Recap of the 3rd Annual San Diego Dermatology Symposium

The 3rd Annual San Diego Dermatology Symposium (SDDS) took place for the first time in-person on March 11–13, 2022, at the Hilton San Diego Bayfront. Many speakers and attendees said this was their first live in-person meeting in 1 to 2 years.  Below is a summary of 3 SDDS lectures. 

Hidradenitis Suppurativa

Jennifer Hsiao, MD, provided us with a review of hidradenitis suppurativa (HS) and her expert tips for management of this disease.¹ The pathogenesis of HS is complex and involves immune dysregulation, hormones, follicular occlusion, genetics, the microbiome, metabolic dysfunction, and local friction or irritation.

Topical treatments include antibiotics and antiseptic washes, as well as resorcinol, which may reduce pain and lesion size. For patients with Hurley Stage I or II HS, antibiotic monotherapy with doxycycline or dapsone may be effective. Combination regimens to consider are clindamycin and rifampin or rifampin and moxifloxacin/levofloxacin and metronidazole. Patients with severe HS may be treated with induction therapy of IV ertapenem for 6 weeks before consolidation treatment with oral antibiotics.

Oral retinoids such as acitretin may be beneficial, although the results for isotretinoin in the literature are mixed. Apremilast is another oral medication that may be beneficial in mild to moderate HS. Hormonal therapy includes spironolactone, oral contraceptives, finasteride, and metformin.

Adalimumab and infliximab are the biologics with the most evidence, although other biologics may be considered, such as secukinumab, ustekinumab, anakinra, or IL-23 inhibitors. Isoniazid, etanercept, and IV immunoglobulin are therapies not currently supported by the literature.

Procedural management of HS includes intralesional steroid injections; botulinum toxin; laser therapy, including laser hair removal; and wide local excision.

When treating a patient with HS, we should consider their medical comorbidities and complications of the disease. For patients with recalcitrant disease or those who are not good surgical candidates, combination therapies and a multidisciplinary approach may be helpful. 

Hyperpigmentation and Hypopigmentation

We received an update on hyperpigmentation² and hypopigmentation³ from Pearl Grimes, MD, FAAD, who suggests a multimodal approach to treating melasma, which has a complex pathogenesis leading to a photodamage phenotype. Although postinflammatory hyperpigmentation can be “cured,” patients with melasma should be counseled that they will likely require maintenance treatment.

Visible light is implicated in the development of hyperpigmentation, with Opsin-3 as the key sensor in melanocytes responsible for stimulating persistent pigmentation. Iron oxides block short wavelengths of visible light and have been shown to have a statistically significant strong antipigmentation effect. Dr Grimes recommends tinted sunscreen or makeup foundations containing high iron oxide levels (at least 3.5% to 5%) such as Dermablend. In terms of topical lighteners, triple combination products have been shown to be most effective (eg, hydroquinone, tretinoin, and fluocinolone). Other effective treatments include topical cysteamine cream, oral tranexamic acid, and Polypodium leucotomos extract. Liposomal glutathione, vitamin E, oral or topical niacinamide, French maritime pine bark extract, and grape seed extract are additional antioxidants to consider. A recent study led by Dr Grimes showed significant improvement in melasma with malasezzin, a novel natural microbiome indole produced by Malassezia furfur. Superficial chemical peels and microneedling may be helpful adjunct treatments to topical therapies. In refractory cases of melasma, treatment with the low-fluence Q-switched Nd-YAG laser or fractional 1550/1540 nm nonablative therapy may be considered.

Vitiligo is a psychologically devastating disease with significant impact on quality of life, and treatment also requires a multimodal approach. Stages of treatment are stabilization of active disease, repigmentation, and maintenance. Therapies for stabilization include oral mini-pulse therapy with dexamethasone, methotrexate, minocycline, IM triamcinolone, narrow band UVB phototherapy, and oral antioxidants. Vitamin D status should be assessed in patients with vitiligo and supplemented in patients with deficiency. Topical calcineurin inhibitors have comparable response rates to topical corticosteroids and may be added to phototherapy for an enhanced response. The excimer laser in combination with topical therapy has also shown high response rates. The 311-nm Titanium:Sapphire laser shows similar efficacy to the excimer laser in localized vitiligo. Afamelanotide is a synthetic analogue of α-MSH administered as an injectable implant that has shown efficacy for vitiligo in recent studies. Other emerging therapies to look out for in vitiligo treatment include prostaglandin F2a analogues (latanoprost and bimatoprost) and topical ruxolitinib cream.

Skin Tightening with Creams, Hormones, Laser Resurfacing, and Surgical Lifting

Ronald Moy, MD, FAAD, led us through a discussion on various modalities for skin tightening.⁴ First, he discussed that hormone decline is at the root of many aging-related diseases, and hormone replacement therapy (HRT) is a cornerstone of anti-aging therapy. Estrogen replacement has been shown to increase skin thickness, epidermal hydration, and skin elasticity; reduce wrinkles; and enhance vascularization, content, and quality of collagen. Of note, estrogen is safe to use in women with a history of breast cancer, and bioidentical estrogen is superior to synthetic estrogen. Topical application of estrogen cream can similarly increase skin thickness and improve the appearance of wrinkles. HRT with testosterone has also been shown to significantly increase collagen content in postmenopausal women. Both oral dehydroepiandrosterone (DHEA) replacement (50 mg) and topical DHEA can provide anti-aging effects through increased skin thickness, sebum production, collagen metabolism, and epidermal hydration. Human growth hormone replacement has multiple benefits, including preventing skin thinning and sagging, as well as an overall improved feeling of well-being and prevention of Alzheimer disease, osteoporosis, and heart disease. Topical epidermal growth factor (GF) cream has been shown to thicken skin, decrease senile purpura, and improve wrinkles and signs of photoaging. Clinical applications for topical GF cream include improving the appearance of under-eye bags, atrophic acne scars, and senile purpura.

Laser resurfacing may also help tighten skin. This is a minimally invasive alternative to surgical treatments such as blepharoplasty and face- or neck-lifts. Fractional carbon dioxide laser resurfacing, as well as radiofrequency treatment, provides significant improvement in skin tightening of upper eyelids, infraorbital skin, cheeks, jowls, neck, and peri-ocular rhytids. Immediate skin tightening can be seen; heating of the skin is thought to promote immediate contraction of collagen, immediate collagen remodeling and elasticity, and long-term stimulation in producing new collagen. Radiofrequency skin tightening is also available through technologies such as AccuTite and FaceTite. 

Dr Caroline Tan is a resident at UCLA Dermatology in Los Angeles, CA.

Reference
1. Hsiao J. Hidradenitis Suppurativa. Presented at: San Diego Dermatology Symposium; March 11-13, 2022; San Diego, CA.

2. Grimes P. ​Hyperpigmentation. Presented at: San Diego Dermatology Symposium; March 11-13, 2022; San Diego, CA.

3. Grimes P. ​Hypopigmentation. Presented at: San Diego Dermatology Symposium; March 11-13, 2022; San Diego, CA.

4. Moy R. ​ ​Skin Tightening with Creams, Hormones, Laser Resurfacing, and Surgical Lifting. Presented at: San Diego Dermatology Symposium; March 11-13, 2022; San Diego, CA.