Transcript Hot Topics & Recent Advances in Dermatology – What You Need to
What’s New in Dermatology
Benjamin Barankin, MD FRCPC Toronto Dermatology Centre
Faculty/Presenter Disclosure
Faculty:
Dr. Benjamin Barankin
Relationships with commercial interests: Speaker Honoraria: Abbott Labs Actelion Amgen Astellas Galderma Janssen Johnson & Johnson Leo Pharma Valeant Valeo Pharma
Disclosure of Commercial Support
This program has received financial support from
No Pharma Company.
form of
nothing.
in the Potential for conflict(s) of interest:
Dr. Barankin has received no honoraria in the development or delivery of this presentation.
Mitigating Potential Bias
Bias in this program has been mitigated using independent content
validation as follows: All data has been sourced from evidence that is clinically accepted All support used in justification of patient care recommendations conform to generally accepted standards
Introductions
Dr. Benjamin Barankin, MD FRCPC Dermatologist & Medical Director of Toronto Dermatology Centre 4256 Bathurst St. #400 (Bathurst & Sheppard) Ph: 416-633-0001 Fax: 416-633-0002 www.torontodermatologycentre.com
[email protected]
Toronto Dermatology Centre
2 Dermatologists 90% medical; also laser, surgical, & cosmetic 2 Plastic Surgeons OHIP & Non-OHIP Wait times: 1-3 weeks; Urgent referral squeeze ins UVB-Phototherapy (OHIP-covered): psoriasis, eczema, itchy skin, vitiligo, various rashes Clinical research trials: psoriasis, acne, rosacea, cosmetic Many languages spoken: English, French, Russian, Hebrew, Italian, Cantonese/Mandarin
Disclosures:
** No support/sponsorship for this talk Abbott Laboratories Actelion Astellas Pharma Inc.
Galderma Janssen Leo Pharma Inc.
Pfizer-Amgen-Wyeth Valeant/Sanofi-Aventis/Dermik/Canderm/Medicis Previously: Graceway, 3M, Stiefel
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Ceramide-Based Moisturizers
Appears that disturbances in epidermal lipid compartment structures (esp. ceramides) account for the defects in barrier function of atopic dry skin.
Ceramides are reduced in all atopics, particularly during a flare.
Use of topical ceramides on a regular basis reduces need for topical steroids.
• • • • In Canada, only a few OTC ceramide-containing products: Cerave (cream, lotion, cleanser) Cetaphil Restoraderm™ (lotion) Impruv® (cream) Curel Advanced Ceramide Therapy By prescription: EpiCeram (approved Sept. 2009) – great safety profile & no restrictions of use.
Maintenance Therapy in Atopic Dermatitis & Eczema
Topical tacrolimus (Protopic 0.03% & 0.1% ointments) and pimecrolimus (Elidel cream) are used to treat patients ≥2 years of age with eczema.
Topical calcineurin inhibitors are especially helpful when sensitive areas like face/neck/groin/axillae are involved.
Used twice per week, topical tacrolimus has been shown to be an effective way to prevent, delay and reduce occurrence of atopic dermatitis exacerbations.
References:
1. Proactive disease management with 0.03% tacrolimus ointment for children with atopic dermatitis: results of a randomized, multicentre, comparative study. Thaçi D, Reitamo S, Gonzalez Ensenat MA et al; European Tacrolimus Ointment Study Group. Br J Dermatol. 2008 Dec;159(6):1348-56. 2. Proactive treatment of atopic dermatitis in adults with 0.1% tacrolimus ointment. Wollenberg A, Reitamo S, Girolomoni G et al; European Tacrolimus Ointment Study Group. Allergy. 2008 Jul;63(7):742-50.
Chronic Hand Eczema
Actelion has launched Toctino® (alitretinoin), an oral retinoid for chronic hand eczema.
10 & 30mg capsules; start at 30mg/day with meal.
Similar contraindications as isotretinoin, but much better tolerated. Main SE: headache, LFTs, lipids For patients with severe chronic hand eczema refractory to potent topical steroids, ~ 50% will respond with good success to Toctino® 30mg/day.
Appears to work for a variety of chronic hand conditions (off label) including dyshidrotic eczema and psoriasis.
Expensive, but now ODB covered
What’s New in Psoriasis Topicals
New topical vehicles & formulations: Clobex® spray/lotion/shampoo – effective, and with elegant vehicles likely increase compliance Dovobet® gel – A gel rather than ointment (more elegant) ; treatment for scalp and body Silkis® ointment (calcitriol) – non-steroid option (biologically active metabolite of vitamin D areas 3 ), similar to Dovonex® (calcipotriol), but less irritating for sensitive Foams & Solutions
What’s New in Psoriasis Biologics
Lots of Biologics !!
Remicade (Infliximab) - 5mg/kg IV infusion q 2months Enbrel (Etanercept) – 50mg SC twice weekly Humira (Adalimumab) – 40mg SC q 2 weeks Stelara (Ustekinumab) – 45mg SC q 3 months Many biologics in clinical trials!
What’s New in Psoriasis Biologics
Reduced dosing frequency.
TNF-inhibitors help psoriasis & psoriatic arthritis.
Stelara (Ustekinumab) is the newest biologic, and is a first in class human monoclonal antibody selectively targetting the cytokines IL-12 & IL-23.
More coming ; oral biologics!; biosimilars ODB Coverage: Enbrel, Humira, Stelara.
Pricy: approximately $20-25,000 per year.
Biosimilars coming!
Allergic Contact Dermatitis: Allergens of the Year
2013: Methylisothiazolinone 2012: Acrylates artificial nails, dental prostheses, hearing aids 2011: Dimethyl Fumarate 2010: Neomycin 2009: Mixed dialkyl thioureas (neoprene rubber) 2008: Nickel 2007: Fragrance 2006: P-Phenylenediamine (PPD) 2005: Corticosteroids
What
’
s New in Acne
: Acne: New Treatment Combination – Tactuo gel 2.5% Benzoyl peroxide & Differin 0.1%.
Biacna gel 1% Clindamycin + 0.025% tretinoin Aczone 5% Dapsone ; anti-neutrophilic ; well-tolerated, for papulopustular acne, especially adult female acne Benzaclin gel vs. Clindoxyl gel - 90 vs. 60 day longevity ; pump preferred Isolaz acne laser Suction + Laser Diet may affect acne: Acne worse in those consuming dairy and high glycemic diets.
What’s New in Acne - 2
Epuris – new oral form of Isotretinoin 10, 20, 30, 40mg tablets Better absorption in absence of food (60% vs. 40%) & more precise weight-based dosing Minimal extra cost
What’s New in Rosacea
Azelaic acid 15% (Finacea®) came to market in summer of 2010 for rosacea by Bayer.
Ideal for papulopustular rosacea, but also reduces erythema Main effect due to anti-inflammatory properties Bid ; 50gm tube Subantimicrobial dose antibiotics for Rosacea and Others Apprilon 40mg po od (30/10) Prescription topical anti-redness (alpha agonist brimonidine – Mirvaso®, FDA Approved) product coming in 2013 – daily, fast acting Topical ivermectin coming soon Lasers & Light devices for vascular rosacea Newest info: bacteria inside the gut of the demodex mite may be eliciting immunologic reaction.
What’s New in Hair Loss
Rogaine 5% foam (Minoxidil) Better tolerated, no propylene glycol 3 month supply, ~$140 No compounding issues Anacaps Neoptide lotion
What’s New in Melasma
Lytera Obagi Nu-Derm Fractionated lasers – e.g. ProFractional Triluma - ?2014
Skin Cancers & Pre-Cancers
FDA has approved Erivedge (Vismodegib) for treatment of metastatic basal cell carcinoma (BCC) or locally advanced BCC 150mg po od Picato (Ingenol mebutate) for actinic keratoses Comes from sap of the plant Euphorbia peplus Home therapy, like Zyclara/Aldara/Efudex (& likely similar efficacy) 2 (body; 0.05%) -3 (face; 0.015%) days of application = higher compliance
Metvix - Actinic Keratoses
Photodynamic therapy for: Actinic keratoses, BCCs, Bowen ’ s disease. Traditionally using Blu-U or other laser/light device to activate. Topical application of Metvix® cream (registered in 30 countries) results in the selective accumulation of photoactive molecules in the neoplastic tissue; exposure to red light in the presence of oxygen generates reactive oxygen species which kill neoplastic cells. Healthy surrounding tissue is spared.
Active ingredient in Metvix® cream is methyl aminolevulinate (MAL), a topical photosensitizer molecule that permits effective topical photodynamic therapy.
Aktilite® is an LED light source specifically designed for Metvix because of its 634nm wavelength. **Can also do daylight PDT!
Main issue: cost/coverage.
Metastatic Disease
New drugs approved for: metastatic melanoma (Ipilimumab) 1 st time ever showing prolonged survival aggressive or metastatic basal cell carcinoma (Vismodegib).
Vyloma for Genital Warts – 3.75% Imiquimod
Aldara (imiquimod 5%) has been used since 1997.
Approved and used for treating actinic keratoses, superficial BCCs, and external genital warts; many off-label uses (e.g. SCC in-situ, other warts, molluscum).
Zyclara 3.75% for AKs. Vyloma 3.75% for Genital Warts.
Lower concentration has meant better tolerability and thus compliance; apparently similar efficacy. Zyclara: easier dosing schedule with 2 weeks on, 2 weeks off, then 2 weeks on again. “ 2, 2, 2 ” regimen for Aks.
Vyloma: od for up to 8 weeks.
Both now come in pumps.
Genital Warts
• • • Veregen (Sinecatechins ungt) approved for sale in sept. 2013 for external genital or perianal warts; available Q1 2014.
A concentrate of catechins extracted from green tea leaves 10% & 15% ointment – already part of U.S. & European guidelines for treating genital warts.
HPV: cause of AK & SCC
A leading dermatologist-researcher Dr. Eggert Stockfleth and his lab in Berlin has demonstrated that HPV 21 can be found in 95% of actinic keratoses (AK) and 100% of squamous cell carcinomas (SCC); less commonly, HPV 5 & 8 have also been associated. The need for immunomodulation using agents such as topical imiquimod (approved for treating HPV & AKs) makes even more sense now.
Herpes Simplex Virus (HSV) / Cold Sores
Xerese – Acyclovir 5% & Hydrocortisone 1% cream 5/day ; >12 yo ; approved for lip cold sores Reduces ulceration and duration
Onychomycosis
Tribute Pharma will be launching a topical terbinafine solution for nails.
Valeant will be launching efinaconazole 10% solution likely early 2014 No need to remove weekly (unlike Penlac) Covers candida species Safe, effective, high efficacy, with no monitoring
Unwanted Facial Hair
Vaniqa® (Eflornithine 13.9%) back on market Irreversible inhibitor of ornithine decarboxylase which is a rate-limiting enzyme. Inhibition results in slowed hair growth.
Apply bid to unwanted facial hair; 30gm tube.
Works well in combination with laser hair removal techniques.
20% of women at least once weekly will tweeze/shave/wax/bleach hair.
New laser hair removal systems like lightsheer duet are faster and much less painful.
Injectable Dermal Fillers
Hyaluronic acids – Restylane & Perlane, Juvederm, Teosyal, Ovita, Revanesse Last 4-12 months depending on location injected Belotero launched in U.S., likely will come to Canada Calcium Hydroxyapatite (naturally found in bone) – Radiesse Stimulates body ’ s natural collagen production Deeper injection; lasts 12-18 months Evolence & Artesense – taken off market New: not widely used Beautical (polyacrylamide) – 2-4 years Bio-Alcamid (polyacrilimid) - permanent
New Botulinum Toxins
Botox® – 20 years of approved use in Canada Originally approved March 14, 1990 for Strabismus & Blepharospasm New toxins to market: Xeomin® (incobotulinumtoxinA) – Merz Pharma Canada Launched April 2012 ; same reconstitution as Botox Dysport™ (abobotulinumtoxinA) - Medicis/ Valeant Launched April 2013 ; different reconstitution to Botox Vast array of uses: Wrinkles Hyperhidrosis Blepharospasm Cervical dystonia Migraines, tension headaches Cerebral palsy Post-stroke spasticity Club foot Urinary incontinence Raynaud syndrome
Lasers
Fractionated lasers (e.g. Profractional, Fraxel) provide excellent option for laser resurfacing for: Aging face, acne scarring, melasma.
Safer than traditional CO microthermal zones, leaving areas of normal skin for better healing.
2 laser resurfacing by using
Lasers
Many non-invasive treatments now developed to treat unwanted fat – show modest results, & unlikely to replace tumescent liposuction.
Ultrashape is an ultra-sound based device using selective focused ultrasound to produce mechanical, nonthermal, acoustic effects which target & selectively disrupt fat cells.
Zeltiq has developed “ cryolipolysis ” which employs cold for fat reduction. The device is pressed against the area to be treated; the body reacts to the cold with inflammation and the body disposes of the damaged fat cells.
No anesthesia, no recovery time ; good for stubborn areas of fat
Fat Removal
Sodium deoxycholate by Kythera injected into submental fat (“mesotherapy”) is quite helpful; coming to market in near future.