- Email: [email protected]
New Treatments in Dermatology
New Treatments in Dermatology Dr. Tobey Maurer’s Hot Topics lecture on new treatments in dermatology covered advances in treating common conditions. Some are new, some familiar and back in use again, and some are just starting to come into practice. All will make you rethink how you treat common dermatological conditions. Scabies can be a difficult and irritating condition to treat. It is difficult to visualize scabies mites on the skin. Burrows or mites may be evident, or the individual may only complain of incessant itchiness. The average number found on the skin in a fully involved case is only 10! Classic treatment is permethrin 5% cream, 2 applications 1 week apart. All intimate contacts and clothing must also be treated. In the case of crusted scabies, malathion (a pesticide) and ivermectin (an oral medication) are indicated. Both are highly effective and much easier to use. Are they indicated in regular scabies? Oral invermectin is superior to malathion in adults but both are second-line drugs. The reason is that, while easier to use, it is very expensive, and overuse may lead to resistance; in fact, resistance has been observed with lindaine (Kwell). The firstline treatment of this condition is always permethrin. Melasma is a hyperpigmented state of the skin usually resulting from sun exposure and hormonal influence. First-line treatments are bleaching creams (hydroquinone) and strict sun avoidance. Research has focused on assessing if more aggressive treatments and newer technologies are more effective in treating recalcitrant cases of this condition. A recent study examined the combined effect of laser therapy and peels (salicylic acid peels 20%30% every 2 weeks for 8 weeks). Results failed to demonstrate any advantage over standard therapy.1 The take-home message is that newer therapy is not always better for every condition. Atopic dermatitis can be a vexing situation, especially when treating children. The big change is in using diluted “bleach baths” in treating atopic dermatitis on the body (not the face) in children. The Rx is half a cup of bleach in a full bathtub, followed by liberal use of emollients once daily. Additionally, www.npjournal.org
HOT TOPICS IN PRIMARY CARE Laurel Halloran, PhD, APRN “bleach baths” combined with nasal mupiricin were shown to tremendously reduce the staph aureus carriage rate and severity index of atopic dermatitis. This may be a result of the correlation between decreased staph burden suppression and incidence of eczema flare suppression.2 Maurer pointed out that “what is old is new again” in eczema treatments. Moist wrap treatments are again being used with success. In this treatment, a corticosteroid ointment is applied directly on skin. Then, a moistened first layer (kerlex, gauze) is applied, followed by a dry layer. This is worn overnight. The therapy is repeated nightly for 2 weeks until rash is resolved or every 5 days (monitoring for skin maceration). Research has not borne out any associations between foods, bottle versus breastfeeding, or withholding solid foods or milk after 4-6 months of age and the development of atopic dermatitis. There are some new lotions and creams for treating this condition in the class of calcineurin inhibitors, 2 of which include tacrolimus ointment and pimecrolimus. They have been studied against corticosteroids. Recommendations in children are not to use for extended periods, especially in sunexposed areas. Do not use in immunosuppressed patients. Maurer said that, while these creams/ointments are good, they are not particularly superior to corticosteroids. In her opinion, they work best on the face and are most effective for about 2 years. The use of topical antibiotics in the treatment of minor wounds is controversial. Bacitracin/polymixin cream is often used for minor wounds, including procedures (shaves, snips, and lasers) even in low-risk The Journal for Nurse Practitioners - JNP
665
JNP patients. However, research shows that using antibiotic cream as compared to petrolatum does not improve wound healing for minor wounds.3,4 This is not true for children. Minor scratches, bug bites, and sutured wounds are responsive to topical antibiotic in this population.5 The treatment of psoriasis, arthritis, and hidradenitis suppurativa involves tumor necrosis factor drugs. The most common are entanercept and inflixamab. One newer treatment is in a class of drugs called interleukin 1-beta blockers. Anakinra (Kineret) costs $30,000/year and is injected daily. Newer drugs in this class can be injected only once a month but cost $250,000/year. Prescribers must consider which patients are appropriate for this therapy. Hidradentitis supparativa is an inflammatory process and difficult to treat. Again, older treatments, such as the combination of rifampin and clindamiacin, are being used with good results. Beta blockers are used most often for hypertension, but in dermatology they have been found to be very effectively to shrink infantile hemagiomas. The drug is started at a very low dose and monitored closely. Improvement is noted within 3 days. This treatment may be superior to steroids. Discoid lupus is most often treated with an antimalarial medication hydroxychoroquine 200 mg bid, and now the potential effects in systemic lupus have been realized. Patients experienced fewer thrompembolic events, and it slowed down the inflammatory sequelae. It is now becoming standard treatment to treat all patients with lupus with this medication. Genetics and genomics have permeated dermatology also. Many melanomas have BRAF mutations, and treatment with exclusively surgical excision is often not enough. All skin melanomas should be tested for BRAF mutations. Many new therapies are being developed that target this group of melanomas. A new therapy, Ipilumibab, blocks BRAF gene expression and will increase This column is brought to you by Hot Topics in Primary Care, a Contemporary Forums conference held every August in Jackson Hole, WY. For more information on this presentation, go to http://www.contemporaryforums.com/en/Live-CE-Conferences/. For more information about Contemporary Forums, go to http://www.contemporaryforums.com. For content and CE please go to www.onlinecelibrary.com.
666
The Journal for Nurse Practitioners - JNP
overall survival for metastatic melanoma. Of course, prevention is the best treatment. The International Agency for Research on Cancer completed a comprehensive meta analysis and found that the risk of melanoma (skin and eye) increases by 75% when tanning begins before the age of 306 (El Ghissassi et al, 2009). A well-designed Australian study found that the risk of developing any melanoma is reduced by 50% and invasive melanoma by 73% by daily rather than discretionary use of sunscreen.7 Any dermatological therapy should be targeted toward the patient’s needs, condition, disease level, age, and health. Newer therapy is not necessarily better. Education, follow-up, and prevention will keep both your patient and you happy and healthy! References 1. Kodali S, Guevara IL, Carrigan CR, et al. A prospective, randomized, split-face, controlled trial of salicylic acid peels in the treatment of melasma in Latin American women. J Am Acad Dermatol. 2010:63(6):1030-1035. 2. Lofgren S, Krol A. New therapies in pediatric dermatology. Curr Opin Ped. 2011:23(4):399-402. 3. Taylor SC, Averyhart AN, Heath CR. Postprocedural wound-healing efficacy following removal of dermatosis papulosa nigra lesions in an African American population: a comparison of a skin protectant ointment and a topical antibiotic. J Am Acad Dermatol. 2011;64(3):S30-S35. 4. Draelos ZD, Rizer RL, Trookman NS. A comparison of postprocedural wound care treatments: Do antibiotic-based ointments improve outcomes? J Am Acad Dermatol. 2011;54(3):523-529. 5. Hood, R, Shermock K, Erman C. A prospective randomized pilot evaluation of topical triple antibiotic versus mupirocin for the prevention of uncomplicated soft tissue wound infection. Am J Emerg Med. 2004;22(1):1-3. 6. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens—Part D: radiation. Lancet Oncol. 2009;(10)8:751-752. 7. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011;(20)29:257-263.
Section Editor Laurel Halloran, PhD, APRN, is a professor of nursing at Western Connecticut State University and a family nurse practitioner. She can be reached at [email protected]. Toby A. Maurer, MD, is an associate professor of dermatology at the University of California–San Francisco and chief of dermatology at San Francisco General Hospital in San Francisco.
1555-4155/121/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.06.004
contemporary f o r u m s
a reed elsevier company Providing Quality, Accredited Continuing Education to Thousands of Healthcare Professionals for More Than 25 Years
Volume 8, Issue 8, September 2012
HOT TOPICS IN PRIMARY CARE Laurel Halloran, PhD, APRN “bleach baths” combined with nasal mupiricin were shown to tremendously reduce the staph aureus carriage rate and severity index of atopic dermatitis. This may be a result of the correlation between decreased staph burden suppression and incidence of eczema flare suppression.2 Maurer pointed out that “what is old is new again” in eczema treatments. Moist wrap treatments are again being used with success. In this treatment, a corticosteroid ointment is applied directly on skin. Then, a moistened first layer (kerlex, gauze) is applied, followed by a dry layer. This is worn overnight. The therapy is repeated nightly for 2 weeks until rash is resolved or every 5 days (monitoring for skin maceration). Research has not borne out any associations between foods, bottle versus breastfeeding, or withholding solid foods or milk after 4-6 months of age and the development of atopic dermatitis. There are some new lotions and creams for treating this condition in the class of calcineurin inhibitors, 2 of which include tacrolimus ointment and pimecrolimus. They have been studied against corticosteroids. Recommendations in children are not to use for extended periods, especially in sunexposed areas. Do not use in immunosuppressed patients. Maurer said that, while these creams/ointments are good, they are not particularly superior to corticosteroids. In her opinion, they work best on the face and are most effective for about 2 years. The use of topical antibiotics in the treatment of minor wounds is controversial. Bacitracin/polymixin cream is often used for minor wounds, including procedures (shaves, snips, and lasers) even in low-risk The Journal for Nurse Practitioners - JNP
665
JNP patients. However, research shows that using antibiotic cream as compared to petrolatum does not improve wound healing for minor wounds.3,4 This is not true for children. Minor scratches, bug bites, and sutured wounds are responsive to topical antibiotic in this population.5 The treatment of psoriasis, arthritis, and hidradenitis suppurativa involves tumor necrosis factor drugs. The most common are entanercept and inflixamab. One newer treatment is in a class of drugs called interleukin 1-beta blockers. Anakinra (Kineret) costs $30,000/year and is injected daily. Newer drugs in this class can be injected only once a month but cost $250,000/year. Prescribers must consider which patients are appropriate for this therapy. Hidradentitis supparativa is an inflammatory process and difficult to treat. Again, older treatments, such as the combination of rifampin and clindamiacin, are being used with good results. Beta blockers are used most often for hypertension, but in dermatology they have been found to be very effectively to shrink infantile hemagiomas. The drug is started at a very low dose and monitored closely. Improvement is noted within 3 days. This treatment may be superior to steroids. Discoid lupus is most often treated with an antimalarial medication hydroxychoroquine 200 mg bid, and now the potential effects in systemic lupus have been realized. Patients experienced fewer thrompembolic events, and it slowed down the inflammatory sequelae. It is now becoming standard treatment to treat all patients with lupus with this medication. Genetics and genomics have permeated dermatology also. Many melanomas have BRAF mutations, and treatment with exclusively surgical excision is often not enough. All skin melanomas should be tested for BRAF mutations. Many new therapies are being developed that target this group of melanomas. A new therapy, Ipilumibab, blocks BRAF gene expression and will increase This column is brought to you by Hot Topics in Primary Care, a Contemporary Forums conference held every August in Jackson Hole, WY. For more information on this presentation, go to http://www.contemporaryforums.com/en/Live-CE-Conferences/. For more information about Contemporary Forums, go to http://www.contemporaryforums.com. For content and CE please go to www.onlinecelibrary.com.
666
The Journal for Nurse Practitioners - JNP
overall survival for metastatic melanoma. Of course, prevention is the best treatment. The International Agency for Research on Cancer completed a comprehensive meta analysis and found that the risk of melanoma (skin and eye) increases by 75% when tanning begins before the age of 306 (El Ghissassi et al, 2009). A well-designed Australian study found that the risk of developing any melanoma is reduced by 50% and invasive melanoma by 73% by daily rather than discretionary use of sunscreen.7 Any dermatological therapy should be targeted toward the patient’s needs, condition, disease level, age, and health. Newer therapy is not necessarily better. Education, follow-up, and prevention will keep both your patient and you happy and healthy! References 1. Kodali S, Guevara IL, Carrigan CR, et al. A prospective, randomized, split-face, controlled trial of salicylic acid peels in the treatment of melasma in Latin American women. J Am Acad Dermatol. 2010:63(6):1030-1035. 2. Lofgren S, Krol A. New therapies in pediatric dermatology. Curr Opin Ped. 2011:23(4):399-402. 3. Taylor SC, Averyhart AN, Heath CR. Postprocedural wound-healing efficacy following removal of dermatosis papulosa nigra lesions in an African American population: a comparison of a skin protectant ointment and a topical antibiotic. J Am Acad Dermatol. 2011;64(3):S30-S35. 4. Draelos ZD, Rizer RL, Trookman NS. A comparison of postprocedural wound care treatments: Do antibiotic-based ointments improve outcomes? J Am Acad Dermatol. 2011;54(3):523-529. 5. Hood, R, Shermock K, Erman C. A prospective randomized pilot evaluation of topical triple antibiotic versus mupirocin for the prevention of uncomplicated soft tissue wound infection. Am J Emerg Med. 2004;22(1):1-3. 6. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens—Part D: radiation. Lancet Oncol. 2009;(10)8:751-752. 7. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011;(20)29:257-263.
Section Editor Laurel Halloran, PhD, APRN, is a professor of nursing at Western Connecticut State University and a family nurse practitioner. She can be reached at [email protected]. Toby A. Maurer, MD, is an associate professor of dermatology at the University of California–San Francisco and chief of dermatology at San Francisco General Hospital in San Francisco.
1555-4155/121/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.06.004
contemporary f o r u m s
a reed elsevier company Providing Quality, Accredited Continuing Education to Thousands of Healthcare Professionals for More Than 25 Years
Volume 8, Issue 8, September 2012