In their session, “Early Dermatology Practice Pearls,” on the last day of Fall Clinical 2022, Raj Chovatiya, MD, PhD; G. Michael Lewitt, MD; and Ryan M. Svoboda, MD, shared practice pearls in atopic dermatitis and psoriatic arthritis, along with advances in lymphoma therapy.

Dr Chovatiya kicked off the session with 4 pearls to go back to basics for AD.

• Pearl 1: Does atopic dermatitis (AD) = atopic eczema (AE)?
  • AD, AE, and dermatitis are often used interchangeably to describe “a common, clinically defined pruritic, inflammatory skin condition, characterized by a chronic and relapsing dermatitis in typical anatomical sites.”
• Pearl 2: How do you diagnose AD?
  • Instability or easy irritability of vasomotor nerves (Wise and Sulzberger, 1993)
  • Pruritis, flexural lichenification or linearity in adults, and facial and extensor involvement in infants and children (Hanifin and Rajka, 1980)
  • An itchy skin condition (UK Working Party, 1994)
  • Pruritus and eczema (American Academy of Dermatology, 2014)
• Pearl 3: Is there a classic presentation of AD?
  • AD is more heterogenous than we once thought.
  • Classic descriptions of AD are narrow, simplified, and overlook the most important aspects of the disease.
  • There is a wide variety of AD lesions that are not scaly patches – prurigo nodules, lichenoid papules, and follicular eczema.
  • There are distributions that are not in theD flexures – extensors, head/neck, and hand/foot.
  • Consider non-itch symptoms – skin pain and mental health.
  • Consider eczema beyond the “winter itch” – incidence, chronicity, and persistence.
• Pearl 4: What else do you keep in mind with AD?
  • There are 7 different types of eczema – AD, seborrheic dermatitis, stasis dermatitis, nummular eczema, dyshidrotic eczema, neurodermatitis/LSC, and contact dermatitis.
  • Consider the differential diagnosis list – other papulosquamous disorders (psoriasis), immunobullous disease (pemphigoid), lichenoid disease, infection (tinea), infestation (scabies), drug reaction, immunodeficiency, genodermatoses, nutritional deficiencies, and cancer.

Next, Dr Lewitt took over and discussed 8 pearls for psoriasis.

• Pearl 1: Perform the comprehensive examination.
• Pearl 2: Understand the importance of documentation.
  • Treatments are expensive and often met with resistance from managed care.
  • Your clinic note is the best ammunition; use easy tools (subjective and objective) to build your ammunition.
  • Take pictures.
• Pearl 3: Learn how psoriasis presents in skin of color.
  • It may appear differently in darker Fitzpatrick skin types.
  • The stage may be advanced when the patient presents.
• Pearl 4: Know the tools in your toolbelt. New and approved drugs in 2022:
  • Tapinarof 1% cream
  • Roflumilast 0.3% cream
  • Deucravacitinib
• Pearl 5: Don’t be so quick to switch.
  • The AAD-NPF Guidelines recommended switching to improve efficacy, safety, and/or tolerability.
  • Not all changes may result in improvement.
• Pearl 6: Consider treatment choices for stubborn areas, such as:
  • Intralesional Kenalog
  • 308 nm laser device
  • Topicals – corticosteroids, vitamin D analogues, retinoids, and combination productions
• Pearl 7: Know your vaccines.
  • Be cognizant of which age- and/or disease-state recommended vaccines are live-attenuated.
  • Inquire about foreign travel.
• Pearl 8: Do your part to improve/maximize adherence.
  • Define Interval visits/expectations on day 1.
  • Utilize a biologics “card,” systemic “spreadsheet,” and biologics phone extension.
  • Understand copay assistance and its nuances.

Lastly, Dr Svoboda discussed advances in lymphoma therapy, with emerging and new skin-directed therapy and systemic therapy for patients with early and advanced mycosis fungoides and Sezary syndrome.

Hypericin photodynamic therapy is on the horizon as a novel approach to early stage (IA-IIA) mycosis fungoides. It has comparable efficacy to established skin-directed therapies, but without the acute and cumulative toxic effects seen with other treatments. It is also a simple, in-office treatment.

Mogamulizumab is a potent systemic therapy that is increasingly being used to treat advanced mycosis fungoides and Sezary syndrome. Even if you do not work in a cutaneous T-cell lymphoma treatment center, you may see a patient on this medication. By having knowledge of this entity, a general dermatologist can have a treatment-altering and life-changing impact.

Reference

Chovatiya R, Lewitt GM, Svoboda RM. Early dermatology practice pearls. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.