Live in-person, hybrid, or virtual—conferences are in full swing again. April was a packed month for CME opportunities, with long-running events such as the American Academy of
Dermatology Virtual Meeting Experience (AAD VMX), the Dermatology Nurses’ Association Annual Convention, and the Interdisciplinary Autoimmune Summit (IAS), as well as newcomers such as the Skin Cancer Symposium (SCS) and the Symposium for Inflammatory Skin Disease.
Keep reading for more insights from SCS, IAS, and AAD VMX, and visit the-dermatologist.com for more conference coverage throughout the year!
SCS: Determining Nevi vs Melanoma With Dermoscopy1
Do you know how to discern between nevi and melanoma by dermoscopy? At the inaugural SCS, Ashfaq A. Marghoob, MD, led attendees through a discussion of dermoscopic criteria for cutaneous malignancies.
To start, Dr Marghoob outlined how entropy can play a huge role. An “organized” lesion typically has symmetric distribution of its colors and structures, whereas a “disorganized” lesion is asymmetric. Using this idea, dermatology bases its clinical features of melanoma (the ABCDs) on its overall
disorganized structure in comparison to nevi. It is important to remember that dermoscopy should be used to focus on the distribution of colors and structures, but not variability in lesion shape, size, and borders.
There are only a handful of nevi patterns that have been defined dermoscopically, which tend to be organized noted Dr Marghoob. These include network, globular, and homogenous blue or brown, among others.
Regardless of nevi pattern, context is important, he said. Consider factors such as lesion history; patient concerns, age, signature patterns, or skin phototype; and sun damage. Each factor can influence the dermoscopic evaluation of a nevus. However, dermatologists should remember that nevi can be disorganized as well. Dr Marghoob stated it is important to consider the “ugly duckling” or outlier lesion.
Whereas nevi typically are organized, melanoma are mostly disorganized. A melanoma can present with structures such as atypical network, streaks, or dots and globules; dotted or serpentine vessels; raised or flat blue-white structureless area; milky red areas and globules; or negative network.
While a good rule of thumb is to consider melanomas to be disorganized, it is possible for them to present as organized and more nevi-like. Difficult-to-diagnose melanomas include Spitzoid, verrucous, epidermotropic metastatic, amelanotic, nodular, desmoplastic, and nevoid. Dr Marghoob shared an important pearl on dermoscopy of a lesion suspicious for organized melanoma: if an organized lesion has one of two distinct patterns (streaks/globules forming a starburst pattern, negative network), one of two structures (vessels, ulceration), or one of four colors (blue, black, gray, white), then malignancy should still be suspected.
IAS: IMID-JAK Pearls From Dr Ruth Ann Vleugels2
At IAS, Ruth Ann Vleugels, MD, MPH, MBA, presented “Strategies for Improving IMID Outcomes: The Potential of JAK Inhibitors,” sharing a number of pearls when it comes to utilizing Janus kinase (JAK) inhibitors for the treatment of
immune-mediated inflammatory diseases (IMIDs).
JAK inhibitors have a growing application in rheumatology, dermatology, and gastroenterology as effective therapies for IMIDs. Current JAK inhibitors with approved
indications include
- Tofacitinib: rheumatoid arthritis (RA), psoriatic arthritis, ulcerative colitis, polyarticular juvenile idiopathic arthritis
- Baricitinib: RA
- Upadacitinib: RA
Further, JAK inhibitors have numerous clinical trials or case studies for efficacy in dermatomyositis, psoriasis, alopecia areata (AA), vitiligo, atopic dermatitis (AD), lupus, sclerosis, and sarcoidosis. Dr Vleugels highlighted many examples from the literature in between real case images from her practice.
When it comes to adverse events, JAK inhibitors do have some safety concerns. There is a clear signal for herpes zoster, to which providers should “consider adding a shingles vaccine or looking at varicella zoster virus titers,” said Dr Vleugels. Another serious concern is venous thromboembolic events, which may be a class effect for patients with RA, as the data are still limited in other diseases. Further, compared with (tumor necrosis factor (TNF) inhibitors, JAK inhibitors show consistently lower risks of tuberculosis reactivation and serious infection; however, there is increased concern regarding higher risk of malignancy, though more research is needed to better define the risks.
In the postpresentation Q&A, moderator Mital Patel-Cohen, MD, shared several audience questions regarding specific disease combinations, such as RA and lupus or AD and hidradenitis suppurativa. Dr Vleugels responded that JAK inhibitors can provide relief for patients with multiple comorbidities. This may be because of JAKs applying inhibition on a broader number of pathways, depending on its individual target (JAK1 vs JAK2 vs JAK3 vs TYK2).
In addition, when it comes to getting payer support and approval for JAK inhibitors, Dr Vleugels suggested paying attention to comorbid conditions, including mental health. Documentation of mental comorbidities or conditions that are currently FDA-approved indications (eg, RA with AA) can increase the likelihood of approval and coverage by an insurer.
However, because JAK inhibitors are still largely new therapeutic options, the current evidence regarding safety should be heavily considered. Dr Patel-Cohen asked if there should be any concerns with clotting disorders, particularly in patients who have antiphospholipid syndrome. “Last year, I would’ve told you I was a little concerned but would just use caution through active testing and disease modifications,” said Dr Vleugels, “but recent data makes me a little more careful.” She added that she asks about family history of cardiovascular diseases and clotting disorders and smoking history, among others. Providers should follow complete blood count with differential, liver function tests, and cholesterol.
AAD VMX: Dr Erin Amerson on Using Biologics in Patients With Chronic Viral Infections3
Patients with psoriasis often have more than one comorbidity that can complicate their treatment plan. During the AAD VMX session “Management of Immunosuppressants and Biologics in Patients With Chronic Viral Infections Such as Hepatitis B & C,” Erin Amerson, MD, discussed what dermatologists need to know about prescribing and managing biologics in patients with IMIDs and hepatitis B (HBV) or hepatitis C (HCV).
HBV is a serious health concern. Its sequelae include fulminant liver failure, cirrhosis, hepatocellular carcinoma, and extrahepatic manifestations. Most patients who have HBV acquire it in the perinatal period, either developing chronic HBV (HBsAg+) or occult/resolved infection (HBsAg-). Testing can be confusing since the markers are dynamic and there are more than one option, including core antibody HBcAb (detects active or prior infection), surface antigen HBsAg (active infection), surface antibody HBsAb (detects vaccination or resolved infection), HBV DNA by polymerase chain reaction (level of viral replication).
Therefore, with the number of tests, it is helpful to understand the five different clinical scenarios for HBV:
- Vaccinated/immune: HBsAb+, HBsAg-, HBcAb-
- Chronic infection; HBsAb-, HBsAg+, HBcAb+
- Past infection “occult”: HBsAb-, HBsAg-, HBcAb+
- Past infection “resolved”: HBsAb+, HBsAg-, HBcAb+
- Never infected/no vaccination: HBsAb-, HBsAg-, HBcAb-
"True or false: there are clear evidence-based guidelines for choosing a biologic and lab monitoring in HBV-infected patients?” asked Dr Amerson. The answer is false; patients with HBV and HCV are often excluded from clinical trials, so data on the efficacy of biologics in this patient group are lacking despite good evidence out of Taiwan.
For patients who have a past infection, Dr Amerson shared a proposed adapted treatment algorithm from a review of hepatology guidelines. For biologic agents and drugs with a moderate risk of immunosuppression (eg, TNF, IL-12/IL-23, or IL-17 inhibitors), dermatologists should either (1) start an antiviral prophylaxis and monitor HBV DNA every 3 months or (2) monitor HBsAg, liver function, and HBV DNA every 1 to 3 months. In either option, if reactivation is detected, then the patient should be referred to hepatology. In high-risk immunosuppressants (eg, rituximab or >20 mg of prednisone per day for longer than 1 month), dermatologists should automatically refer to hepatology, begin antiviral prophylaxis, and monitor HBV DNA every 3 months. Following withdrawal of the immunosuppressant, patients should continue their antiviral prophylaxis and have routine laboratory monitoring for 12 months after reconstitution.
For patients with a chronic HBV infection, Dr Amerson shared another proposed treatment algorithm. These patients should be referred to hepatology and be tested for HBV DNA, HBeAb, HBeAg, HDV, HCV, and HIV. Whether the agent is considered moderate or high risk, patients with chronic HBV infection should be started on antiviral prophylaxis and monitor HBV DNA every 3 months.
The risk of reactivation without antiviral prophylaxis in chronic infection is thought to be up to 60% with high-risk therapies and up to 62% in moderate-risk therapies based on Taiwanese literature.
Similarly to HBV, HCV causes hepatologic disease. However, HCV and biologics are less of a concern than its double-stranded counterpart. The risk of reactivation on biologics is very low overall, except for rituximab, which is slightly higher than other options. Dermatologists should test for HCV prior to initiating treatment, and if positive, refer for treatment with one of the excellent options available for HCV.
AAD VMX: COVID-19 Vaccines and the Skin: Dr Freeman Explains Registry Data4
The AAD VMX featured a comprehensive session, COVID-19 Symposium, bringing together nine experts from across the country to discuss the intersection of dermatology and the pandemic. Esther Freeman, MD, PhD, principal investigator and director of the COVID-19 Registry, a collaboration by the AAD and the International League of Dermatological Societies, shared updates, emphasizing reassuring evidence that COVID-19 vaccines are safe and well-tolerated in terms of skin reactions.
Over the year, the registry has accumulated more than 2000 total reports from 52 countries across all continents other than Antarctica. Initial data of 318 patients showed pernio-like lesions, but subsequent analysis with 716 patients revealed a more full spectrum of dermatologic manifestations:
- Penio in more mild cases
- Vesicular, urticarial, macular erythema, and morbilliform lesions in moderate cases
- Retiform purpura in severe cases of COVID-19
- Long-COVID symptoms (ie, >60 days infection)
In December 2020, cutaneous vaccine reactions were added as a reporting option, and the registry now has more than 600 reports. Dr Freeman pointed to a recent study published in New England Journal of Medicine, which analyzed reactions to mRNA-1273 (Moderna vaccine). “What is interesting is not so much that they developed a reaction on the vaccinated arm. We’re all used to people getting large injection reactions at the site of vaccines, but what was really unusual here is these delayed, large local reactions were happening on day 7 or day 8 after [the first dose],” she highlighted.
The second dose reports, however, were reassuring, with reactions either not recurring or being less severe and presenting 2 to 3 days postvaccination. It is not clear what is causing the reactions, especially as 93% of the localized reactions are seen with the Moderna vaccine vs BNT162b2 (Pfizer vaccine).
The clinical trials for the Moderna and Pfizer vaccines demonstrated the vaccines are well-tolerated. The phase 1/2a trial data for Ad26.COV2.S (Johnson & Johnson) reported similar tolerability, with single-digit percentages in erythema and swelling at injection site.
Dr Freeman emphasized, however, that trial data was relatively limited in reporting on skin. She then highlighted what is currently known in the literature from a mid-April 2021 report in Journal of the American Academy of Dermatology. Of 414 individuals who reported one or more cutaneous reactions to an mRNA vaccine, 83% received Moderna vs 17% who received Pfizer. The most common morphologies after mRNA vaccines were delayed large local reactions, local injection site reactions, urticaria, and morbilliform eruptions. The analysis did not include the Johnson & Johnson adenovirus vaccine and we expect to report on it in the future, said Dr Freeman.
Most importantly, based on this real-world evidence, patients and providers alike should know that less than half of patients who experienced a cutaneous reaction after a first dose experienced a recurrence following their second dose. Dermatologists should encourage their patients to continue with their second dose regardless of reactions more than 4 hours postvaccination.
Disclosure: IAS is run by HMP Global, the publisher of The Dermatologist.
References
1. Marghoob A. Dermoscopic features of nevi and melanoma. Presented at: Skin Cancer Symposium; April 7-8, 2021; virtual.
2. Vleugels RA. Strategies for improving IMID outcomes: the potential of JAK inhibitors. Presented at: Interdisciplinary Autoimmune Summit; April 15-18, 2021; virtual.
3. Amerson EH. Management of immunosuppressants and biologics in patients with chronic viral infections such as hepatitis B & C. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.
4. Freeman EE. COVID-19 symposium. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.
