2016 Meeting Summary

PDA SPRING TRAINING DRAWS RECORD NUMBERS TO SCOTTSDALE

by Tyler Maly, MD, University of California - Irvine

The Pacific Dermatologic Association’s (PDA) 5th Annual Spring Training meeting was held on April 16, 2016 at The Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona.  Nearly 125 physicians and physician-extenders attended the one-day, symposium titled “Medical Therapeutics in Dermatology” which was a joint meeting with the Phoenix Dermatologic Society.  Drs. Janellen Smith and Hege Grande Sarpa (UC-Irvine) served as program co-chairs for the fourth consecutive year.

Susan Swetter, MD (Stanford University) is an expert in the diagnosis and management of melanoma. She serves on the National Comprehensive Cancer Network (NCCN) Melanoma Panel and reviewed the latest NCCN and American Academy of Dermatology (AAD) melanoma guidelines, emphasizing what dermatologists, pathologists, and surgeons need to know. Interesting points of discussion included principles of pigmented lesion biopsies, including excisional biopsy orientation on limbs to optimize the accuracy of lymphatic mapping. Dr. Swetter also discussed guidelines for melanoma work-up and surveillance, noting that routine imaging and lab tests for stage I and II melanomas is not recommended in asymptomatic patients. In her second lecture titled, “Challenges of Treating Melanoma In Situ, Lentigo Maligna Type”, Dr. Swetter discussed the benefit of broad shave biopsies over smaller scouting punch biopsies when a large pigmented lesion concerning for lentigo maligna (LM) is encountered. She also highlighted the utility of Wood’s lamp in evaluating LM margins prior to excision. Relative contraindications to surgery and the role of imiquimod as both primary and adjuvant treatment for LM were also reviewed.

Kevin Cooper, MD (Case Western Reserve University) first presented his algorithmic approach to treating psoriasis. A co-inventor of the first biologic therapy for psoriasis, Dr. Cooper led a detailed discussion of patient factors to consider when selecting topical, oral, and/or injectable therapies. He also discussed the latest molecular research linking psoriasis with cardiovascular disease. In his second lecture titled, “Cutaneous T Cell Lymphomas; Run, Pass, or Punt?”, Dr. Cooper first discussed the diagnosis and work-up of CTCL and its subtypes before providing a staged-based approach to management. Beyond topical and light therapies, Dr. Cooper reviewed the use of systemic retinoids and HDAC inhibitors for more advanced disease, emphasizing the dermatologist’s unique ability to determine their level of involvement in patient care as new therapies continue to emerge.

Harper Price, MD (Phoenix Children’s Hospital) gave two exciting pediatric lectures at this year’s Spring Training. In “Vascular Tumors in Children: When to Work-up and When/How to Treat”, Dr. Price importantly noted that the most rapid growth of infantile hemangiomas (IH) occurs between 5.5 and 7.5 weeks of life, which is when dermatologists have the best opportunity to mitigate this growth and related anatomic/functional complications of IH. She also highlighted recent changes in our understanding of the natural course of IH, urging providers treat or refer early and not wait to see if lesions will involute with time, as the latter may result in permanent disfigurement. She also discussed high-risk features, appropriate work-up and treatment of IH. In her second lecture, “Moles in Children and When to Worry”, Dr. Price reviewed clinical and dermoscopic features of benign scalp and acral melanocytic nevi in children, noting that benign lesions in children often have worrisome features when using traditional ABCDE criteria. Interestingly, she cited research by Cordoro KM et al. suggesting the standard ABCDE system fails to recognize over half of childhood melanomas. Additional ABCD detection criteria (Amelanotic; Bleeding, Bump; Color uniformity; De novo, any Diameter) used together with conventional ABCDE criteria may facilitate earlier recognition and treatment of melanoma in children.

Joseph Merola, MD (Brigham and Women’s Hospital) is a board certified dermatologist and rheumatologist with a special interest in autoimmune diseases of the skin and joints. In his “Psoriatic Arthritis for the Dermatologist” talk, Dr. Merola highlighted the pathophysiology shared by skin and joints in psoriasis and psoriatic arthritis (PsA), noting increased risk of PsA in patients with scalp, nail and intertriginous involvement. He also reviewed key questions dermatologists should ask when screening for PsA, physical exam findings such as enthesitis that help distinguish PsA from RA, and labs/imaging to consider prior to referral to rheumatology. Interestingly, Dr. Merola noted that TNF-inhibitors are the only current therapies uniquely equipped to treat all types of musculoskeletal involvement, whereas traditional treatment with DMARDS such as methotrexate do not adequately treat axial disease, dactylitis, or enthesitis. In his riveting lecture on connective tissue diseases, Dr. Merola discussed his approach to screening patients with cutaneous lupus erythematosus for systemic involvement. In addition to CBC, basic metabolic panel, and ANA, he noted the utility of urinalysis as an excellent screen for nephritis. Importantly, an ANA only needs to be checked once, and that a titer of 1:160 or higher should be considered positive. A fascinating overview of drug-induced lupus was also presented, noting clinical features and auto-antibody profiles are drug specific. Dr. Merola’s last pearl was the use of acral botox injections for the treatment of recalcitrant Raynaud’s phenomenon.

John Zone, MD (University of Utah) kept attendees on the edge of their seats throughout his two immunobullous lectures. An expert in blistering disease of the skin, Dr. Zone first reviewed immunopathology and serology of common immunobullous diseases, noting that up to 20% of patients with bullous pemphigoid (BP) may never develop blisters/bullae, but will still have positive BP serologies. Therefore dermatologists should consider IIF and/or DIF to rule out BP in appropriately selected pruritic patients without blisters. Attendees also enjoyed a case-based review of dermatitis herpetiformis and cicatricial pemphigoid. Lastly, Dr. Zone illustrated the value of monitoring patient response to treatment via disease specific antibody titers. In his second lecture titled, “Treatment of Immune Disease – When and How”, Dr. Zone reviewed exciting data demonstrating efficacy of omalizumab for BP, and IVIG for scleromyxedema. Anticipating, preventing and managing side effects of systemic steroids were also discussed. Dr. Zone stressed the importance of ‘putting yourself in the patient’s shoes’ when considering treatment options before providing his own detailed approach to treating immunobullous diseases.

Rachel Kornik, MD (University of California, San Francisco) dazzled attendees with diagnostic and therapeutic pearls for female genital dermatoses. In her first lecture on vulvar ulcers, Dr. Kornik emphasized the high frequency of co-existent pathology in the female genital area, often requiring multiple directed therapies to achieve optimal outcomes. She reviewed exam findings that aid in distinguishing female genital dermatoses, such as ‘knife-like’ linear ulcers in vulvar Crohn’s disease. Finishing strong, Dr. Kornik’s final lecture titled, “Lichen Sclerosus Without Hocus Pocus”, was filled with excellent case-based discussions and treatment pearls for lichen sclerosus, such as the need to address associated atrophy secondary to estrogen deficiency. Interestingly, herpes outbreaks during treatment with topical steroids can present as unusual fissures or large ulcers. Dr. Kornik recommends asking about a history of genital herpes before starting high potency steroids for the treatment of genital lichen sclerosus and consider treating with prophylactic antiviral therapy while using topical steroids. Lastly, Dr. Kornik provided management pearls for simple and complicated cases of female genital lichen sclerosus.

Spring Training attendees also enjoyed a potpourri of impressive and rare cases presented by residents from the University of Arizona and Mayo Clinic Arizona. Syphilis re-asserted itself as the ‘Great Mimicker’, along with an unusual case of scarring alopecia, acquired acrodermatitis enteropathica, and cutaneous EBV-positive plasmablastic lymphoma, to name a few.

Special thanks to AbbVie and Celgene for their sponsorship.  We look forward to working with the Phoenix Dermatologic Society and returning to Scottsdale for our 6th Annual Spring Training Meeting in April 2017.