2017 Meeting Summary
HIGHLIGHTS FROM PDA’S 2017 SPRING TRAINING
By Tina Suneja, MD, Kaiser Permanente - Colorado
The Pacific Dermatologic Association’s (PDA) 6th Annual Spring Training was held on April 22, 2017, at the picturesque Scottsdale Plaza Resort in Scottsdale, Arizona. Drs. Janellen Smith and Hege Grande Sarpa again co-chaired this meeting, which was held in partnership with the Phoenix Dermatologic Society. Over 100 physicians and physician extenders were in attendance for the one-day CME meeting, which focused on “Medical Therapeutics in Dermatology”. In addition to the invited speakers, 8 residents from the University of Arizona and the Mayo Clinic Arizona presented cases of interesting and challenging patients.
Whitney High, MD, JD, MEng (University of Colorado), is a dermatopathologist and clinician who discussed challenging pigmented lesions and the ever-expanding arsenal of tools to aid us in diagnosis. These tools include immunostains, such as S-100, HMB-45, P16, and combination stains, such as KiMart (MART-1/Ki-67). Other diagnostic tools include those based in genetic analysis, such as comparative genomic hybridization (aCGH), fluorescent in-situ hybridization (FISH), and gene expression profiling (GEP). Two types of GEP tests were discussed - 23-GEP (Myriad myPath) and 2-GEP (DermTech). Dr. High also reviewed another challenging entity for dermatologists - the so-called “BAPoma”. Dr. High, also a lawyer by training, spoke about medicolegal issues in dermatology and dermatopathology. Misdiagnosis of melanoma and skin cancer are major risk points for dermatologists. Dr. High offered suggestions to minimize these risks; these include ensuring 1) the sample size is adequate, 2) the history is correct, 3) the pathology report is solid, 4) biopsy books are run regularly, and 5) communication lines are open between dermatologists and dermatopathologists.
Mario Lacouture, MD, is the director of the onco-dermatology program at Memorial Sloan Kettering Cancer Center in New York. He discussed cutaneous reactions to melanoma therapies and immunotherapies. These medications include chemotherapy, signal transduction (BRAF, MEK) inhibitors, and immune checkpoint (PD1 and PD-L1) inhibitors. Dermatologic side effects occur in the majority of patients treated with these modalities. An early and proactive approach by dermatologists is critical to ensure consistent dosing of anticancer therapies and quality of life for patients. Dr. Lacouture also spoke about the use of oncologic drugs in dermatologic disease. These medications include BRAF inhibitors for langerhans cell histiocytosis, topical rapalogues for angiofibromas and cutaneous Kaposi’s sarcoma, JAK inhibitors for alopecia areata and GVHD, and neurokinin 1 receptor inhibitors for pruritus.
John Koo, MD, (University of California, San Francisco) spoke about advances in the management of psoriasis. One new product is a new combination aerosol foam spray, which is designed to have better absorption than other topical formulations. New biologics include anti-IL 17 agents such as secukinumab, ixekizumab, and brodalumab. Dr. Koo also compared evidence-based adverse effects/risk versus anecdotal, class, and theoretical risks in FDA labeling of these agents. He concluded his talk with a discussion of a plaque-based, sub-blistering dosimetry excimer laser strategy that can achieve PASI-75 after just 2 treatments in patients with generalized plaque psoriasis. Dr. Koo is board-certified in both psychiatry and dermatology. He discussed practical treatments in psychodermatology. Dr. Koo emphasized the importance of developing a rapport with these often challenging patients. This is vital to optimize the patient’s willingness to attempt treatment and remain compliant.
Laura Pincus, MD, is the Co-Director of the Cutaneous Lymphoma Clinic at the University of California, San Francisco. She presented an overview of treatment of cutaneous lymphoma and new therapies update. Conventional treatments for limited disease (patch stage CTCL) include topical steroids and topical nitrogen mustard, and treatments for widespread disease (patch/plaque stage CTCL) include
s narrow-band UVB and PUVA. Systemic therapies are needed in tumor stage disease, as skin-directed therapies are ineffective. These systemic therapies include radiotherapy, bexarotene, methotrexate, ECP, and chemotherapies. New treatments are targeted therapies against specific genetic mutations. Such mutations include aberrancies in T-cell receptor signaling, JAK/STAT pathway, NK-kB pathway, and epigenetic alterations. In her second lecture, Dr. Pincus discussed how to evaluate an erythrodermic patient to exclude CTCL. Dr. Pincus presented several case reports, which outlined her algorithm in the evaluation of these patients. She also presented a detailed differential diagnosis for adult erythroderma. Evaluation of adult erythroderma includes a detailed examination of the skin, peripheral blood, and lymph nodes. Dr. Pincus emphasized caution with TNF inhibitors in the setting of erythroderma and the use of PD-1 as a potentially helpful immunomarker.
Jennifer Fu, MD, is a Mohs surgeon and clinical faculty in the Hair Disorders Clinic at UCSF. She presented an update on treatment of alopecia areata. She discussed a paradigm shift in how we view the pathogenesis of alopecia areata and new therapeutic modalities. Alopecia areata is now seen as a disorder of immune privilege collapse leading to pathogenic hair follicle cycling in the genetically predisposed individual. New targeted treatments include oral JAK inhibitors, which can result in near-complete, but non-durable, regrowth of hair. In her second lecture, Dr. Fu presented an update on cicatricial alopecia and the rising incidence of frontal fibrosing alopecia. She discussed pearls on how to optimize clinical evaluation/progression and treatment of these patients.
Drew Kurtzman, MD, is the Director of the Connective Tissue Disease Clinic at the University of Arizona. Prior to joining the faculty in 2016, he completed a fellowship at Brigham and Women’s Hospital in Dermatology-Rheumatology. Dr. Kurtzman presented pearls for diagnosis and management of challenging autoimmune connective disease cases, including cutaneous lupus erythematosus, dermatomyositis, and sclerosing skin conditions. In his second lecture, Dr. Kurtzman shared pearls for treating refractory cutaneous dermatomyositis, how to recognize cutaneous signs of rheumatologic diseases, and how to formulate a differential diagnosis for sclerosing disorders. He also reviewed therapies for Raynaud’s phenomenon.
PDA would also like to extend special thanks to AbbVie, Celgene, and Valeant for their sponsorship and support of the event. We look forward to a return to the desert for our next Spring Training in April 2018.