Proceedings of the Fifth SKIN SPECTRUM SUMMIT
Supplement to February 2020 The Chronicle of Skin & Allergy, presented in cooperation with the Journal of Ethnodermatology
Supplement to February 2020 The Chronicle of Skin & Allergy, presented in cooperation with the Journal of Ethnodermatology
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Proceedings of the Fifth
The Chronicle
of SKIN & ALLERGY
Supplement to
The Chronicle of
Skin & Allergy,
February 2020
SSS-2019 02-10-20_Layout 1 2/12/2020 5:17 PM Page 2
From the
SKIN
SPECTRUM SUMMIT
CURRUCULUM
CHAIRS
February 2020
Will you join us in supporting diversity and inclusiveness in dermatologic care?
Dear Colleague:
D R. GARY
SIBBALD DR R. DANIELLE MARCOUX DR. JASON RIVERS
Derma tologist and Internist
Professor of Medicine and
Public Health, University of Toronto
Derma tologist
CHU Sainte-Justine
University of Montréal
Dermatologist
Clinical Professor of Dermatolog
y
University of British Columbia
We welcome you to this annual edition of the Proceedings of Skin Spectrum Summit.
As these Proceedings are being distributed, we are preparing the sixth annual iteration of the Summit,
a live Continuing Medical Education event. This year’s conference will be national in scope and will
be held at the Chestnut Conference Centre of the University of Toronto on Saturday, April 18. You are
encouraged to register and attend this accredited session.
It strikes us that several things have changed since the first Summit was held in 2014. Interest in the
clinical subject of Ethnodermatology has grown demonstrably over these years, and we are gratified to
have played a role in raising awareness. Practitioners and researchers are gaining practical therapeutic
knowledge, through observation, trials, and genomic research, about the traits shared across our different
lineages -- as well as some factors that may somewhat distinguish us.
Our primary goal has been to facilitate better care for our Canadian communities.
The celebration of diversity and inclusiveness are key to the Canadian character, and the provision
of access to care for all has become the principle that in several ways defines who we are as a nation. Yet,
we note with concern from watching the evening newscasts that there is by no means universal acceptance
of these humanitarian values; moreover, in certain jurisdictions there are controversies affixed to
providing clinical care to immigrants and refugees.
As we have stated in previous editions of this publication: as physicians, we know that levels of
melanin may represent in several meaningful ways the least of our differences. We are all ethnic, and we
are all continuously learning from, and teaching each other.
We hope you will join our eminent faculty for the 2020 Skin Spectrum Summit in Toronto for a lively
and rewarding exploration and exchange of knowledge
concerning the treatment of cutaneous disorders
in different populations, particularly those
with Fitzpatrick skin types III through IV.
Please enjoy this monograph, and do consider
attending this year’s national Skin Spectrum Summit.
You may register at the conference website,
www.skinspectrum.ca
Published annually
as a supplement to
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ACNE
Acne management
DR. AFSANEH AlAvi ..............................................................................................................4
Topical clindamycin-tretinoin an effective Tx option for acne
DR. MONiCA K. li ........................................................................................4
Treating hormonal acne in women
DR. RENiTA AHluwAliA................................................................................5
Conveying the rationale of acne Tx to patients
DR. ANDREw F. AlExiS..................................................................................6
Topical scar management
DR. JERRY TAN ............................................................................................7
Mitigate acne scarring by treating it immediately
DR. CATHERiNE MAARi..................................................................................7
intermediate systemic acne treatment
DR. JERRY TAN ............................................................................................8
Choosing appropriate acne therapy
DR. JERRY TAN ............................................................................................9
ATOPIC DERMATITIS
Clinical presentation of AD in children with skin of colour
DR. DANiEllE MARCOux ..................................................................................................10
Myths and misconceptions in AD
DR. KEviN PEHR..................................................................................................................10
Skin barrier function plays an important role in AD
DR. AFSANEH AlAvi ..........................................................................................................11
Optimizing topical therapy in AD
DR. MAHA DuTil ................................................................................................................12
Steroid sparing and reducing flares in AD
DR. KATiE BElEzNAY..........................................................................................................12
Morphologic variants of AD in skin of colour
DR. MARiSSA JOSEPH ........................................................................................................13
Patients with AD are genetically predisposed
DR. iSABEllE DElORME ....................................................................................................14
Educating patients about AD, complications
DR. MARCiE ulMER............................................................................................................14
AESTHETICS & HAIR
Safe, effective aesthetic Tx in skin of colour
DR. HANEEF AHiBHAi ........................................................................................................16
How does skin aging differ among races?
DR. MARiSSA JOSEPH ........................................................................................................16
Grooming practices for Afro-textured hair
DR. RENéE A. BEACH..........................................................................................................17
Traction alopecia in men wearing turbans
DR. RENéE A. BEACH..........................................................................................................17
Diagnostic dilemmas and treatment options in Afro-textured hair
DR. RENéE A. BEACH..........................................................................................................18
HYPO- & HYPERPIGMENTATION
Diagnosing and Tx options for hyperpigmentation
DR. JAGGi RAO ....................................................................................................................20
CONTENTS
Hyperpigmentation and scarring
DR. KATiE BElEzNAY..........................................................................................................21
light patches on the trunk may turn out to be progressive
macular hypomelanosis
DR. ANDREw F. AlExiS ......................................................................................................21
Tyrosinase activity contributes to hyperpigmentation
DR. RENéE A. BEACH..........................................................................................................22
Scleroderma has a similar presentation to vitiligo
in patients with skin of colour
DR. ANDREw F. AlExiS ......................................................................................................22
KELOIDS & MYCOSIS
Controlling onychomycosis and toe web bacteria
DR. GARY SiBBAlD ............................................................................................................24
Treatment of keloids
DR. RENéE A. BEACH..........................................................................................................25
PSORIASIS
How to spot psoriasis in Fitzpatrick skin types v and vi
DR. ANDREw F. AlExiS ......................................................................................................26
Common areas, modalities of treatment and subtypes of Pso
DR. GARY SiBBAlD ....................................................................................26
Treating mild, moderate and severe psoriasis
DR. CATHERiNE MAARi ..............................................................................27
Clearing of psoriasis plaques may not mean the
end of treatment for patients with skin of colour
DR. ANDREw F. AlExiS ..............................................................................28
Signs of psoriasis
DR. JAGGi RAO ..........................................................................................28
Treating scalp Pso in women of African ancestry
DR. ANDREw AlExiS ..................................................................................29
ROSACEA
Treatment options for rosacea
DR. KEviN PEHR..................................................................................................................30
Rosacea management: Early Dx reduces morbidities
DR. MAHA DuTil ......................................................................................30
Rosacea underreported, underdiagnosed in patients with skin of colour
DR. MONiCA K. li ......................................................................................31
MELANOMA, SUN PROTECTION
when brown patches are not melasma
DR. ANDREw F. AlExiS ......................................................................................................32
The three basic methods for sun protection
DR. SuNil KAliA........................................................................................33
WOUND MANAGEMENT
Sickle cell disease may complicate ulcers in patients of colour
DR. BRiAN KuNiMOTO ......................................................................................................34
Risk factors for diabetic foot ulcers and
what to look for in an initial foot exam
MARiAM BOTROS ....................................................................................35
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ACNE
Acne management
Dr. Afsaneh Alavi
4 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
According to Dr. Afsaneh
Alavi, the key to determining
the best course of action
for acne treatment and management
is consulting with patients
on how they feel and their perception
of their condition. Dr.
Alavi discussed acne management
strategies at Skin Spectrum Summit
in Toronto.
Acne has four pathogenic factors:
an alteration in the keratinization
process, sebum production by
the sebaceous gland, release of inflammatory
mediators into the skin
and P. acnes follicular colonization.
Studies have shown that a certain
phenotype of acne responds
better to topical treatment. Dr. Alavi
suggests a combination of retinoids
and benzoyl peroxide as a single
agent for the first line of therapy for
comedonal and inflammatory acne.
During her presentation, Dr.
Alavi alluded to a survey of 3,000 to
4,000 dermatologists and non-dermatologists,
which showed that only
50% of dermatologists use retinoids
in the management of acne. For
non-dermatologists, fewer than 30%
were using retinoids as a treatment
option.
“Retinoids are a great treatment
in the management of acne,” she
said. “What may be the barrier for
treatment using retinoids is dryness
of the skin and irritation that counselling
and using moisturizer can resolve.”
For pregnant women, azelaic
acid, either 15% gel or 20% cream, is
an option when treating post-inflammatory
hyperpigmentation.
Topical and systemic antibiotics
should not be used as a monotherapy
in the management of acne, said
Dr. Alavi.
“Experts use neither topical
[nor] systemic antibiotics as a single
agent as a treatment for a patient
with acne,” Dr. Alavi said, “because of
resistance.”
Isotretinoin is the first line of
therapy for very severe acne, such as
cystic and conglobate acne.
“The recommendation is that if
you have a patient [who] at the end
of treatment … still has acne, you
proceed [with isotretinoin] until the
final clearance,” said Dr. Alavi.
Acne flares can also be eliminated
by initiation of a low dose of
isotretinoin.
For maintenance, Dr. Alavi recommends
topical retinoids with or
without benzoyl peroxide. Topical
antibiotics should not be used as
acne maintenance therapy.
Laser, intense pulsed light and
photodynamic therapy should not
be considered first-line therapy for
inflammatory acne.
“If other treatments fail, [these
therapies are] an option,” she added.
Topical
clindamycintretinoin
an effective
Tx option
for acne
Dr. Monica K. Li
Topical combination treatment
options are now being
recommended in North
America and Europe as one of the
first-line therapies for patients
with acne, said Dr. Monica K. Li
during her presentation at Skin
Spectrum Summit in Vancouver.
“There are different synergistic
and additive mechanisms of action
when using a topical combination approach,
which will then target multiple
pathogenic factors underlying the
progression of the acne,” said Dr. Li.
“The topical combination approach
allows for better patient compliance
because there are less
ingredients and less products that
they have to use as part of their skin
care and acne management,” stated
Dr. Li. A topical combination treatment
can also help practitioners achieve desired
treatment outcomes, according
to Dr. Li, because of a higher likelihood
of increased patient compliance.
One of the most effective topical
combination treatment options is a
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Dr. Monica K. Li
clindamycin-tretinoin gel (Biacna,
Bausch Health).
During her presentation, Dr. Li
discussed a clinical study that looked
at the safety, efficacy and tolerability
of clindamycin-tretinoin as a treatment
option for acne. After a 12-week
period, patients saw a significant reduction
in papules and pustules, with
results seen as early as two weeks.
Compared to tretinoin alone, the
combination treatment had a faster
onset of action by six weeks.
“Studies have shown that clindamycin
can improve the effectiveness
of retinoids,” said Dr. Li.
“Topical retinoids can improve the
penetration of other active agents,
allowing for better concentration
and penetration into the pilosebaceous
unit, where the formation of
the microcomedone first starts.”
Dr. Li also talked about how the
combination of a topical clindamycintretinoin
gel with a benzoyl peroxide
wash was an effective treatment option
for a patient who was uncomfortable
with systemic treatment options.
The patient was a 43-year-old female
with severe papulopustular
acne on her face and upper back.
“The severity of her presentation
warranted a course of isotretinoin....
This patient declined all of the systemic
options because she was not
comfortable with their potential
side-effect profiles,” said Dr. Li.
After four months, the patient
had some papules and pustules but
also showed significant improvement.
According to Dr. Li, the takehome
point from this case is that
“benzoyl peroxide can be added to
the combination of a topical clindamycin-tretinoin
for a triple-modality
approach where we are targeting
different pathogenic factors underlying
acne development.”
“If we look at phase III studies on
the effectiveness of the combination of
clindamycin with tretinoin across all
skin types, we can see that not only are
fairer-skinned patients doing very well
with this medication, but also those
with skin types IV to VI,” said Dr. Li.
Dr. Li’s presentation was supported
through an unrestricted educational
grant from Bausch Health.
Treating hormonal
acne in women
Dr. Renita Ahluwalia
The prevalence of acne in females is on the rise, Dr. Renita Ahluwalia
reported during her presentation at Skin Spectrum Summit in
Toronto.
“Fifty per cent of women in their 20s and 35 per cent of women in their
30s experience acne,” said Dr. Ahluwalia. “The main age of referral for women
with acne has increased by eight years over the last decade, from 18.5 to
26.5.”
During her talk on acne in the female patient, Dr. Ahluwalia spoke about
how it is important to consider hormonal factors when treating female patients
with acne. “Up to 85 per cent of adult women complain that their acne
flares a week before their period, with hormonal flares higher in women over
age 30 compared to younger women.”
When treating hormonal acne, it can be helpful to consider the etiology of
the acne. Prior to a woman’s menstrual period, a woman experiences an increase
in her progesterone and estrogen, which can stimulate the premenstrual
acne flare.
Dr. Ahulwalia talked about how a combination topical regimen of clindamycin
phosphate 1.2%/tretinoin 0.025% [Biacna, Bausch Health] and topical
dapsone 5% [Aczone, Bausch Health], along with an over-the-counter benzoyl
peroxide cleanser and supported with the hormonal birth control spironolactone,
was an effective treatment for a patient with severe hormonal acne.
“What is really unique about the tretinoin in this [topical combination product]
is that there are two forms of it: one that is immediately available and one
that solubilizes slowly by going into the skin and into the follicle to increase
penetration,” said Dr. Ahluwalia. “Another key point about the tretinoin in this
product is that it is not degraded by sunlight or benzoyl peroxide.... The delayed
release of the second form [of tretinoin] and its small particle size [allow]
it to enter into the pilosebaceous unit and target those resistant P. acnes.”
In a three-week head-to-head trial, patients treated with the
clindamycin/tretinoin combination product had less stinging, scaling and erythema
compared to those receiving a combined product of adapalene and
benzoyl peroxide. There was also a 50 to 60% decrease in both inflammatory
and non-inflammatory lesions after 12 weeks.
“[Topical dapsone 5%] works better in female patients,” said Dr. Ahluwalia.
“Studies have shown that 48.6 per cent of women achieve clearer skin [compared
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to] 34.4 per cent of men.” Dr.
Ahluwalia also stated that this product
works on both inflammatory and noninflammatory
lesions and patients are
sustaining treatment results for over a
year.
A Canadian study on topical
dapsone 5% treatment in 101 female
patients showed very effective
results. Using the global acne grading
score as a measuring tool, 69%
of patients achieved success.
After three months of the topical
combination regimen, Dr.
Ahluwalia's patient had noticeably
improved skin but was not completely
clear of acne. It was to further
target the hormonal
component of her patient’s acne
that Dr. Ahluwalia prescribed 100
mg daily of spironolactone.
“When there is a hormonal component,
we have to address that.”
Dr. Ahluwalia’s presentation was
supported through an unrestricted
educational grant from Bausch
Health.
Dr. Renita Ahluwalia
Conveying the rationale of acne Tx to patients
Dr. Andrew F. Alexis
Explaining the rationale behind
choices in a therapeutic
regimen for acne can help
patients be more confident in a
doctor’s recommendations and
encourage better adherence to
treatment, said Dr. Andrew F.
Alexis in a presentation at Skin
Spectrum Summit in Montreal.
“It helps to very briefly tell the
patient that acne is caused by four
key factors, including overproduction
of sebum — oil, in layman’s
terms for the patient; follicular hyperkeratinization,
which to the patient
you can describe as blocked
follicles; overgrowth of bacteria —
P. acnes or the new name, C.
acnes; and inflammation,” said Dr.
Alexis.
That then allows a practitioner
to explain to patients how their particular
presentation of acne is being
driven by those factors and how the
combination of recommended treatments
works to correct the situation.
He noted that benzoyl peroxide
(BPO) is frequently used in acne
treatments because not only is it antimicrobial
— without encouraging
antimicrobial resistance — it also
has some comedolytic effects. BPO
also works well in conjunction with
other agents, allowing for fixed-dose
combination products that simplify
administration while addressing multiple
pathogenic factors of acne at
the same time.
“Topical dapsone, one of the recent
additions to our topical acne armamentarium,
has a range of
anti-inflammatory effects and is
available as an aqueous gel. It tends
to be very well tolerated,” Dr. Alexis
said. He noted that studies have
looked at the efficacy of combining
topical dapsone with BPO or with a
fixed-dose combination of BPO and
the retinoid adapalene.
“When we do it like this, we use
[topical dapsone] once a day — offlabel
instead of … twice a day — and
use the retinoid formulation in the
evening, typically,” he said.
“One word of caution is when
you combine topical dapsone directly
with a benzoyl peroxide,” Dr.
Alexis said. “You want to do that at
separate times, not in the same
place and time. Otherwise, you can
get a tan-brown discolouration.”
Topical retinoids are one of the
most important classes of medication
in managing acne, said Dr.
Alexis. “They help to normalize follicular
desquamation but also have the
added benefit of reducing hyperpigmentation,
which, of course, is very
relevant to patients with skin of
colour.”
This class of medications is also
valuable as a maintenance therapy,
used in conjunction with another
therapy, such as an oral antibiotic, to
bring acne under control and then
used alone after the antibiotic is
stopped to prevent acne flares, he
said.
Antibiotics, although they are
effective at reducing microbial
overgrowth and have anti-inflammatory
properties, should not be
used as monotherapy due to the
risk of encouraging antimicrobial
resistance, he said. As well, the
choice of antibiotic — based on efficacy,
safety and cost — should be
explained to the patient. Minocycline,
for example, is extremely efficacious
and has a low risk of
inducing photosensitivity but can
potentially induce some unusual
side effects, including drug hypersensitivity
syndrome and pigmentation
of scars and mucous
membranes.
“There is even evidence from a
French study that patients of African
ancestry were more likely to develop
this drug hypersensitivity syndrome
from minocycline,” Dr. Alexis said.
“So when thinking about patients of
colour, this, coupled with the pigmentation
concern, makes this a
second-line agent. So we depend
more on doxycycline [in darkerskinned
patients].”
6 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
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Topical scar management
Dr. Jerry Tan
Facial scars have a strong negative impact on
quality of life and can be frequent after inflammatory
acne, noted Dr. Jerry Tan in a presentation
at Skin Spectrum Summit in Toronto.
Fortunately, there are a growing range of treatments,
including topical approaches, for not only reducing
the appearance of scars but also helping to prevent
their formation.
For atrophic scars, one treatment that has been investigated
in a study of patients with acne scars but no
active acne is adapalene 0.3% gel.
“The vast majority of patients had moderate or
greater improvement in terms of overall scar severity,”
said Dr. Tan of that study. “What we saw is that the patients
also had increased deposition of collagen and procollagen,
which is what we expect if this product is going
to be able to enhance repair.”
For hypertrophic scars, which are more common in
reactive, darker skin, there are more options.
Treatments for hypertrophic scars
that have already formed include silicone
sheets and sometimes intralesional triamcinolone
acetonide injections, said Dr.
Tan. “And there are a lot of other options
now, including some of the vascular
lasers..”
However, when a lesion is progressing
from macular erythema into the beginnings
of hypertrophy, only a few
options are available for which there is
level 1 or 2 scientific evidence, he said.
These include silicone sheets and onion
extract, the latter of which has been
shown to produce good results on surgical
scars.
Another new option is a topical for-
Dr. Jerry Tan
mulation of putrescine. It has been studied in all sorts of
hypertrophic scars in a cosmetic surgery clinic, as well as
in the prevention of hypertrophic scars post-breast reduction,
said Dr. Tan.
“This product reduces the activation of tissue transglutaminase,
an enzyme that enhances cross-linking of collagen,”
he said. Excess cross-linking of collagen can make
the tissue very hard, forming a lump, hypertrophic scar or
keloidm which is undesirable.
“You want the soft [collagen] that helps to elevate and
gives you tissue structure, but you do not want excessive
cross-linking. And this agent seems to help with that.”
Crucial to preventing acne scars is getting inflammation
under control quickly, Dr. Tan said. “In acne, the
analoyg is that of a forest fire: as long as the fire is burning,
you are going to get stumps in the forest. So put out
the fire quickly.”
It is also valuable to think about the nature of an individual
patient’s scar risk. If it is mostly atrophic, there is
evidence for topical
retinoids. If there is
concern about hypertrophic
scars and the
patient already has
some, still has active
acne and is receiving
surgery on areas at
high risk of hypertrophic
scars — particularly
a patient of
colour — “then you
may really want to consider
some of these
topical options to help
mitigate [the] risk of
scar formation.”
Mitigate acne
scarring by
treating it
immediately
Dr. Catherine Maari
It is important to treat acne immediately
when you see that
some scarring is occurring to mitigate
potential life-long scars. This
was a point made by Dr. Catherine
Maari during her presentation at
Skin Spectrum Summit in Montreal.
“Even if the acne is not severe
but the presence of scars is seen, we
need to intervene and treat aggressively
because once there are scars,
they are very difficult to remove,”
said Dr. Maari.
During her presentation, Dr.
Maari described the case of a patient
she was not initially seeing for
acne but who had acne with scarring
that had not been treated. The patient
was initially resistant to treatment.
However, after completing a
course of isotretinoin, his acne
cleared, but he was still left with permanent
scars. “I wish I had seen this
patient earlier,” said Dr. Maari. “Any
time you see severe acne scarring
but are not comfortable prescribing
oral medication or isotretinoin, make
sure to refer the patient [to a dermatologist]
right away.”
It is also important to treat milder
acne, according to Dr. Maari, espe-
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cially in patients with skin of colour
when post-inflammatory hyperpigmentation
is seen. “Even if the scars
are not punch-out, hyperpigmentation,
once there, can last for months
or even years,” she said.
In addition, the importance of
treating acne in skin that is prone to
hyperpigmentation, regardless of the
severity, was emphasized by Dr.
Maari. “If the patient has one to two
papules or pustules a month but
each leaves a hyperpigmented macule,
they eventually add up and can
cause cosmetic concern to the patient.
This type of patients are the
ones we want to treat earlier to try to
better contral the acne. I will be more
aggressive with these patients to try
and control pigmentation.”
Dr. Maari outlined potential
treatment options for various types
of acne. For comedonal lesions, she
recommended the use of topical
retinoid. For inflammatory lesions,
she suggested either antibiotics or
benzoyl peroxide. Patients who have
sebum secretion should be treated
with isotretinoin or oral contraceptive,
and patients who have a mixed
acne can be treated with a combination
treatment, such as clindamycintretinoin
(Biacna, Bausch Health) or
other combination treatments.
“Do not underestimate the impact
of acne. I tailor my treatment
according to the needs of the patient,”
she said.
Dr. Maari’s presentation was supported
through an unrestricted educational
grant from Bausch Health.
Intermediate systemic acne treatment
Dr. Jerry Tan
Systemic therapy for acne represents an array of
effective treatments beyond antibiotics and
retinoids, but some of the “common wisdom”
regarding their use is incorrect, according to Dr. Jerry
Tan, who spoke at Skin Spectrum Summit in Toronto.
During an intermediate overview on acne, Dr. Tan
talked about systemic treatments, including oral antibiotics
and isotretinoin, but also spironolactone oral contraceptive
pills for female patients, antihistamines and
lifestyle changes.
Regarding oral antibiotics, he suggested avoiding
minocycline in favour of tetracycline or doxycycline. “The
problem with minocycline [is that] it is one of the only … cyclines
that has been associated with a high risk of [issues
such as autoimmune hepatitis and drug-induced lupus]….
Of the different moieties of cyclines, this seems to be the
most allergenic of them all. So if you can avoid it, why not?”
Avoiding this antibiotic is also supported by a lack of
evidence that it works any better than the other cyclines,
Dr. Tan said.
“If you are looking to reduce the risk of antibiotic resistance,
add BPO washes, add BPO gels. Limit [antibiotic]
use to three months.”
For female patients, spironolactone-based oral contraceptives
are another effective option, he said.
“The overall quality of evidence we have for spironolactone
in acne is low,” said Dr. Tan. “But I have to tell you,
based on the sessions with other acne experts and people
who treat a lot of acne, this is one of those unheralded
heroes in our toolkit. And the reason is it works so
well; it is so smooth and has so few side-effects.”
He mentioned a hybrid systematic review that found
spironolactone 100 to 200 mg/day reduces inflammation
and inflammatory lesion counts. Higher dosing was associated
with an increased risk of side–effects — breast
tenderness and irregular menstrual periods — so Dr. Tan
recommended starting patients at 50 mg/day, slowly increasing
to 200 mg and then slowly lowering the dose if
the acne comes under control.
Contrary to common thought, routine potassium
monitoring is largely unnecessary when treating acne with
spironolactone, he said, except in patients with diabetes
or kidney disease, such as type 4 renal tubular acidosis.
A Korean study from 2014 showed that adding the
antihistamine desloratadine to oral isotretinoin improves
results, Dr. Tan said. “It makes the isotretinoin work
faster, it makes it work more thoroughly and when you
actually evaluate the effect of the desloratadine, it reduces
inflammation and sebum secretion.”
As desloratadine is available over the counter in
Canada, practitioners can feel confident that it is reasonably
safe. This is particularly true for patients with premenstrual
acne flares, who would only need to take it for
a week or two at a time, he said. It could also be used to
augment another treatment for patients on topicals who
do not want to move to other systemics or for patients
concerned about antibiotic resistance.
Oral isotretinoin has a bit of a bad reputation, Dr. Tan
said, in part because some patients develop severe cheilitis.
But the frequency and severity of cheilitis are partly
due to outdated ideas about dosing the medication, he
said. Recommendations to treat to a total cumulative
dose of 120 to 150 mg/kg are a legacy of an era when
isotretinoin treatment was limited to four months, he said.
As that is no longer the case, it makes more sense to treat
to clearance rather than to a fixed total dose.
Starting a patient at a 10 mg dose and gradually increasing
it to achieve clearance, and using lower maintenance
dosing such as 0.1 to 0.5 mg/kg, can avoid or
reduce many side-effects, including cheilitis.
“It is still going to get you there. It is still going to get
the patient where they want to go.”
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Choosing appropriate acne therapy
Dr. Jerry Tan
“At the end of the road, all
you want is to maximize
outcomes, so it starts
with appropriate selection of
treatment,” said Dr. Jerry Tan in
his presentation on acne at Skin
Spectrum Summit in Vancouver.
Dr. Tan believes that successful
treatment begins with providing patients
with anticipated timelines so
that their mindset can be “based on
practical reality.” Then it is important
to select a type of treatment that is
available to each patient and follow
through with the proper application.
Dr. Tan noted that acne starts
with hormonal triggers. Some of
these hormonal triggers may include
a Western diet, dairy intake and
changes in pubertal sensitivities.
These triggers can influence sebocytes
in terms of the amount and
quality of sebum that is made. In
fact, Dr. Tan reported that “sebum
by itself can trigger acne.” Sebum
has the ability to activate inflammatory
mechanisms, leading to increased
inflammation. However, in
other cases, hormones can increase
sebum, which increases proliferation
of P. acnes, which generates lipases.
After identifying acne and its
triggers, Dr. Tan suggested the use
of a combination of treatments that
have already been proven to be successful.
Retinoids are one of the only
products that stop the development
of microcomedones. Dr. Tan emphasized
that “comedones are technically
inflammatory, and when
biopsied, inflammatory infiltrates can
be found.” To treat these, he advised
the use of a combination of topical
retinoids and benzoyl peroxide, both
of which have been known to work
against the proliferation of comedones.
However, Dr. Tan described
the importance of certifying that the
treatment is both available and affordable
to the patient.
Dr. Tan related the application
of a topical treatment to playing a
sport: “When you are thinking about
topical treatments, I want you to
think about defence. You have to
cover the field. You don’t know
where the next spots might come
from.” He emphasized the need to
engage with patients through positive
reinforcement as adherence to
the treatment requires reminders.
Dr. Tan discussed a study that discovered
that the first week after
prescription, only 60% of patients
are opening the tube; however,
when they are reminded by their
doctor, the percentage increases to
100%.
Even when the treatment has
been stabilized, Dr. Tan recommends
that patients continue with
persistent treatment as trials have
shown that maximum improvement
plateaus only at 20 weeks, after
which patients should move forward
with healthy lifestyles.
TORONTO
APRIL 18, 2020
8 am to 4 pm
You are invited to join us
at the 2020 Summit and
receive a discount on
registration fees.
See back cover
in cooperation with JOURNAL OF ETHNODERMATOLOGY • 9
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ATOPIC
DERMATITIS
Clinical presentation of AD
in children with skin of colour
Dr. Danielle Marcoux
Atopic dermatitis (AD) is more prevalent in children with skin of
colour, specifically children who are of African-American, Asian or
Pacific Islander decent, compared to children with Caucasian skin,
noted Dr. Danielle Marcoux during her presentation at Skin Spectrum
Summit in Montreal.
“Right now, around the world, one in five children have some manifestation
of atopic dermatitis. Fortunately, less than 10 per cent have moderate-severe,”
said Dr. Marcoux.
The clinical presentation of AD is different in both children and adults
with skin of colour compared to patients with Caucasian skin, she said. Different
clinical characteristics include erythema that is more grey, violet or
brown in colour; dyschromia; follicular accentuation, particularly in African-
Americans; and lichenification in Asians, and there is often extensor involvement.
Erythema is an important factor when using the SCORing Atopic Dermatitis
(SCORAD) scale to rate the severity of a child’s AD, said Dr. Marcoux. “If you
adjust the erythema score ... the child could be six times more likely to be
rated as having severe AD.” For example, “if you say there is no erythema, you
lower the score of the child.”
Dyschromia is “a source of anxiety for parents because they see changes
in colour on their children’s skin,” said Dr. Marcoux. “It is all the post-inflammatory
hyperpigmentation. When it is more round and white, we label it pruritus
alba, which [means] white scales.”
“As far as phenotypes, Asians have more well-demarcated lesions with
increased scaling and lichenification,” she noted. However, “in African
Americans, there is more extensor involvement; there is also more perifollicular
accentuation and scattered distinct papules on the extensors and
trunk.”
Dr. Marcoux went on to point out the importance of education:
“Therapeutic education, in all chronic disease, is fundamental; you
don’t just hand out a prescription. [Atopic dermatitis] is disturbing to
parents; they are worried. They really need reinforcement and education.”
Myths and
misconceptions
in AD
Dr. Kevin Pehr
There are a number of ideas
about atopic dermatitis (AD)
that are outdated but are
still being referenced in practices.
Some of these were described by
Dr. Kevin Pehr at Skin Spectrum
Summit in Montreal.
“We used to say, ‘Don’t worry;
the child will outgrow [AD] when he
is a teenager’ or ‘Don’t worry; she will
outgrow it when she is an adult,’”
said Dr. Pehr. In truth, he said, 40%
of pediatric AD cases persist into
adulthood.
With as many as 10% of children
experiencing AD, that means
4% of all people could have the condition
last through their whole
childhood.
Another idea Dr. Pehr would like
abandoned is the use of antihistamines
to treat itching in AD and to
help children sleep.
“I will probably get arguments on
this. Every textbook will tell you ‘antihistamines’!
No, no, no.”
“There is no histamine release
involved [in AD],” he said. “Yes, if
you give [children] enough at bedtime,
they will fall asleep because
you drugged them with the anti-
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histamine.... It will not stop them
from scratching. If you put somebody
to sleep with whatever, and if
you do infrared cinematography,
you will see them scratching in
their sleep.”
AD often flares in the winter in
Canada due to how dry the air gets,
but practitioners should not assume
this is the season when patients’ AD
will be the worst. “The air has zero
per cent humidity; it is functionally a
desert here in winter. On the other
hand, for some people, it is the excessive
heat. So you have to ask your
patient: Is it the hot? Is it the cold? Is
it the dry? Is it the wet?” said Dr.
Pehr.
A misconception many parents
have is that being conservative in
their use of medications such as
topical steroids will help address
their children’s AD while using less
medication, he said. However,
treating to clearance is the better
choice.
“The reason I will go back to
‘treat to clear’ is they will use less
medicine overall in the long run.
Most parents—especially parents
of young children—will treat until
the child is sorta-kinda-almostmaybe-sorta
clear or perhaps a little
bit better, which means they are
constantly on and off treatment.
Treat them hard, treat them until
they are completely clear; you will
use less medicine. Even if you have
to wait until the lichenification goes
down.”
Skin barrier function plays an important role in AD
Dr. Afsaneh Alavi
Impairment to the barrier function
of the skin plays an important
role in the path o-
physiology of atopic dermatitis
(AD), Dr. Afsaneh Alavi reported
during her presentation at Skin
Spectrum Summit in Toronto.
“If you look at the pathophysiology
of the disease, even in non-lesional
skin, there is an impairment in
barrier function,” said Dr. Alavi.
“The first line of treatment for
atopic dermatitis ... is emollients,”
said Dr. Alavi. “Emollients help the
barrier to function.”
During her intermediate AD
overview presentation, Dr. Alavi
posed two questions to the delegates
in attendance: “If barrier function
is that important in terms of
[the] pathophysiology of atopic dermatitis,
could [we] prevent atopic
dermatitis if we help the barrier
function of the skin? Could we help
our patients to have less severe disease?”
She answered these questions
by discussing the findings of
the Horimukai, et al. study published
in The Journal of Allergy and Clinical
Immunology (2014; 134(4):824–830).
During the study, 59 neonates
who were considered at high risk for
AD had an emollient moisturizer applied
twice daily for the first 32
Dr. Afsaneh Alavi
weeks of life. The results showed
that approximately 32% fewer
neonates developed AD when compared
to the control group. “If we
can help maintain the barrier function,
we can prevent some degree of
AD. That is why [barrier function] is
so important,” said Dr. Alavi.
Current AD guidelines suggest
using an emollient moisturizer and
avoiding triggering factors as the first
line of AD management. Dr. Alavi
stressed the importance of proper
moisturization: “Lots of times, patients
come and say, ‘I use moisturizer,
but it doesn’t get better.’ In
most cases, [moisturizers] are underused.”
In adults, the recommended
amount of moisturizer per
week is 250 grams; however, according
to Dr. Alavi, most patients are not
using this amount.
The two moisturizers that are
typically prescribed to patients are
hydrophilic moisturizers and
lipophilic emollients. Both should be
fragrance free. “Lipophilic emollients
are suggested to be applied after
[active disease] to maintain moisture,”
stated Dr. Alavi.
Dr. Alavi also discussed other
treatment options for AD, including
topical anti-inflammatory agents
such as steroids and calcineurin inhibitors,
phototherapy, PDE4 inhibitors
and topical JAK inhibitors.
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Optimizing topical therapy in AD
Dr. Maha Dutil
Topical treatment of atopic dermatitis (AD) involves
a multi-angle approach for both managing
flares and ongoing maintenance, but there
are both well-established therapies and new agents
for this condition that can produce improvement.
That was one message Dr. Maha Dutil included in her
presentation on AD at Skin Spectrum Summit in
Toronto.
The basis of any care regimen is emollient use, Dr.
Dutil said, noting that studies have shown that moisturizing
alone can improve the eczema score. Bathing habits,
too, are a non-medical factor that can impact AD symptoms,
she said, recommending that patients with AD only
bathe once every two to three days to reduce the drying
effect.
Topical treatments for AD include topical steroids,
topical calcineurin inhibitors (CNIs) and PDE4 inhibitors.
Steroid phobia is common even though, when used
properly, steroids are very valuable, she said.
“If you counsel the patient and use low- to mediumpotency
steroids, you do not really have many side effects,”
Dr. Dutil said. “There is a long history of safety
when used correctly, and they are very effective at cooling
inflammation down quickly. They relieve the itch, and
they are inexpensive.”
She recommends prescribing low-potency steroids
for the face and folds and mid-potency steroids for the
body, arms and legs. “I leave the high-potency [steroids]
… for the palms and soles.”
For patients who do not respond to a topical steroid,
have developed a side-effect or an intolerance or have
become dependent due to overuse, Dr. Dutil says switching
to a topical CNI or a PDE inhibitor could be a good
choice.
Topical steroids should also be avoided in adolescents
or preadolescents. “If you happen to hit them during
their growth spurt with a topical steroid, you increase
12 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
the risk of sideeffects,”
she said.
CNIs “suppress
inflammation
by inhibiting
calcineurin-dependent
T-cell activation.
They are
anti-inflammatory
without being antiproliferative.
They improve
skin barrier function,
and they reduce
Staph.
carriage.” With these products, patients should be counselled
that approximately 20% of patients experience a
transient burning sensation on application, lasting
roughly 10 minutes, for the first few days of treatment. Although
there is a safety warning in the monographs of
these products, Dr. Dutil noted that in 20 years of clinical
experience with topical CNIs, no link has been found between
use of these products and skin cancers or lymphomas.
The newest option is PDE4 inhibitors, one of which,
crisaborole, was approved in Canada in late 2018. “Phosphodiesterase
degrades cyclic AMP and is overactive in
patients with atopic dermatitis. So by decreasing phosphodiesterase,
cyclic AMP goes up in the cell, and it reduces
inflammation,” said Dr. Dutil.
She mentioned a four-week study of PDE4 inhibitor
treatment in patients aged 2 and older with mild-to-moderate
AD. In that study, by day 29, a third of patients were
clear or almost clear, with a two-grade improvement. “It
helps the itch within a week. It is probably because cyclic
AMP goes up in all the cells, not just the skin cells. It also
goes up in nerve cells. That may be an effect.”
Steroid sparing and
Dr. Katie Beleznay
Individuals with very dark skin
may be at elevated risk of developing
atopic dermatitis
(AD). That, combined with the
chronic nature of AD and the tendency
for darker skin to develop
difficult-to-treat post-inflammatory
pigment changes, suggests
that encouraging treatment adherence
and reducing the frequency
and severity of AD flares
are particularly important in this
population.
This was a point brought up by
Dr. Katie Beleznay in a talk at Skin
Spectrum Summit in Vancouver.
Dr. Beleznay said that on presentation
many patients expect she
will be able to cure their eczema.
“And I say, This is a chronic condition,
similar to high blood pressure
or diabetes,’” she said. “Some conditions,
some people get them despite
everything you do. What we are
going to do is try to help you manage
it better.”
She said she often illustrates the
cycle of AD to patients by drawing a
sinusoidal curve, explaining that the
peaks of the curve represent AD
flares. She tells patients, “Our goals
with treatment [are] to reduce the
peaks—the severity of the flares—
and … increase the time between
the flares.”
The cornerstone of any treat-
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and reducing flares in AD
ment program, however, is adherence,
Dr. Beleznay said.
“I … ask people about vehicle
preference because the best cream
is the one that a patient will actually
use. If I give them an ointment, but
they are never going to use it because
it is too greasy, even though
it may be a little bit more potent
[than a cream] or might work a bit
better in a specific area, it is not
going to do any good if it sits on
their shelf.”
Another factor impacting patient
adherence is fears—warranted or
not—patients have regarding some
active ingredients.
“In my practice, I mention
steroids, and people sometimes say,
‘No, there is no way I am using that.
It is terrible; it thins the skin,’” she
said.
One way to address this concern
is to use a topical calcineurin inhibitor
(TCI) for milder AD or for
maintenance between flares, Dr.
Beleznay said.
“With the flare, when things are
quite bad, at that stage a physician
may want to consider using a corticosteroid
to calm things down. Put
the fire out, per se. Then at the
first sign a new flare is starting,
that is when a physician might
want to use pimecrolimus ... to try
and stop the flare before it gets
too extreme and harder to control.”
TCIs such as pimecrolimus and
tacrolimus have equivalent anti-inflammatory
potency to a low- to
mid-potency steroid, she said.
They can also be safely used on
the eyelids as they do not present
a risk of skin thinning the way
steroids do.
AD frequently occurs on very
visible parts of the body, such as
the face. This is particularly bothersome
in patients with skin of
colour, Dr. Beleznay said, because
even if the flares can be controlled,
they may have induced post-inflammatory
pigment changes that can
persist for a significant amount of
time.
Dr. Beleznay cautiously suggested
that there may be a lower
risk of pigment changes with TCIs.
“There are some studies that say
that steroids themselves can contribute
to hypopigmentation. Most
commonly, I think that is actually related
to the dermatitis itself not
being treated.”
“But we do use the calcineurin
inhibitors for treating some conditions
where there may be some hypopigmentation
or depigmentation,
so that is a consideration.
Dr. Beleznay’s talk was sponsored
by Bausch Health.
Morphologic variants
of AD in skin of colour
Dr. Marissa Joseph
Atopic dermatitis (AD) has different morphologic variants in patients
with skin of colour in comparison with individuals with Caucasian
skin.
This was the key message from Dr. Marissa Joseph’s presentation on AD
in skin of colour at Skin Spectrum Summit in Toronto.
According to Dr. Joseph, it is important to be aware of how AD presents itself
in skin of colour patients. “Sixty per cent of Canadians are visible minorities,
and we have the highest per capita immigration rate in the world. You
really have to think about disease processes in unique patient populations
that are becoming, to be honest, not that unique,” stated Dr. Joseph.
She described a case of a three-year-old girl who was referred to her with a
rash. Dr. Joseph said the rash had very little to no red and was more of a “dusky
grey.” She went on to say that her patient had follicular accentuation and a
lichenoid presentation. In addition, the rash was present on her extensor surfaces.
In darker skin types, “less erythema, violaceous-greyish hue [and] hypo- or
hyperpigmentation may actually be the main indicators of severity. Follicular
accentuation is quite common,” said Dr. Joseph. “Classically, we are taught that
[AD] will occur on flexor surfaces, but very commonly in darker skin types, it is
prevalent on extensors, … so that makes it a little bit difficult to differentiate it
from psoriasis.”
Another case Dr. Joseph described was of a young girl referred to her for
acne. “When we look very carefully, those aren’t comedones; those are just little
follicular bumps.” According to Dr. Joseph, eliciting specific information
from the patient was extremely important, especially in this case. “This was
super itchy for her. Very, very itchy. She was scratching, making it difficult for
her to concentrate. This would represent more of a follicular variant,” said Dr.
Joseph. She prescribed a calcineurin inhibitor, which cleared the rash, something
that would not likely happen if it was simple acne.
In another case, Dr. Joseph saw a young man with no acutely visible rash
but very itchy skin. Upon inspection, the patient had very fine flat-topped little
bumps. “This would represent a lichenoid sort of presentation,” said Dr. Joseph.
“It is not just the usual suspect of an ill-defined eruption on the flexor
areas,” said Dr. Joseph. In patients with skin of colour, AD can have “perifollicu-
in cooperation with JOURNAL OF ETHNODERMATOLOGY • 13
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lar presentations, [and there can be]
dyspigmentation in the presentation,
a lack of erythema, lichenoid presentations
and the presence [of AD] on
extensor surfaces,” said Dr. Joseph.
Patients
with AD are
genetically
predisposed
to it
Dr. Isabelle Delorme
Patients with atopic dermatitis
(AD) are genetically predisposed
to the disease,
reported Dr. Isabelle Delorme
during her talk at Skin Spectrum
Summit in Montreal.
“Atopy is when people have a
predisposition with hyperreactivity,”
said Dr. Delorme.
AD is the first manifestation of
diseases in the atopic march, followed
in order by food allergies,
asthma and rhinitis, said Dr. Delorme.
However, not all people with
atopy will have all of the diseases.
“Some people will have one; others
will have all of them. But, in general,
there is a link that exists between
the diseases,” said Dr. Delorme.
“It appears that the skin barrier
plays a role, not only in atopic dermatitis
but also in the development of food
and airborne allergies,” said Dr. Delorme.
“There is a sensitization through
the skin barrier, which is defective, and
that is where the sensitivity to food allergens,
such as peanuts or eggs, for
example, would appear to pass
through the defective skin barrier.”
AD and the remaining diseases
in the atopic march are more likely
to develop at a young age, according
to Dr. Delorme. Children who develop
food allergies are also at risk of
developing more diseases in the
atopic march. Current treatment
Providing patients with atopic dermatitis (AD), or
a family history of the condition, with good information
can help them prevent flares and
identify signs of complications.
This was part of the message Dr. Marcie Ulmer presented
during a talk at Skin Spectrum Summit in Vancouver.
“I have had a lot of patients come into my practice
very frustrated that they still have their condition,” said
Dr. Ulmer. “They will say, ‘When I was a child, my doctor
told me I would grow out of it.’ So I think it is important
we do not tell our patients that they will grow out of it because
a lot of them do not.... Up to 25 per cent of pediatric
patients have symptoms into adulthood.”
Educating patients about how vital emollient use is in
managing AD is important. Dr. Ulmer described a randomized
controlled trial of emollient use from birth in infants
with a family history of AD, which showed that daily
full-body moisturization could reduce the cumulative risk
of AD by 50% by six months.
“The conclusion was that the skin barrier enhancement
from birth is really a feasible strategy for reducing
the incidence of atopic dermatitis in high-risk neonates,”
she said. “I do recommend it to families.”
“In general, moisturizers are really the cornerstone of
guidelines recommend applying an
emollient to the skin if a child has
food allergies, regardless of AD development,
in order to protect the
barrier function.
Dr. Delorme also discussed the
role of diet in AD. “There is still a lot
of conflicting data. Currently, there is
not enough evidence to recommend
a specific diet to patients as a form
of prevention for atopic dermatitis,”
she said. However, some foods
might aggravate or exacerbate AD,
such as fast food, fruit and fish.
Dr. Delorme stressed the importance
of providing patients not only
with information but also a treatment
plan for AD. “We give patients a lot of
information, but it is good to provide
them with a treatment plan with
things clearly written down to help
them treat themselves [or their children]
properly,” noted Dr. Delorme.
Educating patients about AD, complications
Dr. Marcie Ulmer
atopic dermatitis treatment. If you only recommend one
thing, this is a very good thing to recommend. They help
prevent itch, … help reduce flare frequency and help restore
the lipid balance and skin barrier integrity. They are
shown to have a steroid-sparing effect.”
Sometimes treatment-resistant eczema may not just
be AD, Dr. Ulmer said, describing one of her own patients
with both AD and acne who presented with a tight cluster
of inflamed lesions on her chin. The lesions turned out to
be due to a herpesvirus infection.
“[Patients with AD] are prone to secondary infections
because they have reduced immunity and impaired skin
barrier function,” she said. “Staph is what we will most
commonly see. It can be methicillin sensitive or methicillin
resistant.”
Herpes infections can become disseminated—
eczema herpeticum—which can be very serious and require
hospitalization, said Dr. Ulmer. “But if caught early,
it can usually be treated orally with [valacyclovir].”
The molluscum contagiosum and human papilloma
viruses can also be easily spread by individuals scratching
their itchy AD. Fungal infections such as dermatophytes
and yeasts can also be spread this way. They are all
harder to treat in patients with AD, she said.
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AESTHETICS
& HAIR
16 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
Safe, effective aesthetic Tx in skin of colour
Dr. Haneef Alibhai
Using the correct tools and techniques for aesthetic
dermatology in darker skin can produce
good results while minimizing the risk of inducing
unwanted pigment changes, explained Dr. Haneef
Alibhai at Skin Spectrum Summit in Vancouver.
One technology Dr. Alibhai advocated for skin rejuvenation
in Fitzpatrick skin types IV through VI was picosecond
pulsed lasers.
“The beauty of the picosecond laser is it does not work
photothermally, as other lasers do. Picosecond lasers work
photoacoustically, creating a pressure wave to break down
pigment,” he said.
Rather than heating a target point, these devices cause
a phenomenon known as laser-induced optical breakdown,
which causes a pressure wave that spreads through the tissue,
reaching deeper into the dermis than the lasers could
themselves, Dr. Alibhai said. The pressure waves temporarily
alter the permeability of the cell membranes, which increases
production of elastin and collagen.
This process leads to very little downtime, “and there is
no risk of hyperpigmentation because these laser-induced
optical breakdowns are located below the dermal-epidermal
junction,” he said.
“This is a very good device to lighten unwanted pigment.
It has become my go-to to treat pigmentation on skin
types IV, V, and VI, such as your typical solar lentigines, very
safely.”
Dr. Marissa Joseph began her
talk at Skin Spectrum Summit
in Toronto by examining
the belief that there is a
difference in how individuals of
different races age.
“Is that really true?” she asked before
going on to contrast the features
of aging seen in different skin types.
Thinking about mechanisms of
Of the picosecond lasers, Dr. Alibhai said he prefers a
755 nm device as energy at that wavelength is much more
preferentially absorbed by melanin rather than oxyhemoglobin.
“If you compare it to 532 nm, where the melanin-toblood
ratio is about 2.5, or 1,064 nm, where
melanin-to-blood absorption is about 16 times, at 755 nm,
the difference between melanin and oxyhemoglobin absorption
is actually 50 times.”
This results in very limited risk of pinpoint bleeding,
minimal side-effects and less downtime while lightening pigment
and increasing collagen, he said.
Dr. Alibhai and his colleagues have begun pre-treating
darker-skinned patients with hydroquinone compounds for
the four weeks prior to their picosecond laser appointments,
he said. “That is just for our comfort and safety, so
we can sleep well at night. Just to minimize the risk of [postinflammatory
hyperpigmentation].
Many patients with darker skin have also asked about
correcting dark circles under their eyes, he said. For those
patients, particularly those with hollows under their eyes,
Dr. Alibhai has been treating them with very fine, low-cohesivity,
low-viscosity hyaluronic acid fillers, administered using
a cannula.
“You have to choose the right patient,” he noted, saying
that only three of every 10 patients are a candidate for
treating this way. “If you have the right patient, the right
product and the right technique, you get great results.”
How does skin aging differ among races?
Dr. Marissa Joseph
aging is important across all skin
types, she said.
She spoke about intrinsic aging
and extrinsic aging, making note of the
extrinsic causes of aging, such as UV
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Dr. Marissa Joseph
exposure and smoking.
But, she said, when comparing
Fitzpatrick skin types, darker skin types
tend to experience facial aging at a decreased
rate due to intrinsic factors.
Grooming practices for Afro-textured hair
Dr. Renée A. Beach
When it comes to grooming
practices for those with
Afro-textured hair, you
are considering another type of
normal, according to Dr. Renée
Beach, who presented on hair and
scalp disorders at Skin Spectrum
Summit in Montreal.
Whereas non-Afro-textured hair
types may require washing two to
three times a week, with Afro-textured
hair, weekly washing is generally
adequate enough.
“The hair can be quite fragile for
manipulation, so you really want to
According to a survey of women
aged 18 to 75, “African-American
women reported advanced signs of facial
aging on average 10 to 20 years
later than their Caucasian counterparts,”
she said.
Forehead lines in African-American
women were reported in their
50s, tear troughs did not appear until
their 60s and crow’s feet finally appeared
in their 70s, she said.
Approximately 70% of African-
American women aged 70 to 79 reported
that they still had not observed
lines around their mouths.
“There really is a delayed onset of
things like wrinkles,” she said.
Dr. Joseph went on to rank the
rate of wrinkle onset by race: black patients
experienced the slowest onset,
followed by Hispanic patients, Asian
patients and, finally, white patients.
The reason that darker-skinned patients
experience a decreased rate of
onset may be due to “a protective effect
of increased fibroblast activity,” she said.
This may also explain the increased
risk of keloids in darkerskinned
patients, she said.
This does not mean that patients
with darker skin tones don’t seek or
require treatments or improvements
for anti-aging, she said.
Dermatosis papulosa nigra, small
dark keratoses that appear on the
face and neck, was one of the examples
she gave of an aging condition
specific to people with darker skin.
“There are nuances to addressing
their specific aging concerns,” she said.
have patients [be] careful with regards
to styling practices,” explained
Dr. Beach. “The hair growth is generally
less than other hair types, and
this can be approximately half or
three-quarters of the rate of other
hair types.”
Patients in this cohort prefer to
use conditioners over shampoos
mainly because some of the slipping
agents in conditioners help
Afro-textured hair be more manageable
after it is shampooed.
As a result of the decreased
growth rate in patients with Afrotextured
hair, trimming frequency
should be reduced to twice a year
on average, according to Dr.
Beach.
Additionally, the bedtime routine
for patients with Afro-textured
hair is significant for two reasons:
first, to preserve a certain hairstyle,
and second, to minimize trauma to
the existing hair. Some patients will
apply moisturizing products but will
also protect the hair with something
silky or satiny, such as a bonnet
or particular wrap, to minimize
friction.
Traction
alopecia in men
with turbans
Dr. Renée A. Beach
Traction alopecia is a scalp
disorder that occurs commonly
in women. But as Dr.
Renée A. Beach discussed during
her presentation on hair and
scalp disorders at Skin Spectrum
Summit in Vancouver, a minority
of men, particularly men who
wear turbans, report symptoms
of the condition.
“As a dermatologist, we often
look before we ask, and when we
look, we see that there is loss of the
frontal hairline, with a fringe pattern
[of hair] remaining at the edge of the
front,” Dr. Beach said, describing the
symptoms of traction alopecia.
Female patients will show signs
of gradual hair loss as a result of a
history of wearing swept-back hairstyles,
sleek ponytails and top knots.
According to Dr. Beach, when you
question these patients, they will
admit that when the hairstyles go in,
they are painful. But both female
and male patients often accept the
pain as part of the styling process.
Signs of traction alopecia include
the fringe hair loss along the
edge of the frontal scalp. There is retained
vellus or small terminal hairs
that simply do not get swept up into
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the style. A trichoscopy can show
specific features, but this is a clinical,
bedside diagnosis that doesn’t require
further investigation.
Male patients, who are observing
Sikhs wearing turbans, are at a
greater risk for traction alopecia.
During her talk, Dr. Beach showed
examples of a dermatologist based
in India using the process of inserting
hair grafts and hair plugs in an
attempt to cure a case of traction
alopecia in male patients.
Dr. Renée A. Beach
To avoid further hair loss, patients
need to undergo significant
modification to the way they wear
the turban so that the condition
does not recur.
“Patients who are wearing turbans
or hijabs are encouraged not
to pull them tightly along the hair,”
said Dr. Beach. “Hairstyle modification
is paramount, but there is offlabel
use of minoxidil 5 per cent
foam, which can certainly help in a
subacute situation.”
Traction alopecia is a reversible
form of hair loss; however, at later
stages, a hair transplant may be the
only option for patients.
18 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
Diagnostic dilemmas and treatment
options in Afro-textured hair
Dr. Renée A. Beach
Patients with Afro-textured (AT) hair can have a
variety of issues, including seborrheic dermatitis,
traction alopecia and androgenetic alopecia.
During a talk on hair and scalp disorders at Skin
Spectrum Summit in Toronto, Dr. Beach discussed diagnostic
and treatment options for patients with
conditions related to AT hair.
Seborrheic dermatitis mainly affects the scalp, causing
scaly patches, red skin and dandruff. For treatment,
Dr. Beach recommends the use of a triple-threat therapy
including an anti-yeast, anti-inflammatory medication
and, in some cases, debris removal.
“I have a discussion with [patients] about increased
washing, at least temporarily. I ask them to wash their
scalp twice a week, which I know is really a lot for Afrotextured
hair types,” she said. “Also, [I ask them to] consider
the use of ciclopirox lotion, if they need to, a few
nights a week.”
Mometasone lotion is an option to aid with itching,
and scaling can be done with a 2% salicylic acid compound.
Although the recurrence of seborrheic dermatitis
can be limited by washing and rinsing the scalp, traction
alopecia requires patients to modify their hairstyle.
Traction alopecia is the gradual receding of the hairline.
There is hair at the front of the hairline and then
there are patches of hair with a noticeable regression.
The condition can be caused by wearing the hair in
slicked-back updos and top-knot buns.
“Patients will admit, sometimes reluctantly, to
headaches, tenderness, sometimes broken hairs with
certain hairstyles. And typically, they get a fringe sign [of
hair loss]. Patches of hair along the hairline [are] a dead
ringer for traction alopecia,” said Dr. Beach.
In addition to hairstyle modifications to reduce tension
on the scalp, Dr. Beach recommends the off-label
use of a 5% minoxidil foam. Traction alopecia is reversible
if diagnosed and treated in the early stages.
Weathering and trichorrhexis nodosa—defects in the
hair shaft—occur when there is a lack of hair growth. Hair
strands appear like broomstick hair. Patients also have
broken shafts, simple knots and complex knots throughout
the scalp. The hair has been weathered, which is
caused by heating the hair strands with a blow dryer or
ceramic straightener.
“When we heat the hair strands, they literally get air
bubbles in the shaft, and the air bubbles are tied to
breakage,” said Dr. Beach. “When patients with Afro-textured
hair dry comb their hair without any sort of product
on their hair, it can amount to a daily haircut in terms of
the breakage that they sustain.”
She suggests air-drying the hair and minimizing
the friction with a seamless comb. Products with
“slip” that contain ingredients such as glycerine, as
well as trimming off dead ends, can be helpful in
treatment.
Androgenetic alopecia is a type of hair loss common
in middle age. Affecting 40% of females and 50% of
males, androgenetic alopecia is gradual and progressive
and can be described as follicular miniaturization. Thicker
hairs turn into vellus hairs and whisk away.
This type of hair loss is a combination of genetics,
heritage and androgen activity.
Dr. Beach suggests a 5% minoxidil foam for treatment
and notes that if spironolactone is prescribed to
patients, there is a dosage difference between men and
women.
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SKIN
SPECTRUM SUMMIT
CHAIRS &
FACULTY
Dr. Renita Ahluwalia is a staff dermatologist
at Women’s College Hospital
in Toronto.
Dr. Afsaneh Alavi is a dermatologist at
York Dermatology Clinic and Research
Centre in Richmond Hill,
Ont., and is the Past President of
the Canadian Hidradenitis Suppurativa
Foundation.
Dr. Andrew F. Alexis is Chair of the
Department of Dermatology at
Mount Sinai West in New York, and
Director of the Skin of Color Center
at Mount Sinai St. Luke’s. He is also
an associate professor of Dermatology
at the Icahn School of Medicine
at Mount Sinai.
Dr. Haneef Alibhai is the Medical Director
of MD Cosmetic & Laser clinic in
Vancouver, and a Clinical Instructor
in the University of British Columbia’s
Faculty of Medicine.
Dr. Renée A. Beach is Head of the
Alopecia Clinic at Women’s College
Hospital in Toronto.
Dr. Katie Beleznay is Director of the
Vancouver Acne & Rosacea Clinic
and a dermatologist at Carruthers
& Humprey Cosmetic Dermatology
and Seymour Health Centre in
Vancouver.
Mariam Botros is the Chief Executive
officer of Wounds Canada (formerly
known as the Canadian Association
of Wound Care).
Dr. Isabelle Delorme is a dermatologist
based in Drummondville, Que.
In addition to her clinical activities,
she devotes time to Continuing
Medical Education and
operates her own research centre
dedicated to clinical research in inflammatory
diseases.
Dr. Maha Dutil is a dermatologist in
private practice, a consultant at
Women’s College Hospital in
Toronto, and Assistant Professor of
Medicine in the Dermatology Department
at the University of
Toronto.
Dr. Marissa Joseph is a pediatrician
and dermatologist and is the Medical
Director of the Ricky Kanee
Schachter Dermatology Centre at
Women’s College Hospital in
Toronto. She also works at the
Hospital for Sick Children where
she manages children with complex
dermatologic disease.
Dr. Sunil Kalia is a dermatologist and
the Co-Director of the Clinical Trials
Unit at the Skin Care Centre in
Vancouver.
Dr. Brian Kunimoto is the founding
Director of the Vancouver General
Hospital Wound Healing Clinic
from 1990 to present. He has a special
interest in wound bacteriology.
Dr. Monica K/ Li is a dermatologist
practicing at City Medical Aesthetics
Center in Vancouver and at The
Skin Doctor/Enverus Medical in
Surrey, B.C.
Dr. Catherine Maari is Associate Professor
at the Faculty of Medicine at
the University of Montreal and
practices dermatology at the
CHUM (University of Montreal
teaching hospital) and Saint-Justine
Hospital in that city.
Dr. Danielle Marcoux is a Clinical Associate
Professor at the University
of Montreal and dermatologist at
CHU Sainte-Justine in Montreal.
She is a founder and past-president
of the Camp Liberte Society, a
camp for children with dermatologic
disorders.
Dr. Kevin Pehr teaches at Jewish General
Hospital/McGill University in
Montreal, where he is Chief of Cutaneous
Lymphoma, and operates a
private practice that encompasses
medical, surgical and aesthetic
dermatology.
Dr. Shafiq Qaadri is a Toronto-based
family physician, Continuing Medical
Education (CME) lecturer,
medical writer and broadcaster.
Dr. Jaggo Rao is founder of the Rao
Dermatology Centre in Edmonton
and a full Clinical Professor of
Medicine at the University of Alberta.
Dr. Jason Rivers is a Clinical Professor
of Dermatology at the University of
British Columbia. He practices
medical and cosmetic dermatology
at Pacific Derm in Vancouver, and
is President of the Acne and
Rosacea Society of Canada.
Dr. Gary Sibbald is a dermatologist
and internist with a special interest
in wound care and education.
He is a Professor of Medicine and
Public Health at the University of
Toronto and an international
wound care key opinion leader (educator,
clinician and clinical researcher).
Dr. Jerry Tan is an Adjunct Professor at
Western University, Windsor campus
and practices general dermatology
in Windsor, Ont. He is the
Medical Director of Healthy Image
Centre for Aesthetic Dermatology
and Windsor Clinical Research Inc.
Dr. Marcie Ulmer is a dermatologist at
Pacific Derm in Vancouver where
she has a comprehensive medical
and aesthetic dermatology practice.
She is a Clinical Instructor in
the Department of Dermatology
and Skin Science at UBC.
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Diagnosing and Tx options for hyperpigmentation
Dr. Jaggi Rao
HYPO- &
HYPER-
PIGMENTATION
When dealing with patients
suffering from hyperpigmentation,
Dr. Jaggi Rao
recommends that practitioners
start by looking at why the skin is
hyperpigmented. Dr. Rao discussed
the consultation process
and treatment options for patients
with hyperpigmentation
during his presentation at Skin
Spectrum Summit in Vancouver.
There are two different categories
of hyperpigmentation:
melanotic or melanocytotic, according
to Dr. Rao. Melanotic hyperpigmented
conditions have too many
melanosomes compared to the
baseline, whereas melanocytotic hyperpigmentation
occurs when there
are excess melanocytes.
Melanotic conditions include
freckles, melasma and facultative
pigmentation. Melanocytotic symptoms
include different types of
Dr. Jaggi Rao
moles, nevus of Ota and Ito, blue
nevus and lentigines.
Using the Fitzpatrick skin phototype,
Dr. Rao suggests that doctors
begin the consultation process
by assessing the patient’s baseline
pigment, the level of pigmentation
without the disorder.
“This is reflective of the constitutive
epidermal pigmentation
that a person would have,” Dr.
Rao explained. “People who have
darker skin types … have more labile
melanocytes, and if you are
too aggressive with the treatment,
you can cause more pigmentation
or post-inflammatory hyperpigmentation.
Typically, this will happen
for Fitzpatrick skin type III to
VI.”
To achieve synergy in treatment,
Dr. Rao suggests a multiproduct
approach to effectively
treat hyperpigmented skin.
“If you can go ahead and both
prevent further pigment gain and
promote loss and do it in multiple
levels, then we will be able to have
better and safer therapy,” Dr. Rao
said.
Multi-layer therapy is another
treatment option for hyperpigmentation
Dr. Rao discussed.
Utilizing enzyme inhibitors of
the melanin pathway as well as
melanin transfer, exfoliants and antioxidants
can treat the pigments
that are excess not only in the epidermis
but also in the dermis.
“We now know that infrared radiation
can also cause free-radical
accumulation, and that might contribute
to damage,” said Dr. Rao.
Although Dr. Rao focused his
presentation on topical agents for
the treatment of hyperpigmentation,
he acknowledged that different
types of sunscreens as well as multimodality
therapy can be used to
treat the disorder.
“You can use a lot of this with
other modalities, such as laser therapies,
peels and so forth, as long as
you know how to do it properly,
you’re well trained and you have
that comfort level,” suggested Dr.
Rao.
Dr. Rao’s presentation was supported
through an unrestricted educational
grant from Vivier Pharma.
20 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
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Hyperpigmentation and scarring
Dr. Katie Beleznay
hyperpigmentation is one of the top reasons
that skin of colour patients seek dermatological care,” said Dr.
“Post-inflammatory
Katie Beleznay a presentation at Skin Spectrum Summit in
Vancouver.
Dr. Beleznay emphasized how early and effective intervention is essential to
prevent pigmentary issues and scarring. Specifically, she discussed how keloid
scarring is more common in skin of colour. In addition, for skin of colour patients,
some hair-grooming products may cause or worsen acne, leading to what Dr.
Beleznay described as “pomade acne.”
After inflammatory wounds, the pigmentation of skin can occur. Post-inflammatory
hyperpigmentation is more common in darker-skinned patients,
whereas post-inflammatory erythema is more common in patients with
lighter skin types. Dr. Beleznay stressed that these skin discolourations, although
they are not true scars as the skin is not pitted or depressed, can
last for years. Therefore, “it is important to set up expectations, how to treat
this, when will it fade, so [patients] are not thinking it is going to be gone the
next day,” said Dr. Beleznay.
Epidermal lesions may persist for up to six to 12 months, but dermal hyperpigmentation
can last for years and may be more disconcerting than acne. Facial
acne scarring occurs in 95% of patients and develops within 12 weeks. Dr.
Beleznay described how facial acne scars can manipulate the perception of an
individual, presenting a survey that found that people with clear skin are more
often associated with positive traits.
Dr. Beleznay suggested the use of oral antibiotics, which can be less irritating
to the skin than topical therapies. She named isotretinoin as a potentially
remissive treatment for acne, which was found to be safe and effective
in African-American, Middle Eastern, Asian and Asian-Indian populations.
Isotretinoin reduces sebum production by 70%, reverses follicular hyperkeratosis
to normalize epidermal differentiation, reduces P. acnes and inhibits
the inflammatory reaction, which reduces the amount of neutrophils attracted
to the troubled site.
In terms of scarring with the use of isotretinoin, Dr. Beleznay advised
that “less scarring develops in those receiving isotretinoin early in their disease
process.”
Dr. Beleznay stressed that it is important to be clear with patients as treating
acne and acne scarring can be an expensive and lengthy endeavour.
Light patches on the trunk
may turn out to be progressive
macular hypomelanosis
Dr. Andrew F. Alexis
In his presentation titled “Diagnoses
Not to Miss” at Skin
Spectrum Summit in Montreal,
Dr. Andrew F. Alexis provided information
on several tricky skin
conditions that can easily be mistaken
for something else.
Many of these conditions, he said,
are not “everyday” conditions that dermatologists
encounter in their practice.
However, one of the more
common, although often misdiagnosed,
conditions he spoke about was
progressive macular hypomelanosis
(PMH).
This condition usually appears as
white or light-coloured patches on the
patient’s trunk.
“Usually, when we see these little
hypopigmented macules that coalesce
to patches on the trunk, the diagnosis
is pretty straightforward: we think
tinea versicolor,” said Dr. Alexis.
But not all of these types of
patches on the trunk are tinea versicolor,
he said.
PMH also presents as hypopigmented
macules that coalesce to
patches that appear on the chest and
back.
“You often try to treat it as tinea
versicolor. You give [patients] every
antifungal known to man, and it just
doesn’t go away,” he said.
With tinea versicolor, fine scales
are often observed, but not with PMH.
In cases where no scale is observed
and antifungals are ineffective,
it’s often PMH, he said.
Unlike tinea versicolor, the condition
is not caused by yeast, which triggers
a fungal infection. Instead, PMH is
a bacterial infection, which he said is
thought to be mediated by the bacteria
P. acnes, also known as C. acnes.
The P. acnes bacteria can be found
using a Wood’s lamp, under which it
fluoresces.
According to Dr. Alexis, treatment
should be directed at the P. acnes
bacteria, which means using either a
topical benzoyl peroxide wash or topical
clindamycin formulations.
Resolution should happen in approximately
12 weeks, he said.
For best results, Dr. Alexis recommends
phototherapy, such as narrowband
UVB, in addition to topical
antimicrobial therapy.
“With that I hope that I have
helped to broaden the differential of
common presentation of dark spots
and light spots and patients of colour,”
he said.
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Tyrosinase activity contributes to hyperpigmentation
Dr. Renée A. Beach
Increased activity of the tyrosinase enzyme
is a contributing factor to skin dyspigmentation
according to Dr. Renée A. Beach, who
spoke at Skin Spectrum Summit in Montreal.
“When we think about hyperpigmentation, what
we are really thinking about is the enzyme tyrosinase,”
said Dr. Beach. If a person’s trigger is ultraviolet
light, for example, this “activates the tyrosinase
enzyme to enhance or increase melanin production....
Our bodies are actually doing this as a means
of trying to protect our skin; however, what happens
is, in a sense, overcompensation, which leads to dyspigmentation.”
Dr. Beach spoke about ways to inhibit tyrosinase,
resulting in an overall more even skin tone.
According to Dr. Beach, benzene-1,4 diol (hydroquinone)
is the most effective treatment option
for improving dyspigmentation. “It is used for a variety
of conditions,” she said. “I use it in practice for
Scleroderma has a similar
presentation to vitiligo in
patients with skin of colour
Dr. Andrew F. Alexis
Vitiligo is not the only cause of hypopigmentation in patients with
skin of colour, said Dr. Andrew F. Alexis in a presentation at Skin
Spectrum Summit in Vancouver.
“When there is a striking contrast of normal and involved skin and it has that
sort of milk-white appearance, it is usually vitiligo. However, not all depigmented
patches on the skin are vitiligo. We have to keep an open mind and consider
other diagnoses,” he said.
“Light patches, loss of pigment on the face, [are] a pretty common scenario
22 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
post-inflammatory hyperpigmentation; it is also
used under supervision for melasma.” Benzene-1,4-
diol is an aromatic organic compound, and when
used in the range of 2 to 4%, it inhibits the activity of
tyrosinase.
“Two per cent [benzene-1,4-diol] can be used on
all skin types to help prevent and treat hyperpigmentation,”
stated Dr. Beach. She emphasized the importance
of educating patients on the process of
benzene-1,4-diol treatment, stating that patients
need to understand that the effects are gradual and
it can take anywhere from three to four months to
produce results.
Dr. Beach also said that “patients with olive,
brown or black skin will probably notice a greater
benefit because they are generally starting off from a
higher level of dyspigmentation in many cases because
their skin depigments more readily.”
She also mentioned the importance of properly
using sunscreen to both prevent further damage
and to inhibit tyrosinase. “When we use something
like sunscreen or sunblock, tyrosinase activity is alleviated
or decreased. You get a decreased melanin
production; you get skin protection and an overall
more even skin tone,” said Dr. Beach.
Dr. Beach recommends that patients use at
least a broad-spectrum SPF 45 sunscreen because
she feels most people do not apply their sunscreen
thickly enough. “My rule is SPF 30 does not really
manifest as an SPF 30,” said Dr. Beach, meaning that
a higher SPF is needed.
“We want to help [a patient’s] pigmentation, but
part of the issue is making sure we prevent further
dyspigmentation, which is why sunscreen is an important
element,” said Dr. Beach.
Dr. Beach’s presentation was supported
through an unrestricted educational grant from
Vivier Pharma.
when treating patients with skin of colour,” noted Dr. Alexis. “While vitiligo can certainly
affect the periorificial areas of the face, ... you have to look at the whole patient,”
not just the affected areas.
During his presentation, Dr. Alexis described the case of a patient who was
referred to him with a diagnosis of vitiligo; however, further evaluation revealed
that she actually had scleroderma.
The patient, an African-American woman, had patches of hypopigmentation
on her face and trunk, but, most importantly, she had taut, bound-down skin and
a tapering of her digits.
Noted Dr. Alexis: “When scleroderma presents in darker skin, it often presents
with an associated pigment change, which might be the first thing the patient
notices, and the thing that would drive the patient to a physician or, specifically, a
dermatologist.”
Systemic sclerosis has a higher rate of prevalence in women of African-American
ancestry, usually with a worse prognosis compared to other groups, said Dr.
Alexis.
Dr. Alexis provided another example of a patient who was also diagnosed
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Dr. Andrew F.
Alexis
Dr. Danielle Marcoux
Dr. Isabelle Delorme
with vitiligo prior to seeing him, but
clinical examination, biopsies and a
serological workup were consistent
with scleroderma.
After looking at the whole patient,
he saw “areas with some hyperpigmentation
and hypopigmentation.... In
the area with the loss of pigmentation,
there is some follicular sparing, creating
a salt-and-pepper appearance,”
said Dr. Alexis. According to Dr. Alexis,
“this salt-and-pepper appearance, especially
involving the trunk, is a very
striking and common presentation of
scleroderma in darker-skin patients.”
Dr. Alexis also stressed palpating
the skin. “Don’t forget the importance
of palpation. Don’t just stand at the
edge of the bedside or doorway when
diagnosing what seems to be a pigmentary
concern.”
Dr. Marcie Ulmer
Dr. Kevin Pehr
Dr. Katie Beleznay
Dr. Haneef Alibhai
Dr. Shafiq Qaadri
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KELOIDS,
MYCOSIS
24 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
Controlling onychomycosis
and toe web bacteria
Dr. Gary Sibbald
In his presentation at Skin Spectrum Summit in Toronto, Dr. Gary Sibbald
spoke about preventing diabetic foot ulcers by first outlining
treatment for onychomycosis and toe web bacteria.
“The average wear and tear in the foot for someone who lives an average
lifespan is the equivalent of walking 115 thousand miles,” said Dr. Sibbald.
It is no surprise, then, that 75% of the population experiences foot pain at
some point, said Dr. Sibbald.
Many other physical ailments can first manifest in the foot, he said. Those ailments
include arthritis, peripheral vascular disease, cardiac disease and diabetes.
“A foot out of alignment results in discomfort and pain in the ankle, the knee,
the hip and the back,” he said.
For patients with diabetes, 85% of amputations begin with a foot ulcer, said
Dr. Sibbald. For this population, an onychomycosis infection can be especially
concerning.
“In a population of persons with diabetes, 1 per cent of them have gangrene,”
said Dr. Sibbald. For those with diabetes and onychomycosis, 5% have gangrene,
he said.
He noted that 2% of persons with diabetes and a foot ulcer will develop gangrene.
If they have diabetes, a foot ulcer and onychomycosis, the incidence goes
up to 6%.
When taking a nail clipping for culture, the most important part is to get the
subungual debris, said Dr. Sibbald.
“This is really where most of the fungus is. About 30 per cent can be falsely
negative on culture, so you may need three cultures. But if we see a KOH [test]
with fungal filaments, that’s enough,” he said.
There are 22 different conditions that can mimic fungus, Dr. Sibbald said. He
offered a piece of advice for identifying tricky cases.
“The most important pattern is distal streaking where it’s wider distally than
proximally,” he said.
If unsure about the diagnosis, he recommends 1% hydrocortisone powder
and antifungal cream.
Dr. Sibbald also talked briefly about bacteria between the toes. The tightest
toe web is typically between the fourth and the fifth toe, he said.
In patients with diabetes, this can become a problem area for bacterial and
fungal infections, so he recommends
checking in this area first before going
proximally to check the others.
“Bacteria, specifically Staph and
Strep, can get in. That causes lymphangitis
and subsequent cellulitis,
and these people end up in emergency
departments,” he said.
He recommends using 10% povidone-iodine
on this area by applying it
with a cotton applicator.
“It’ll control gram-positive, gramnegative
and anaerobic bacteria; it
will treat dermatophyte fungus,
yeast and viruses. This is a way to
keep that space clean,” he said. He
also recommends breathable
footwear for patients with this condition
Dr. Gary Sibbald
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Treatment of keloids
Dr. Renée A. Beach
The best treatment for keloids is to try to avoid them altogether, according
to Dr. Renée A. Beach, who presented on scarring at Skin
Spectrum Summit in Montreal.
“The problem with keloids is that we do not have great treatments,” Dr.
Beach explained. “We have treatments that help and treatments that work for
a subacute period, whether that is three to six months, but I always tell people
prevent it so that we do not have to have this conversation.
“If you know it is in your family or you know you have a tendency, try to
prevent it or avoid practices that are going to help form keloids.”
On top of there being no permanent removal of the scar, it is also difficult
to find surgeons who will excise keloids because they can recur in some capacity.
For a cost-effective treatment option, Dr. Beach suggests using clobetasol.
She prescribed twice-daily applications of clobetasol cream to a 19-year-old
female patient without extended health benefits.
“This is an instance where you want to use your side-effects as your therapeutic
effect,” Dr. Beach said. “Often times you will hear a patient say, ‘Oh, I
don’t want to use a steroid because it is going to thin my skin.’ This is the time
we say, ‘Exactly; this is what we are hoping for.’”
Patients using this regimen for three to five months will not improve the
colour of the scar. A Caucasian patient will end up with a flat, red scar but will
not have a keloid anymore. A patient with brown, olive or black skin can experience
hypopigmentation, according to Dr. Beach.
“Clobetasol treatment is certainly OK, as long as your patient understands
you are not doing anything to improve the colour of the keloid, and that is
across skin colours,” she said.
For a patient with an unlimited budget, Dr. Beach suggests consulting a
plastic surgeon to see if the keloid can be removed cosmetically. Therapy with
pulsed dye laser can be used to mitigate some of the redness. CO2 ablation is
also an option.
Additionally, for a patient not concerned with costs, Dr. Beach recommends
a three- to six-month course of imiquimod.
“I usually ask them to use it about four to five days a week and see them
back in about four to six weeks,” she said. “The patient needs to understand it
is going to look worse before it starts to look better. [The prescription] will
need a couple of refills; depending on their drug plan, that can get expensive.”
Dr. Jason Rivers
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PSORIASIS
How to spot psoriasis in
Fitzpatrick skin types V and VI
Dr. Andrew F. Alexis
As part of his talk on psoriasis
in skin of colour at Skin
Spectrum Summit in
Toronto, Dr. Andrew F. Alexis detailed
a number of ways that the
skin condition can present differently
in darker skin.
This was part of a larger talk debunking
myths surrounding the prevalence
of psoriasis in darker skin and
comparing the disease’s colour presentation
and shape across skin
shades.
He began his talk by discussing
how psoriasis in darker skin has come
to be understood better over the
years. Although it was once considered
a “rare” skin condition in people
of colour, Dr. Alexis debunked that
myth.
“This was due to underreporting,”
he said. “Thankfully, more recent studies
have shown that the prevalence of
psoriasis in darker skin is far from
rare; in fact, these studies have shown
the prevalence rate [to be] in the one
to two per cent range.”
As far as psoriasis in darker skin
types goes, Dr. Alexis said that sometimes
the presentation is classic; it is
usually sharply demarcated, brick red
or pink, and can have plaques with silvery
scales.
“However, once we get into the
more darkly pigmented ranges of the
spectrum, including Fitzpatrick type V
and type VI, the redness may be
masked by melanin and may start to
look a little more purple or violaceous
than red,” he said.
The sharp lines of demarcation
and characteristic scale will still be
present, he said, but because of the
purplish hue, it can be difficult to distinguish
from lichen planus, another
papulosquamous disorder.
One factor that can help differentiate
the two disorders is the location
on the body where it is found.
“Lichen planus tends to favour the
flexural side of extremities, including
the wrist and forearm, while psoriasis
will be more extensor,” he said.
The shapes of the lesions of the
two disorders differ as well, he said.
“In lichen planus, plaques tend to
be more flat topped and polygonal.”
Hyperpigmented lesions ranging
from dark brown to red brown may
appear on darker skin as opposed to
red lesions on lighter skin.
Certain skincare practices may
also hide the character of the scale. In
his presentation, Dr. Alexis gave the
example of a patient who had a nightly
routine of applying petrolatum ointment
on his scaly plaques and scraping
off the scales with a kitchen knife.
“This is a lesson to be learned as
far as asking about what patients are
doing and considering how that might
impact the clinical appearance of the
plaques in front of us,” he said.
Common areas,
modalities of
treatment and
subtypes of Pso
Dr. Gary Sibbald
In his presentation at Skin Spectrum
Summit in Toronto, Dr.
Gary Sibbald spoke about topical
treatments for psoriasis. He
discussed the “many faces of psoriasis,”
including the subtypes; the
different modalities of treatment;
and the common areas at which
psoriasis tends to manifest itself.
Psoriasis subtypes include plaque
psoriasis, guttate psoriasis, pustular
psoriasis and erythrodermic psoriasis,
said Dr. Sibbald. He went on to point
out that there is “‘A’ evidence for most
of what we do in psoriasis,” referring
to randomized controlled trials.
He said that for any patient with
5% or less psoriasis coverage, he
would recommend starting with
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Treating mild, moderate and severe psoriasis
Dr. Catherine Maari
Dr. Catherine Maari
In her presentation at Skin Spectrum
Summit in Montreal, Dr.
Catherine Maari spoke about
treating psoriasis in its different
forms: mild, moderate and severe.
Topical treatments can work best
for mild psoriasis, whereas moderate
psoriasis can respond well to phototherapy,
she said. For severe psoriasis,
she recommends biologics.
She outlined a few topical treatment
options.
“Corticosteroids are still the gold
standard,” she said.
She also mentioned a topical vitamin
D analogue, calcipotriene. “[Calcipotriene]
cream does not exist
anymore; there is only the ointment.
For the patient who does not like
greasy treatment but says, ‘I do not
want a cortisone,’ this is the only thing
you can offer,” she said.
She also said that doctors can try
a mix of betamethasone dipropionate
and calcipotriol.
For hands and feet, she recommended
using a “very strong” cortisone,
such as halobetasol propionate, clobetasol
or betamethasone dipropionate.
She also emphasized that doctors
should tell their patients to pay no attention
to the percentages listed on the prescription
packaging as the potency of the
individual corticosteroid matters more.
“They will see .05 per cent [of a
high-potency corticosteroid] and think
it must be weak and apply that on
their face. Or they will see 1 per cent
hydrocortisone and … will think that is
stronger and apply that on their body,
and it does not work.”
Be very clear about which topical
is to be used on which part of the
body, she said.
That said, Dr. Maari expressed
her frustration with topical psoriasis
treatments in general.
“We have not had any great topical
treatments … come on the market
in the last 20 years,” she said.
Dr. Maari said that for her, the
unmet need in psoriasis is more in the
mild to moderate range.
“For extensive psoriasis patients,
we have great treatment,” she said.
For scale psoriasis, which she said
can be difficult to treat, she has found
good results with fluocinolone in oil
form, although she noted that it is a
very greasy treatment.
Finally, she touched on biologic
treatments for more extensive cases.
Biologics are very effective treatments
with minimal side-effects, she
said. The downside is that they are
very expensive.
“The problem is they cost $20,000
a year, and the patient needs to be on
the treatment forever,” she said.
Despite the cost, biologics can almost
completely clear severe psoriasis,
she said.
topical corticosteroids.
“They only work for a very short period
of time,” said Dr. Sibbald. Salicylic
acid increases penetration, and he even
recommended using petrolatum, which
he said has an antipsoriatic effect.
He also suggested that additional
supplemental treatments should include
local physical modalities, ultraviolet
light, biologics and systemic agents.
In his list of treatments, he also mentioned
methotrexate, although he
noted it has B rather than A evidence.
Dr. Sibbald went on to describe
the differences between the various
topical treatment vehicles for psoriasis:
lotions, creams, ointments,
patches, pastes and gels.
“We always talk about these
terms, but do we really know what
they mean?” he asked the audience.
A lotion is a powder in water, a
cream is composed of oil in a continuous
water base, an ointment is water
with a continuous oil base, a patch is
occlusive delivery, a paste is a powder
in an ointment and a gel is a powder
in a lattice, said Dr. Sibbald.
Ointment vehicles do have an
antipsoriatic effect, he noted. He also
warned against compounding a gel.
“A gel is an unstable modality that
must not be compounded,” he said.
Common sites where psoriasis
manifests or “areas of trauma,” said Dr.
Sibbald, include the elbows, knees, scalp
and torso. Less common sites include
the genitals and the nails. If the nails are
involved, he said, be aware that this
could point to psoriatic arthritis.
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Clearing of psoriasis plaques may not mean the
end of treatment for patients with skin of colour
Dr. Andrew F. Alexis
In a presentation on psoriasis in pigmented
skin delivered at Skin Spectrum Summit in
Montreal, Dr. Andrew F. Alexis asked his audience
to keep an open mind while diagnosing
the skin disorder and to take into account the
patient’s concerns about hyperpigmentation.
“You need to really look head to toe at the patient
and, if it just does not fit, have a low threshold
for biopsy,” he said while referring to a patient with
sarcoidosis, which he called “one of the great imitators”
of psoriasis in darker-skinned patients.
The quality of life impact of psoriasis can be
greater in people with skin of colour, he said, which
makes it even more important for a dermatologist to
get the diagnosis right the first time and to take into
account some cultural and aesthetic concerns as
well.
Dr. Alexis explained why the quality of life is impacted
more so in people with skin of colour.
“It is probably that the associated pigmentary alterations
contribute to a greater quality of life impact,”
he said.
Some cultural aspects to perceiving the disease
may also play a role, he explained.
To demonstrate this, he showed an example of
a patient whose psoriatic scaling had improved with
treatment, along with redness and other symptoms,
but who was left with hyperpigmented patches on
her legs.
“In a research study, she might be considered a
treatment success, but in real life, she doesn’t think
the treatment is even working because functionally
she still can’t comfortably expose her skin.”
Clearing up both plaques and pigment alteration
can become part of the treatment in darkerskinned
patients, he said. This persistent pigment
alteration may lead to a much longer treatment period
for patients with skin of colour.
He stated that after clearing the psoriasis, he will
start working on the hyperpigmentation with topical
bleaching agents.
When it comes to data on the treatment of psoriasis
in skin of colour, Dr. Alexis said they are quite
limited.
“When you look at all of the studies, there is one
consistent theme: the demographics hover around
90 per cent Caucasians.”
For this reason, there are fewer data for patients
with skin of colour.
Dr. Alexis said has worked with the data that do
exist and has not found any safety or efficacy differences
in any of the treatments for psoriasis.
Regarding his clinical impression of treating hyperpigmentation
before it becomes a problem, Dr.
Alexis said this: “Early and appropriately aggressive
treatment might reduce the impact of the severity
and duration of hyperpigmentation.”
Signs of psoriasis
Dr. Jaggi Rao
28 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
changes may indicate
psoriatic arthritis
“Nail
as nails are an extension
of the skin itself,” said Dr.
Jaggi Rao in a presentation at Skin
Spectrum Summit in Vancouver.
Dr. Rao described psoriasis as
an immune-mediated chronic inflammatory
skin condition that impairs
the physical and emotional aspects
of an individual’s life. He states
that “nothing is destroying or attacking
the skin; it has to do with the influence
of the immune system to
create the reaction we see.” Dr. Rao
lists the five main types of psoriasis
as psoriasis vulgaris, guttate psoriasis,
pustular psoriasis, inverse psoriasis
and erythrodermic psoriasis.
Psoriasis vulgaris is the most common
as it is seen in 80 to 90% of all
psoriasis cases. Guttate psoriasis is
caused by the presence of group A
streptococcus. Pustular psoriasis,
identified through the studded pustules
commonly found on palms and
soles, and erythrodermic psoriasis,
which involves blood vessel dilation
(which can change thermal regulation),
are both types that require
emergency urgent care.
Psoriatic arthritis can be identified
through the change in appearance
of the nails. Dr. Rao explained
that nails “do not have blood vessels
but have keratin and different forms
of skin cells.” Some changes that
occur can be pits and grooves,
white-yellow discolouration, separation
of the nail from the nail bed, a
thickened plate, scales of the nail
bed, splinter hemorrhages, pustules
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and more fungal infections. He reported
that these symptoms are
usually not unilateral and would be
visible on the hands and feet.
With psoriatic arthritis, Dr. Rao
advised that topical treatments do
not work particularly well as the nail
functions as a barrier to the treatment.
Instead, Dr. Rao suggested injection-based
or oral treatments.
Dr. Rao said that in the past,
psoriasis would be treated with a series
of topical, systemic and phototherapy
treatments; however, he
now believes in using more aggressive
therapies earlier, as long as
they’re safe. He cautioned that patients
need to qualify for these more
extreme treatments, which he does
by first using systemic treatments
plus light therapy. “If that fails, they
qualify to move on to the more intensive
treatments,” said Dr. Rao. As
with any treatment process and
plan, Dr. Rao emphasized that the
main goal is patient satisfaction.
Treating scalp Pso in women of African ancestry
Dr. Andrew F. Alexis
When treating a woman
of African ancestry with
psoriasis of the scalp,
Dr. Andrew F. Alexis recommends
that doctors take into account
differences in hair
structure and in hair-care practices.
“When prescribing topical
therapy in particular, we have got
to go an extra step and think
about prescribing something that
will be compatible with this patient’s
hair type and hair-care regimen,
especially hair-washing
frequency,” said Dr. Alexis in a
presentation at Skin Spectrum
Summit in Vancouver.
Generally, he said, hair-washing
frequency is lower in women of
African ancestry, for a variety of
practical and cultural reasons.
Once-weekly or once-everyother-week
washing is common, he
said.
“To prescribe something that involves
washing the hair every single
day would not be aligned with this
patient’s normal hair-care practices,
so we have to come up with a regimen
that involves a good compromise.”
He said that this compromise
could be something such as onceweekly
washing with a medicated
shampoo and using potent topical
leave-on products on the scalp for
the rest of the week.
It is best to get the patient’s
feedback on what they would prefer
as far as dosing regimen and
Dr. Alexis
vehicle, whether they prefer a
water-based, an oil-based or
some other formulation, said Dr.
Alexis.
“Breaking down the various options
and getting the patient’s own
input on the selection goes a long
way for adherence and better outcomes,”
he said.
One product that is particularly
well suited for treating scalp
psoriasis in this population, he
said, is a fixed-combination formulation
of calcipotriene and betamethasone.
Among its advantages are that it
does not dry out the hair and is easy
to leave in without washing.
“However, particularly in more
severe cases of scalp psoriasis, we
may need to consider non-topical
therapies,” he said.
One treatment that is particularly
effective against scalp psoriasis
is secukinumab, he noted.
In summary, Dr. Alexis said
that he advises doctors not to forget
to convey to the patient that
“you are in with them for the long
haul” and to give them realistic
timelines.
“Take into account hair-care
practices and query patients about
traditional cultural practices that
may influence the presentation of
their disease,” he said.
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ROSACEA
Treatment options for rosacea
Dr. Kevin Pehr
Although there is no lab test
to diagnose rosacea, there
are several treatment options,
which Dr. Kevin Pehr discussed
during his talk at Skin
Spectrum Summit in Montreal.
“If the patient understands
therapy-quality conditions, they’re
not expecting cure,” Dr. Pehr said.
“It is chronic. It is not adult acne.”
To begin with, Dr. Pehr recommends
asking questions to gain an
understanding of what is most worrisome
to the patient.
“Ask, ‘What aspect bothers you?
Is it the flushing? Is it the broken
blood vessels? Is it the itchy feel? Is
it the papules and pustules? Is it the
eyelids?’ Maybe they all bother the
patient, but find out what bothers
them the most and focus the treatment
on that to start,” he said.
When treating the nose area,
Dr. Pehr recommends spraying
oxymetazoline nasal spray on the
skin twice a day. The relatively inexpensive
treatment works about a
third of the time, according to Dr.
Pehr. Additionally, patients can use
brimonidine gel, an alpha-2 agonist,
which is applied in the morning and
works roughly 80% of the time. The
gel lasts about 12 to 13 hours before
wearing off.
For erythrotelangiectatic and
background erythema, Dr. Pehr suggests
laser therapy or intense
pulsed light, but cautions that this
treatment is expensive and is not
permanent.
There are various options when
it comes to treating papules and
pustules, including ivermectin,
which is expensive but effective.
Azelaic acid can be used for treatment
and is also good for post-inflammatory
hyperpigmentation but
can be a little irritating.
Although, in theory, low doses
of systemic antibiotics, such as
tretinoin or benzoyl peroxide, will
work for the treatment of papules
and pustules, Dr. Pehr avoids these
treatment options because they are
irritating for the patient.
With phyma, or bulging nose,
Dr. Pehr says isotretinoin may work
as a treatment option, but surgery
may be required.
When it comes to ocular
rosacea, Dr. Pehr says often patients
won’t think to ask their dermatologist
about the condition.
“Ask them about it,” he said.
“The patient will not volunteer. They
do not feel it is their business, especially
in my case. They say, ‘Well,
you’re a skin doctor; this is my eye
problem. Why say something to
you?’”
Dr. Pehr suggests that with
“good, hard treatment,” the patient
should see a response within the
first two months, but it could take
up to six months. It is important
that patients understand that the
treatment could clear their rosacea
symptoms for the rest of their life
but that they could also relapse
once the treatment stops.
Rosacea
management:
Early Dx
reduces
morbidities
Dr. Maha Dutil
Education and open dialogue
are crucial for doctors helping
their patient manage
rosacea symptoms, according to
Dr. Maha Dutil, who discussed
treatment options and things to
avoid during her talk on rosacea
management at Skin Spectrum
Summit in Toronto.
“Early diagnosis and treatment
will reduce morbidities,” Dr. Dutil
said. “Counsel on skin care, sun protection
and [avoiding] triggers. It
takes a lot of time, but unless [patients]
do all these things, your therapeutic
options do not work well.”
There are many topical treatments
available to patients, such as
metronidazole gel and 1% cream
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and azelaic acid gel 15%, which can
be used for both acne and rosacea.
Ivermectin 1% cream and brimonidine
gel, which restricts the blood
vessels to help reduce redness, can
also be used. Benzoyl peroxide, an
acne medication, helps papulo, pustular
rosacea.
When the disease is more severe,
Dr. Dutil suggests using systemic
antibiotics. To avoid altering
the microbiomes, she says to use
only anti-inflammatory doses of
doxycycline. Isotretinoin can also be
used in treatment. For phymatous
rosacea and vascular lesions, lasers
can be used. Surgical interventions
are also an option for phymatous
rosacea.
Dr. Dutil says to avoid using an
acne wash with salicylic or glycolic
acid as it will aggravate rosacea
symptoms. Instead, use a gentle
cream. Additionally, sun protection
is important. Dr. Dutil suggests
using chemical-free sunscreens as
chemical sunscreens tend to aggravate
rosacea. Also, makeup can help
cover the redness of rosacea symptoms.
There is a study showing that
an antimicrobial dose of doxycycline
can produce similar efficacy and
safety in skin types IV to VI as well
as skin types I to III.
“Prescribe effective treatments,
topically and systemically, if
needed,” said Dr. Dutil. “Let’s reduce
the disparities in rosacea management.”
Rosacea underreported, underdiagnosed
in patients with skin of colour
Dr. Monica K. Li
The management of rosacea in light and dark
skin types is very similar according to Dr. Monica
K. Li, who presented on strategies to manage
rosacea symptoms at Skin Spectrum Summit in Vancouver.
“Unfortunately, because the entity itself is underreported
and underdiagnosed in those with skin of colour,
there is not a lot of data specifically looking at management,
and the efficacy of management strategies for this
patient population,” Dr. Li explained.
With the increased risk of post-inflammatory hyperpigmentation
in darker-skinned patients, physicians and
clinicians need to be vigilant when implementing lasers
and light-based therapies to ensure that this patient
population does not experience potential adverse effects
as much as possible.
The goal of rosacea management is to reduce papules
and pustules in patients, which can reduce the chronic inflammation
occurring on the face, leading to potential
scarring and post-inflammatory hyperpigmentation.
When using laser and light therapies, the goal is to
reduce superficial capillaries and to resurface the possible
phymatous changes that can result as rosacea progresses.
Dr. Li cautions practitioners to be careful when
choosing laser and light therapies for darker skin phototypes
because there is an increased risk of post-inflammatory
hyperpigmentation that can result as a sequela
of these interventions.
“I use a long-pulse 1064 nm laser, Nd:YAG. We can
also use a 595 nm pulsed dye laser to reduce the diffused
redness that can be seen on the face,” said Dr. Li.
“Because of the chronic nature of rosacea, usually a series
of treatments are required every one to two years
to improve some of the facial redness and symptoms
experienced by darker-skinned patients.”
For supportive measures to help both fair- and
dark-skinned patients, it is important to avoid triggers
such as spicy foods, alcohol and sun exposure when
possible.
Additionally, dermatologists should be advising and
helping patients to use photoprotection, particularly
with physical agents containing zinc oxide and titanium
dioxide, consistently. The use of bland emollients and
moisturizers is important because essentially all patients
with rosacea have hypersensitive skin.
When using a new skin-care product, patients
should apply the product to a test-spot area for a week
to determine tolerance prior to more generalized application
of the product on the entire face.
Patients should be counselled to use physical blockers
as opposed to chemical blockers. Chemical blockers
can be more irritating to rosacea patients with sensitive
skin. Also, patients should avoid alcohol-based exfoliating
products (astringents), which can further drive the
redness and irritation on facial skin.
Established options for rosacea management include
an oral 40 mg subantimicrobial-dose doxycycline
taken once daily. Studies show that this treatment
method has similar efficacy and safety for skin phototypes
I to III, as well as those with phototypes IV to VI. In
the U.S., a topical oxymetazoline cream is available for
the treatment of facial redness in both lighter and
darker skin phototypes.
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When brown patches are not melasma
Dr. Andrew F. Alexis
MELANOMA,
SUN
PROTECTION
In a presentation titled “Diagnoses
Not to Miss” at Skin Spectrum
Summit in Toronto, Dr.
Andrew F. Alexis sorted through a
number of cases in which his patients
exhibited pigmentation
symptoms that could easily be
misinterpreted as more common
diseases at first glance due to
their fairly standard appearance.
In some cases, skin hyperpigmentation
can be brought on by unusual
skin-care regimens or
reactions to other therapies, he
said.
“When one is presented with symmetrical
brown patches on the face,
the diagnosis is usually melasma, but
not always.”
He outlined a number of cases in
which these brown patches turned
out to be something different than expected.
Dr. Alexis proceeded to discuss a
case involving a 53-year-old African-
American woman with brown patches
on her face, which he said is a very
common complaint. He described her
patches, which appeared on the
cheek and temple, as being brown
with a purplish-grey hue. She also had
a past medical history of hypertension,
for which she was prescribed diltiazem.
“What else can it be?” he asked
the audience.
It turns out that diltiazem triggered
a photodistributed lichenoid
drug eruption, he said.
“After identifying the causative
agent — diltiazem in this case — discontinuing
it and switching to a chemically
unrelated antihypertensive, she
got better,” he said.
He noted that this purplish-grey
photodistributed lichenoid drug eruption
could also be caused by therapies
such as antimalarials, thiazide diuretics,
furosemide, ethambutol and tetracycline.
“When you see dark patches on
the face that aren’t quite brown but
[are] more greyish blue or lichenoid
looking, consider photodistributed
lichenoid drug eruption,” he said.
He used other examples to give
an idea of the process he went
through to find the correct diagnosis.
One case involved a woman with
post-inflammatory hyperpigmentation
brought on by months of harsh scrubbing
of her facial area “in an effort to
even her skin tone,” said Dr. Alexis.
“She was trying to treat hyperpigmentation
but induced hyperpigmentation
from her very irritating skin-care
regimen,” he said.
A second case he noted was a patient
with lichen planus pigmentosus,
which tends to be in a photodistributed
area, he said. Characteristics include
bluish-grey pigmentation on the
face, head and neck.
He used these cases as a lesson
to the audience to be thorough in
their investigation of the causes of a
patient’s symptoms.
“When thinking about the common
things we see in patients of
colour, it is easy to get into a little bit of
a rut. Not every brown patch on the
face is melasma, and not every white
patch is vitiligo,” he said.
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The three basic methods for sun protection
Dr. Sunil Kalia
Dr. Sunil Kalia
The three basic forms of sun protection are
seeking shade, wearing protective clothing
and using sunscreen, but it is not always
that simple, according to Dr. Sunil Kalia.
In his presentation at Skin Spectrum Summit in
Vancouver, Dr. Kalia went over the finer details of
each form of protection.
Since the ozone layer protects from UVC, UVB
and UVA are the most worrying because they can
cause skin cancer, he said.
“UVB can cause direct DNA damage, and UVA
can cause indirect DNA damage,” said Dr. Kalia.
Moreover, unlike infrared light, UV light is not
warm, so it cannot be felt. UVB peaks around the
noon hours, so much of the key messaging for skin
protection centres around avoiding sun exposure
between 10 a.m. and 3 p.m., he said.
According to Dr. Kalia, simply avoiding the sun
during these times is the most effective way to protect
against damage. But if that is not possible, wearing
protective clothing and sunglasses and using
sunscreen are the next best options, in that order.
“Clothing gives good protection, but what is the
protection factor of something like a thin white T-
shirt? It’s equivalent to an SPF of about five,” he said.
Although that is not adequate, the T-shirt cannot
be wiped off and does not have to be reapplied, he
said. For clothing, he recommends darker shades,
heavier fabrics and tighter weaves. The type of fabric
matters too.
“Polyester, wool, then cotton,” he said. “For a pair
of jeans, the protection factor on that is 200 SPF,
which is amazing, but, of course, it is hard to wear
that thick pair of jeans when it is really hot.”
Although it is more expensive, UV protection factor
clothing also exists. This brought him to the subject
of sunscreens.
“When you see the sunscreen bottle, what are
you looking for?” he asked.
Most people look for SPF, but that is not the only
factor to consider, he said. UVA protection is also another
important factor to consider.
Although many sunscreen bottles will tell you to
apply 15 to 30 minutes before sun exposure, Dr.
Kalia said that is not necessary. Applying just before
going out will still work.
He also said that most sunscreens recommend
that the user reapply them every two hours, but that
is just an arbitrary number. It is better to reapply
sunscreen based on perspiration, if or when it is
wiped off or after swimming, he said.
It is also not necessary to rub it in deeply, he
said. A light application is sufficient.
Finally, he recommends using two tablespoons
of sunscreen for the full body and half of one teaspoon
for the face.
“That’s quite a bit of sunscreen,” he said. “You
could be going through a whole bottle of sunscreen
in one day if you’re doing it properly.”
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Sickle cell disease may
complicate ulcers in patients of colour
Dr. Brian Kunimoto
WOUND
MANAGEMENT
In his presentation at Skin Spectrum Summit in
Vancouver, Dr. Brian Kunimoto spoke about sickle
cell disease and its complicating effects on venous
leg ulcers or livedoid vasculopathy in patients of
colour.
“Clinically, in dermatology, we see patients who have extremely
painful venous ulcers,” he said.
These ulcers can lead to a drastic decrease in quality of
life. A person with venous insufficiency can develop hypoxia
around the ankles, and this can trigger a sickle cell crisis, he
said.
“Which really is a vicious circle because you get the hypoxia,
you get the ulceration and then you get the sickle cell
crisis, which causes more hypoxia, and it just goes around
and around,” he said.
Dr. Kunimoto explained the difference between sickle
cell trait and sickle cell disease.
“Sickle cell trait is when the situation is heterozygous,
and it is an autosomal recessive inheritance of a single
amino acid substitution in the beta globin protein as part of
hemoglobin,” he said.
Patients who are heterozygous
have sickle cell trait. Patients who are
homozygous have sickle cell disease,
he said.
Approximately 300,000 infants
worldwide are born with sickle cell
disease each year, he said, the majority
coming from central Africa.
“This is truly a genetic disorder
that affects people of colour,” he said.
According to Dr. Kunimoto, one
of the effects of sickle cell disease is
that cells pile up.
“They get very sticky,” he said. “Red blood cells stick together,
they stick to platelets, they stick to white cells and
they stick to the walls of the vessels.”
This causes an increase in blood viscosity, which can
trigger thrombotic events.
“Thrombosis in the vessels becomes a real problem
with plugging and potentially something known as vasculopathy,”
he said.
Because of all this, ischemic injury can occur, which can
lead to reperfusion injury and a severe stimulation of inflammation,
he said.
A patient with ischemic changes may develop livedoid
vasculopathy, which Dr. Kunimoto said is less common.
Livedoid vasculopathy looks very different, he said. The
ulcers can look irregular in shape. When they heal, they heal
with atrophie blanche, which is associated with dilated
blood vessels and pigmentation, he said.
In managing a venous leg ulcer, he said first rule out arterial
disease by doing an arterial Doppler ultrasound. Then
concentrate on local wound care, which involves periwound
protection.
“A lot of them drain a lot of
fluid, so you have to select a good
moisture balance dressing,” he
said. He also emphasized the use
of compression bandaging.
“If your patient has sickle cell
disease, make sure you consult
with a hematologist because all of
the conditions are comorbidities
that a hematologist can really help
with,” he said.
Dr. Brian Kunimoto
34 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
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Risk factors for diabetic foot ulcers
and what to look for in an initial foot exam
Mariam Botros
In her presentation in Montreal at Skin Spectrum
Summit, Mariam Botros outlined some
risk factors for diabetic foot ulcers and amputation,
as well as what doctors should be
looking for in their initial diabetic foot exam.
According to Diabetes Canada, 11 million Canadians
live with diabetes and prediabetes, she said.
Foot ulcers are also costly to treat, she said, so
doctors should concentrate on trying to prevent it.
According to Botros, 85% of diabetic foot ulcers and
amputations are preventable.
“If we can’t prevent it, we want to manage it appropriately,”
she said.
Neuropathy is the “key permissive factor” for the
development of diabetic foot ulcers, she said. This is
because once patients lose the ability to sense pain
in their feet, the skin breaks down quickly.
Miriam Botros
In searching for a systematic approach to preventing
foot ulcers, she said that doctors need to
start by going back to assess the patient.
One alarming symptom to take note of would be
pain in a neuropathic foot, which means an infection
is quite advanced, she said.
Another red flag is finding exhibited inflammatory
signs, which could indicate that the infection is
progressing.
Other risk factors for ulcers and amputation are
a history of amputation or ulcers, she said. In addition,
Dr. Botros mentioned peripheral neuropathy,
foot deformity, peripheral arterial disease, diabetic
nephropathy, diabetic retinopathy, poor glycemic
control, smoking, inappropriate footwear and other
psychosocial considerations.
When doing a diabetic foot exam, she recommends
looking at a few key categories: skin and nails,
peripheral neuropathy, peripheral arterial disease,
bone deformity and footwear.
“These are the categories that we want to see
addressed in a diabetic foot exam,” she said.
Callouses increase pressure on the foot, so debriding
the callous is always a good idea, she said.
They’re not there to protect the wound, contrary to
some misconceptions, she said. Deformity can also
increase the pressure rate.
Investigating for fungal infection is also a key
part of the diabetic foot exam, she said, emphasizing
that doctors check first between the fourth and fifth
toe web space.
A vascular examination is also recommended, as
well as checking for loss of sensory perception in the
foot.
Botros also recommends that doctors make
sure their patients are wearing appropriately supportive
footwear. Whether the footwear is too large
or too small, it can cause friction, which could result
in a diabetic foot ulcer, she said.
Once the foot exam is complete, she said that
the attending doctor must categorize the risk level. If
the risk is urgent, the doctor must address patients
by either treating them themselves or referring them
to a multidisciplinary team.
Patients who have undergone lower limb amputations
have lower quality of life, high rates of depression
and loss of productivity, she noted. For this
reason, she said, preventive measures and noting
red flags early are keys to preventing amputation
and ensuring a higher quality of life.
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Improve diagno osis of dermatologic conditions in patients with skin of colour.
challenges that they may face in their treatment.
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