MauiDerm 2014 kicks off with therapeutic updates, industry advances

The MauiDerm 2014 meeting kicked off Sunday with a Hawaiian blessing led by the conference's organizer, George Martin, M.D., Dermatology and Laser Center of Maui, Kihei, Hawaii.

In an engaging session, Hensin Tsao, M.D., followed with his annual "Year in Review." He discussed select studies he felt exhibited the most important advances in dermatology from the past year, and offered insight into how the findings might impact how dermatologists evaluate and manage patients.

"There was a time when very few people recommended sentinel lymph node biopsy for anything under 1 mm, but I think there has been a shift in our attitude," he said, following results of his first case question which prompted the attendees to cite under which conditions they would recommend the procedure. Dr. Tsao is clinical director of the melanoma and pigmented lesion center, Massachusetts General Hospital, Boston.

Attendees gleaned several valuable takeaways from the studies he highlighted, including:

• Breslow thickness greater than 0.75 and ulceration or the two most predictive features among thin melanomas of having a positive sentinel lymph node biopsy;

• prophylactic penicillin may reduce the risk of cellulitis recurrence by about 50 percent;

• although rare, secondary cutaneous malignancies from kidney transplants have been reported.

Neal Bhatia, M.D., associate clinical professor, Harbor-UCLA Medical Center, Los Angeles, and Ted Rosen, M.D., professor, Baylor College of Medicine, Houston, offered an update on the data surrounding new and existing drugs for a number of indications.

Apremilast (Celgene) is a drug that is expected to have many different uses, Dr. Bhatia said. It's exciting, he said, because there is data available for indications such atopic dermatitis, lichen planus, Behçet’s disease, psoriasis and psoriatic arthritis. Apremilast increases cyclic AMP through PDE4 inhibition which modulates the inflammatory response. Apremilast is currently in phase 3 trials for ankylosing spondylitis, psoriatic arthritis and psoriasis.

According to Dr. Rosen, apremilast will likely be approved for psoriatic arthritis, followed within the year by approval for psoriasis, giving dermatologists another oral systemic option with a different mechanism of action than other therapies.

Also for psoriasis, Dr. Rosen mentioned desoximetasone (Topicort, Taro Pharmaceuticals), which is now available as a spray and is indicated for the treatment of plaque psoriasis in patients ages 18 and older. Certolizumab pegol (Cimzia, UCB) is now approved for psoriatic arthritis in addition to rheumatoid arthritis and Crohn's disease. Dr. Rosen noted that safety and efficacy have not been established for use in patients with plaque psoriasis, and use of certolizumab pegol for psoriasis is currently off-label.

For chronic urticaria, clinicians are looking at the asthma medication omalizumab (Xolair, Genentech/Novartis), said Dr. Bhatia, who noted the best data is for the 300 mg dose. It appears to be especially useful for patients who are resistant to topical treatments and unaware of triggers.

There is also a flood of antifungals available or coming, Dr. Bhatia said. He touched on new and comparison data for luliconazole, efinaconazole, tavaborole, itraconazole 200 mg, econazole foam, and ketaconazole gel, which has been reformulated for use on the face. Dr. Rosen cautioned that the Food and Drug Administration has limited the use of oral ketaconazole due to the potential for severe liver injuries and adrenal gland problems. The FDA now says the oral tablets should not be a first-line treatment for any fungal infection, and should only be used for endemic mycoses and then only when alternative antifungal therapies are not available or tolerated. It is no longer indicated for dermatophyte infections and it is not indicated for the treatment of fungal infections of the skin or nails.

Additional updates included:

• A self-occluding topical anesthetic (Pliaglis cream, lidocaine 7 percent/tetracaine 7 percent, Galderma) is available for superficial dermatologic procedures that might be uncomfortable, such as mild laser abrasion, tattoo removal, filler injections, etc.

• Acyclovir buccal (Sitavig, BioAlliance Pharma) for recurrent orolabial herpes simplex virus is a treatment based on a novel technology - a polymer derived from milk which adheres to mucosa. It's a slow release but has a high local concentration with minimal blood level, Dr. Rosen explained. It is an adhesive tablet applied to the lesion until it falls off at about six hours.

• Carbinoxamine (Karbinal ER, Tris Pharma) is an extended release suspension antihistamine that is mildly sedating. It is an active antihistaminic complexed with sodium polystyrene sulfonate, from which it's released. It is indicated for allergic rhinitis, conjunctivitis, uncomplicated urticaria, angioedema, and dermatographism.

• Vashe skin and wound hydrogel (PuriCore) is a hypochlorous acid-containing material intended to relieve pruritis and burning, and pain from conditions such as atopic dermatitis, allergic contact dermatitis, radiation dermatitis, and thermal burns.

• Adapalene benzoyl peroxide (Epiduo) received approval to treat patients ages 9 and older.

Regarding devices, Dr. Rosen mentioned the recent over-the-counter clearance by the FDA for Celluma (BioPhotas), an LED therapy device that previously had been cleared for prescription use for the treatment of acne, muscle and joint pain, muscle and joint stiffness, muscle spasm, arthritis and compromised local blood circulation.

Finally, Professor Eggert Stockfleth, M.D., of Charité University Hospital Berlin, introduced the first global S3 guidelines for the treatment of actinic keratosis, which is currently under development. It is meant to be the highest level of evidence-based recommendations. These guidelines will have an influence in both the United States and Australia, he said.

In partnership with the International League of Dermatological Societies and the European Skin Cancer Foundation, Dr. Stockfleth and colleagues assembled a panel of international experts to begin discussing the creation of the guidelines because actinic keratosis is an early stage cancer lesion, which impacts most people around the world.

The panel’s goal was first to develop a global-wide definition of actinic keratosis. Secondly, it sought to increase awareness of the disease and educate colleagues such as general practitioners who will see many cases due to the shortage of dermatologists. For example, he noted that England has 62 million people and only 348 dermatologists; Germany has 80 million people and 4,000 dermatologists.

The guideline development process began with a Cochran review, which lead to consensus discussions for treatment recommendations by subgroups. The team has now turned the resulting guidelines over to additional experts outside of the original development group.

"Having participated in the guidelines it was simply the most rigorous analysis of the data ... it was very impressive," Dr. Martin said in wrapping up the session. He urged all attendees to review the guidelines once they are vetted to the community and industry organizations.

For those with an interest in evidence-based guidelines, Dr. Stockfleth referenced www.euroderm.org as a wealth of guidelines on many different conditions.

Stay tuned to Dermatology Times as we bring you more daily highlights from MauiDerm 2014 and further in-depth coverage on the data presented following the meeting.