What's hot?
What's hot
December 30, 2017
In this monthly column, members of Dermatology World's Editorial Advisory Workgroup identify exciting news from across the specialty.
Annie Chiu, MD
Body contouring is not only in demand among patients but presents a unique challenge for physicians to achieve consistent aesthetically pleasing outcomes. Devices that eliminate unwanted fat are increasingly widely used, and now patients are looking for ways to improve skin laxity and tightening. Despite the number of skin tightening energy-based devices on the market, skin tightening itself is not an FDA-approved measurable endpoint, so it is almost impossible to compare one device to another. As with the face, combination therapy will be superior and the last few years have seen the hyperdilution of traditional injectable fillers such as PLLA and calcium hydroxyapatite to improve large areas of skin quality, provide modest volume, and boost skin tightening results from energy-based devices. As patients increase their interest in body treatments, we will continue to see increased growth of injectable fillers used on the body not necessarily to fill, but to improve skin laxity. This will also likely be the next big breakthrough for body injectables...a product that either provides large body area revolumnization or an injectable meant to provide a collagen and elastic tissue boosting ability to address laxity.
Jeffrey S. Dover, MD, FRCPC
Lasers are changing the way we treat scars. Unfortunately, achieving insurance reimbursement for these treatments has been a true challenge. Two new CPT codes have been created for ablative treatment of burn and traumatic scars. They are:
0479T: Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1 percent of body surface area of infants and children
0480T: Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure)
A group of dermatologists, represented by Dr. Murad Alam on the CMS national committee, have been instrumental in developing these codes. They are considered category III codes and are reimbursed based on health care insurance discretion. It is best to pre-authorize the service prior to rendering to ensure reimbursement. Dr. Alam and the AAD suggest that we use the codes to demonstrate their widespread importance in our field (see this month’s Cracking the Code column, p. 8). Doing so will help to value them and hopefully we will start getting reimbursement for these procedures from insurers.
John Harris, MD, PhD
Immunotherapy provides an exciting new option for patients with advanced-stage melanoma, with patients experiencing responses previously unseen with conventional therapies like chemo and radiation. However, responses to these treatments are still variable, ranging from complete responses with tumor regression and normal life span, to unresponsiveness with tumor progression. One recent study reported that the composition of a patient’s gut microbiome predicted their response to anti-PD-1 immunotherapy (Science. 2017 Nov 2. doi: 10.1126/science.aan4236. [Epub ahead of print]). Patients with a higher diversity of bacteria in the gut, as well as those with a high abundance of a particular bacterial species, experienced improved responses to therapy. In addition, when fecal samples from responding patients were transplanted to germ-free mice prior to melanoma implantation, the recipient mice had slower tumor growth and better responses to immunotherapy when compared to mice receiving fecal samples from non-responding patients. This suggests that the gut microbiome not only could predict therapeutic responses, but may in fact directly modulate these responses. Whether fecal transplants will be offered to melanoma patients as part of a therapeutic strategy will require more studies, but “personalized medicine” may be getting more personal.
Sylvia Hsu, MD
Systemic corticosteroids are currently the gold standard treatment for pemphigus.
A multicenter, parallel-group, open-label, randomized trial in 25 dermatology departments in France enrolled 90 newly-diagnosed adult pemphigus patients (Lancet. 2017;389(10083):2031-2040). These patients were randomly assigned (1:1) to receive either prednisone alone, 1.0 or 1.5 mg/kg/day tapered over 12 or 18 months (prednisone alone group), or rituximab 1 g IV on days 0 and 14, and 500 mg IV at months 12 and 18, combined with prednisone regimen, 0.5 or 1.0 mg/kg/day tapered over 3 or 6 months (rituximab plus short-term prednisone group). The primary endpoint was the proportion of patients who achieved complete remission off-therapy at month 24 (intention-to-treat analysis). At month 24, 41 (89%) of 46 patients assigned to rituximab plus short-term prednisone were in complete remission off-therapy versus 15 (34%) of 44 in the prednisone alone group. More severe adverse events were reported in the prednisone-alone group, than in the rituximab plus prednisone group. The findings in this trial suggest that for patients with pemphigus, first-line rituximab with short-term prednisone is more effective and safer than prednisone alone.
Risa Jampel, MD
The investigation of the immunologic pathogenesis of psoriasis has focused mainly on adults and has been fundamental in developing and evaluating new and effective treatments. The tissue immunology of pediatric psoriasis is explored in a pilot study by Rosenblum et al (J Am Acad Dermatol. 2017;77:417-424) as they compared lesional skin from 10 pediatric psoriasis patients to adult psoriasis patients as well as to normal controls. They used multiparameter flow cytometry, a method that quantifies T-cell subsets and intracellular cytokine production. Although their sample size was small (10 pediatric patients), they discovered that pediatric patients had higher interleukin (IL) 22 and lower IL-17 compared to adult patients. The findings support the potential treatment of pediatric psoriasis with anti-IL-22 therapy; possibly a specific target for children.
It will be fascinating to read the results of larger studies that help to further characterize pediatric patients of different ages, severity of disease, family history, course of disease, morphology of disease, as well as other variables. As more and more medications are available for us to treat psoriasis patients, we will be even more selective in our choice of treatment based on specific patient characteristics.
Rob Sidbury, MD, MPH
When to use systemic therapy for atopic dermatitis, especially in children, can be a clinical dilemma. Severity scales are imperfect and not often used outside the context of trials; and until the recent approval of dupilumab, the only FDA-approved systemic therapy was prednisone. The International Eczema Council (IEC) has offered some guidance (J Am Acad Dermatol. 2017 77(4):623-33).
They advise first to ascertain the following: a) diagnostic certainty b) optimization of existing topical therapies including querying any potential barriers, such as steroid phobia c) identification and elimination of any relevant triggers. If disease is still poorly controlled, then systemic therapy including phototherapy should be considered. Quality of life impact is an essential consideration. Once a decision to treat systemically has been made, which agent will depend on patient factors such as co-morbidities and vehicle delivery preference as well as drug factors like onset of action and demands for laboratory monitoring.
As new systemic medications for AD are developed it will be critical that providers establish a consistent approach toward patient selection; these IEC guidelines can help.
