nor somewhat comfortable.” There was no significant difference in comfort prescribing treatment regimens for CCCA and TN (Table 2). Resident comfort with treating hair conditions did not differ significantly by geographical region or by clinic setting. Residents participating in a program with access to a hair-specific clinic felt more comfortable counselling patients on protective hair

and treatment are vital to control disease progression and hair regrowth. To our knowledge, this analysis is the first of its kind assessing the degree of disparity within hair-related education in dermatology residency. Even further, there is a paucity of literature reflecting the true nature of hair disparities in patients with SOC. Some studies have shown differences in clinical trial enrollment for and disease presentation of alopecia areata, toxic exposure to chemicals in hair products, physical activity due to hair styling, advocacy efforts, and utilization of dermatologists for cicatricial alopecias.11–16 Given that underrepresented in medicne residents tended to feel more comfortable managing specific hair conditions, the true level of resident comfort with managing these conditions may actually be overestimated as they represented 24% of participants. Even though 45.5% of participants reported having a hair-specific clinic, the majority of responses from this group showed no differences in comfort level treating diseases like CCCA, TA, and TN. This suggests that having a hair clinic alone may not confer adequate benefit to hair-specific education other than by increased comfort in counselling.

practices (p=0.0298), however, there was no difference in comfort level counselling on specific product use or in the development of healthy hair regimens.

DISCUSSION

Our study assessed overall dermatology resident comfort level in recognizing, counselling, and treating common hair conditions compared to afro-textured hair-related conditions. CCCA, TN, and TA are hair diseases that disproportionately affect the Black community. This is due to a combination of factors including genetic and environmental causes that can lead to significant scarring and psychological distress. Early recognition

Comfort levels in treatment of CCCA and TN were statistically insignificant, although treatment of CCCA was reported as “somewhat comfortable” by the underrepresented in medicine group. The authors believe that training on the recognition and treatment of CCCA with recent advancements in understanding of this disease process may attribute to this. As for TN, there has been little progression in the understanding and treatment of TN, or hair breakage, especially in Black women. Therefore, both groups noting “somewhat uncomfortable” levels is reasonable as many Black women with TN typically do not seek care from a dermatologist due to the patient’s perceived lack of foundational knowledge of physicians in treating these conditions as well as adequate outside resources.6 To combat this, Gorbatenko-Roth, et al suggest several measures that may improve SOC patient dermatologic care satisfaction. These include enhancing residency training in SOC, increasing cultural competency, cost-conscious care, and empathetic communication skills.10,17 Forming alliances with hair stylists with knowledge of protective hair care practices could also improve patient care and trust in the community.

While most dermatology resident participants feel at least somewhat comfortable recognizing and treating a variety of hair conditions overall, comfort levels in managing afro-textured hair-specific concerns is limited demonstrating a disparity in comfort level regarding SOC-related hair conditions regardless of background. Overall lack of comfort may be linked to a lack of di-

Table 1: Overall resident comfort with afro-textured hair conditions

Table 2: Resident comfort treating afro-textured hair conditions given underrepresented background

rect ongoing patient care experience with this population, less focused hair care curriculums, general lack of interest, or absence of evidence-based strategies for intervention. Although there have been many calls to action for increasing SOC in dermatology curricula over the last 10 years, few have focused broadly on hair-related issues in this specific population.18–20 Improving residents’ comfort level of counseling in this community can allow patients to feel understood, thus increasing the likelihood of following recommendations, returning for follow-up care, and potentially improving the physical and psychological health of patients.21 It is the opinion of the authors that it is important that increased focus is placed on hair issues in this community, not just CCCA, as many of the prior studies related to SOC education narrowly focused on hair as a part of the full conversation.9,10,17–20

Of note, residents from underrepresented backgrounds were more comfortable counseling on multiple aspects of healthy hair care likely due to higher community awareness of specific hair disorders and increased interest in healthy hair strategies for these common conditions. In the past, these attributes were not typically valued as highly as other metrics within the residency selection process. However, more recently, the field of dermatology has mitigated this problem through holistic review and diversity initiatives.17 Although improvements have been made, the field continues to lag when it comes to diversity in both residents and faculty of colour.17,22 Thus, it is important to continue to strive toward increasing diversity within academic faculty and trainees, which may also aid in improving collective knowledge through crosscultural sharing in treating patients with SOC.

Future studies are necessary to assess the extent of disparities related to afro-textured hair and potential curriculum interventions to assist with improving comfort level of managing and counseling in these patients.

LIMITATIONS

Limitations of this study include its small sample size, potential lack of generalizability, potential recall bias inherent to survey data collection methods, and selection bias of those who chose to complete the survey. Additionally, we realize that increased comfort treating a condition does not necessarily mean all aspects of the condition are being appropriately treated. Nonetheless, the purpose of this study is to address dermatology resident comfort counselling on safe hair practices among SOC patients in clinical settings, comfort level treating these conditions, and to shed light on a topic warranting further investigation.

CONCLUSION

To our knowledge, this is the first study examining dermatology resident comfort level in recognizing and treating various hair disorders, especially those specific to SOC. Dermatology residents can better serve their patients by being more comfortable counselling SOC hairrelated concerns. Integrating diverse learning opportunities into resident curricula regarding the presentation of hair conditions in SOC patients may improve resident confidence in clinical settings. Additionally, we believe striving for greater diversity in dermatology residencies can help mitigate this particular gap in patient care through sharing of information and patient comfort. More studies are needed to assess resident comfort treating SOC hair-related conditions. Dermatology residency programs need to continually evaluate the degree of exposure their residents receive to SOC hair-related conditions within their respective curriculums and clinical settings.

CONFLICTS OF INTEREST

None.

FUNDING

Supported by the Wayne State University Graduate Medical Education Seed Grant.

STUDY APPROVAL

The authors confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies: Wayne State University IRB approval #21-083933.

AUTHOR CONTRIBUTIONS

ST, CC, NW, YA, and GP: Study conception and design. ST and CC: Data collection. ST, CC, NW, YA, and GP: Analysis and interpretation of results. ST, CC, NW, YA, and GP: Draft manuscript preparation. All authors reviewed the results and approved the final version of the manuscript.

SUPPLEMENTARY DATA

Supplementary material associated with this article can be found at https://links.lww.com/IJWD/A42 and https://links.lww.com/IJWD/A43.

REFERENCES

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2. Taylor SC: Skin of color: biology, structure, function, and implications for dermatologic disease. J Am Acad Der-

matol 2002; 46(2 Suppl Understanding):S41–62.

3. Perlman KL, Williams NM, Egbeto IA, Gao DX, Siddiquee N, Park JH: Skin of color lacks representation in medical student resources: a crosssectional study. Int J Womens Dermatol 2021; 7:195–196.

4. Haskin A, Kwatra SG, Aguh C: Breaking the cycle of hair breakage: pearls for the management of acquired trichorrhexis nodosa. J Dermatolog Treat 2017; 28:322–326.

5. Khumalo NP, Jessop S, Gumedze F, Ehrlich R: Hairdressing and the prevalence of scalp disease in African adults. Br J Dermatol 2007; 157:981–988.

6. Tolliver S, Shipp D, Alexis A, Kaffenberger BH: A descriptive study of black women with and without hair loss and their perception of dermatologists. Int J Dermatol 2019; 58:e182–184.

7. Mhlaba JM, Pontes DS, Patterson SS, Kundu RV: Evaluation of a skin of color curriculum for dermatology residents. J Drugs Dermatol 2021; 20:786–789.

8. Akintilo L, Hahn EA, Yu JMA, Patterson SSL: Health care barriers and quality of life in central centrifugal cicatricial alopecia patients. Cutis 2018; 102:427–432.

9. Ibraheim MK, Gupta R, Dao H, Patel A, Koshelev M: Evaluating skin of color education in dermatology residency programs: data from a national survey. Clin Dermatol 2021; 40:228–233.

10. Gorbatenko-Roth K, Prose N, Kundu RV, Patterson S: Assessment of black patients’ perception of their dermatology care. JAMA Dermatol 2019; 155:1129–1134.

11. Thompson JM, Park MK, Qureshi AA, Cho E: Race and alopecia areata amongst U.S. women. J Investig Dermatol Symp Proc 2018; 19:S47–50.

12. Ding J, Joseph M, Chawla S, Yau N, Khosa F: Disparities in alopecia clinical trials: an analysis of female and minority representation. J Cutan Med Surg 2022; 26:516–518.

13. Hobbs LK, Brown S 3rd, Smith RJ, Salkey K, Harvey V: The CROWNing

event on hair loss in women of color: a Framework for Advocacy and Community Engagement (FACE) Survey Analysis. Cutis 2022; 110:189–193.

14. Arnold JD, Yoon S, Friedman AJ: Disparities in the utilization of dermatologists for primary cicatricial alopecias. J Drugs Dermatol 2020; 19:784–785.

15. Zota AR, Shamasunder B: The environmental injustice of beauty: framing chemical exposures from beauty products as a health disparities concern. Am J Obstet Gynecol 2017; 217:418.e1–6.

16. Huebschmann AG, Campbell LJ, Brown CS, Dunn AL: “My hair or my health”: Overcoming barriers to physical activity in African American women with a focus on hairstyle-related factors. Women Health 2016; 56:428–447.

17. Akhiyat S, Cardwell L, Sokumbi O: Why dermatology is the second least diverse specialty in medicine: How did we get here? Clin Dermatol 2020; 38:310–315.

18. Nijhawan RI, Jacob SE, WooleryLloyd H: Skin of color education in dermatology residency programs: does residency training reflect the changing demographics of the United States? J Am Acad Dermatol 2008; 59:615–618.

19. Ebede T, Papier A: Disparities in dermatology educational resources. J Am Acad Dermatol 2006; 55:687–690.

20. Kaundinya T, Kundu RV: Diversity of skin images in medical texts: recommendations for student advocacy in medical education. J Med Educ Curric Dev 2021; 8:23821205211025856.

21. Tolliver SO, Hefner JL, Tolliver SD, McDougle L: Primary care provider understanding of hair care maintenance as a barrier to physical activity in African American Women. J Am Board Fam Med 2019; 32:944–947.

22. Qiu M, Bae GH, Khosravi H, Huang SJ: Changes in sex and racial diversity in academic dermatology faculty over 20 years. J Am Acad Dermatol 2016; 75:1252–1254.

Research of Note

SIX-YEAR BRODALUMAB PHARMACOVIGILANCE DATA CONFIRMS S AFETY

To assess long-term safety of brodalumab, researchers summarized pharmacovigilance data from six years of real-world clinical practice. They calculated crude adverse event (AE) reporting rates per 100 patients for common AEs and AEs of special interest reported to Ortho Dermatologics by U.S. patients and healthcare providers from Aug. 15, 2017 through Aug. 14, 2023. Brodalumab exposure was estimated as time from the first to last prescription-dispensing authorization dates. Data were collected from 5,138 U.S. patients (estimated exposure of 6,900 patient-years). Over six years, 13 cases of adjudicated major adverse cardiovascular events were reported (0.25 events/100 patients). Among 57 reported malignancies affecting 49 patients, four were possibly related to brodalumab. One new case of indeterminate inflammatory bowel disease unrelated to brodalumab was reported. No new suicide attempts were reported in year six, and there were no completed suicides throughout six years.

MG Lebwohl, JY Koo, AW Armstrong, et al: Brodalumab: Six-year U.S. pharmacovigilance report, in Dermatol Ther (Heidelb), Nov. 26, 2024, online ahead of print.

TIMING OF DUPILUMAB INJECTION IMPACTS AD EFFIC ACY

Investigators evaluated whether the administration time of dupilumab affects its effectiveness in patients with atopic dermatitis (AD), by virtue of the circadian oscillations of immune system activity. Researchers included all (55) adult patients with AD treated with dupilumab from Jan. 2020 to Jan. 2024 at a single university medical unit. Data recorded at baseline (T0) and at the 16-week-treatment visit (T16) included itch severity, sleep disturbance, Eczema Area and Severity Index, Patient-Oriented Eczema Measure, Dermatology Life Quality Index, and immunoglobulin E levels. The authors compared response between two groups, based on injection time: between 12:00 a.m. and 12:00 p.m. (21 patients) versus between 12:00 p.m. and 12:00 a.m. (32 patients). All clinical parameters improved from T0 to T16, without significant differences between groups. However, there was a greater improvement in these parameters in subjects taking dupilumab between 12:00 a.m. and 12:00 p.m., compared with the others.

A Borghi, ME Flacco; et al: Time of day of biological treatment administration and outcomes in atopic dermatitis: Results from a preliminary retrospective study, in Dermatitis Nov. 26, 2024, online ahead of print

Diagnostic Quiz

What are these lesions?

A Atrophic lichen planus

B. Ashy dermatosis

C. Lupus erythematosus

D Lichen sclerosus

THE EDITORS invite your participation in this regular feature of the journal. Please send all images and correspondence to: Medical Editor, The Chronicle of Skin & Allergy 1460 The Queensway, Suite 212, Etobicoke, Ont. M8Z 1S4 Telephone: (416) 916-2476

E-mail: health@chronicle.org

What THE LAY PRESS is saying about . . .

EXPERT WEIGHS IN ON THE FRUGAL DIET THAT 'CURED' VICTORIA BECKHAM'S ACNE

An article in the Daily Mail (Nov. 27, 2024) discusses Victoria Beckham’s claim that her restrictive diet of grilled fish and steamed vegetables cured her adult acne. Beckham, who also avoids meat and wheat, has followed this routine for 25 years. However, dermatologists argue that while diet plays a role in skin health, such a restrictive regimen is unnecessary and may even harm long-term wellbeing. The British Association of Dermatologists emphasizes that acne is primarily influenced by hormonal changes, genetics, and skincare habits rather than specific foods. London-based dermatologist Dr. Justine Kluk says that reducing sugar and refined carbs might help manage breakouts, but eliminating wheat alone is unlikely to prevent acne. According to the article, Beckham also uses an expensive light therapy device, claiming it boosts collagen and smooths skin. While experts acknowledge that light therapy may help with inflammation and collagen production, they caution that athome devices yield modest results.

Dermatology news your patients may be reading

WOMEN WARNED OF THE 'BIG SKINCARE MISTAKE THAT LEADS TO PREMATURE AGING’

A GBN News (Nov. 28, 2024) article highlights the importance of proper moisturizer application to maintain youthful skin. Dr. Keyana Emamian, a general practitioner and aesthetic specialist based in Dubai, warns that neglecting to apply moisturizer to the neck, chest, and hands can accelerate visible aging. She stresses that these areas often reveal signs of aging first and should be included in daily skincare routines. Dr. Emamian also addresses a common misconception that oily skin doesn’t need moisturizer, emphasizing that even oily skin types require hydration to maintain a healthy barrier and prevent pollutants from entering. She recommends moisturizing twice daily, morning and evening, to lock in moisture and protect the skin. For those seeking anti-aging benefits, Dr. Emamian advises using moisturizers with specific active ingredients to enhance results. She explains that wellmoisturized skin appears plumper and less prone to wrinkles, while dry skin can look dull and accentuate fine lines. Proper hydration is crucial for a smooth, clear complexion.

GEN-Z LOVES PIMPLE PATCHES. ARE THEY WORTH A TRY?

An article in The Manual (Nov. 27, 2024) highlights the growing popularity of pimple patches, particularly among Gen-Z (people born between 1997 and 2012). New Yorkbased dermatologists Dr. Hannah Kopelman and Dr. Viktoryia Kazlouskaya explain that these adhesive stickers can help speed up pimple healing by preventing picking and shielding blemishes from bacteria. Some patches also contain active ingredients such as salicylic acid or hydrocolloid to absorb fluid and reduce inflammation. While pimple patches are most effective for whiteheads and surface-level acne, they may offer limited benefits for deeper cystic pimples. Toronto dermatologist Dr. Geeta Yadav emphasizes that patches are not a replacement for proper acne treatment but can aid in preventing scarring and irritation. Dermatologists recommend choosing patches based on skin needs, noting that microneedle patches can deliver ingredients more deeply. However, users with allergies to adhesives should exercise caution.

HAILEY BIEBER AND HER GLOWING SKIN

Hello Magazine reports (Nov. 28, 2024) that Hailey Bieber has unveiled her latest skincare routine, offering a step-by-step breakdown of her current favourites. In a recent TikTok video titled "The current quick routine," Hailey shared her go-to products, many of which are from her beauty brand, Rhode Skin, but she also applied a product viewers hadn't seen her use before. The routine begins with Rhode’s Pineapple Refresh cleanser, which she massages before wiping it off with a warm cloth. Next, she applies the brand’s popular Glazing Milk Toner, a lightweight essence that hydrates and strengthens the skin barrier. For the next step, Hailey uses SkinCeuticals' P-Tiox serum, an advanced peptide anti-wrinkle formula, marking a rare inclusion of a non-Rhode product. She concludes with Rhode’s newly launched Barrier Butter, an intensive moisture balm designed for overnight hydration.

Photo by: Tag-El -Din Anbar MD, Manal Barakat MD, and Sahar F Ghannam MD PhD, via Wikimedia Commons

rroC tce rewsna A. Atrophic lichen planus

Identifying and managing sensitive skin triggers

What does sensitive skin look like?

If your patient’s skin responds strongly to chemicals, dyes, or fragrances found in products that touch their skin, or they sometimes experience rashes and irritation from their clothing, they may have sensitive skin.

Some of the most common signs and symptoms of sensitive skin include1:

• Red skin with or without swelling.

• Skin that itches, stings, or burns.

• Dry skin that may peel, crack, blister, or bleed.

• Patches of skin that feel dry, hard, and leathery.

Identifying Common Triggers of Sensitive Skin

Developed in association with:

Dr. Carrie Lynde LLB, MD, FRCPC, Dermatologist

Taking the time to investigate potential irritants in the patient’s workplace, outside environment, and home can help to make the connection between the trigger and their reactive skin.

“I recommend taking the time to do a series of elimination questions to find irritants and remove them from the patient’s environment. Keeping a skin diary can also help identify patterns and potential skin irritation triggers. If there are multiple triggers, it can be helpful to eliminate all of them and slowly reintroduce them one at a time to isolate the specific trigger.”

There are three main areas to explore:

• What type of work does the patient do?

• Are they exposed to soaps, chemicals, latex gloves, or frequent hand washing?

• Does the patient spend a lot of time outdoors?

• Have they recently come in contact with poison ivy, oak, or sumac?

• Is the patient using skincare products with potentially irritating ingredients like retinol or glycolic acid?

• Is a fragrance-free, dye-free detergent, fabric conditioner, and dryer sheet being used?

The role of textiles in sensitive skin

Laundry products are frequently overlooked as a possible trigger of sensitive skin. Many patients are unaware of the irritation that fragrance can cause, and clothing and bed sheets washed in scented laundry detergents can lead to widespread rashes. “As a dermatologist, I always recommend my patients use hypoallergenic, fragrance-free, dye-free laundry products like the Tide, Downy, and Bounce Free & Gentle regime as the first step in managing their sensitive skin.”

The entire laundry routine needs to be free! When talking to patients about their laundry routine, it is important to remind them that the entire routine needs to be “free” from dyes and perfumes to avoid skin rashes and sensitivity. This includes fabric conditioners and dryer sheets.

Laundry Detergent,

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