August 2014
CLINICAL 18
Single-dose tablet
effective for labial herpes
August 2014
COSMETIC 28
Incorporating lasers
Volume 35 No. 8
ONCOLOGY 50
August 2014
Complement
or competitor?
Experts weigh in on the role for electronic surface
brachytherapy in the dermatologists office
Managing locally
advanced BCC
Medication
adherence
success,
PRECAUTIONS: treatment
FOR EXTERNAL
USE Steven
ONLY. NOT FOR OPHTHALMIC
Feldman, M.D., discusses the
USE.
important
adherence
plays
' E
role
in patient management
d
FOLLOW
US ONLINE:
/
W
^
Clinical
W
^
Jesitus
h John
| Senior Staff Correspondent
John Jesitus | Senior Staff Correspondent
Electronic surface brachytherapy allows derma
SUCCESSFULLY managing cutaneous drug
DermatologyTimes.com
Cutaneous drug
reaction diagnoses
require art, urgency
DermatologyTimes.com
tions in the differential diagnosis of most
and
d
many
experts
say. And if the specialty doesnt
cutaneous
eruptions,
recognizing
seize
the opportunity, they add, it might lose some
severe reactions where treatment may
skin cancer treatments to radiation oncologists.
improve outcomes, an expert says.
ADVERSE REACTIONS: Z
Diagnosing cutaneous drug reacThe appeal of electronic surface brachy d
tions
is almost
an art, says
David R.
therapy to the dermatology community is that
Adams, M.D.,
sulfacetamide,
are Pharm.D.,
noteworthy:professor
instances of
of Stevens-Johnson
this is something performed in our offices
dermatology
at Penn
State
Hershey
that has a cure rate, as best we understand it,
to aMedical
syndromeCenter,
resembling
systemic lupus
erythematosus; in one case
Hershey,
Pennsylvathat approximates that of Mohs surgery, says
tZE/E'^
nia. Usually its based on the clinical
Wm. Philip Werschler, M.D., a dermatologist
WW/
appearance of the reaction
and evaluain Spokane, Washington, and assistant clinical
tion of the timing of medication adminprofessor of medicine/dermatology, University of
istration. This can vary, depending on
Washington School of Medicine, Seattle.
the type of reaction.
Copyright 2014 Mission
Pharmacal Company.
DRUG REACTIONS
see page 25
Electronic surface brachytherapy is also
All rights reserved.
AVA-14111
0640I.01
C01 Rev 007130
Dermatology Times
August 2014
CLINICAL 18
Single-dose tablet
effective for labial herpes
August 2014
COSMETIC 28
Incorporating lasers
Volume 35 No. 8
ONCOLOGY 50
Managing locally
advanced BCC
Determining appropriate
treatment strategies
BUSINESS 66
Insurance exchange,
ACO pressures mounting
Dermatologists face increasing
pressure to prove their value
August 2014
Complement
or competitor?
Experts weigh in on the role for electronic surface
brachytherapy in the dermatologists office
Electronic surface brachytherapy uses a portable
machine (Xoft Axxent Electronic Brachytherapy
System; iCAD) about the size of a laser to generate
precise, accurately targeted doses of radiation applied
through an applicator placed directly on the skin.
Photos: Philip Werschler, M.D.
THE TAKEAWAY 88
Medication
adherence
As a primary factor impacting
treatment success, Steven
Feldman, M.D., discusses the
important role adherence plays
in patient management
FOLLOW US ONLINE:
DermatologyTimes.com
Clinical
Cutaneous drug
reaction diagnoses
require art, urgency
DermatologyTimes.com
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Electronic surface brachytherapy allows dermatologists to offer patients another safe, effective
option for nonmelanoma skin cancer (NMSC),
many experts say. And if the specialty doesnt
seize the opportunity, they add, it might lose some
skin cancer treatments to radiation oncologists.
The appeal of electronic surface brachytherapy to the dermatology community is that
this is something performed in our offices
that has a cure rate, as best we understand it,
that approximates that of Mohs surgery, says
Wm. Philip Werschler, M.D., a dermatologist
in Spokane, Washington, and assistant clinical
professor of medicine/dermatology, University of
Washington School of Medicine, Seattle.
Electronic surface brachytherapy is also
ADV
Others Promise.
Obagi Delivers.
www.obagi.com
Reference: 1. Professional Skin Care 2012: U.S. Market Analysis and Opportunities. Parsippany, NJ: Kline & Company, Inc.; 2013.
Except as otherwise indicated, all product names, slogans and other marks are trademarks of the Valeant family of companies. Distributed by OMP, Inc.
2014 Obagi Medical Products, Inc., a division of Valeant Pharmaceuticals North America LLC. DM/OBG/14/0035 04/14
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Our Mission
Dermatology Times is the only clinical news resource serving
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IN MEMORIAM
Susan R. Schell
July 25, 1956 - June 8, 2014
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Why would
you settle
for only half
of a solution?
EHR and Practice Management from Compulink.
A comprehensive solution, the best approach.
What if you had a total productivity solution that provided far more than just EHR software to improve
your practices productivity and protability?
Compulink ofers a complete, fully integrated EHR and Practice Management System specic for
dermatology. One designed from the ground up to automate and streamline operations throughout
your entire practice. Our comprehensive solution ofers many benets:
Eliminates steps and redundant data entry
Optimizes patient throughput
Simplies retail product management
Provides complete visibility into clinical, nancial and retail performance
Increases ROI
Best of all, your physicians will love the speed and power of our EHR, all fully certied for Meaningful Use.
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Evaluating the
realities of the
Affordable Care Act
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purchased their own private health insurance so they could be seen more rapidly by
the physician or specialist of their choosing.
This is the type of two-tiered system
Id like not to see in the United States. If
delisting of physicians to narrow the scope
of the provider network continues, my grade
for this component of ACA would be a D.
Higher deductibles In order to avoid
the tax penalty of $95 or 1 percent of an
individuals total taxable income for not
having enrolled in a health insurance plan
under ACA, some patients opted for a lower
cost plan with a high deductible. Many of
these patients failed to realize this and were
shocked to learn that when an unexpected
injury or illness occurs, they are responsible
for perhaps a sizeable portion of their care.
In some cases, the deductible may range
from $3,000 to $5,000. While this problem
may have been driven by the terms of the
ACA (since uninsured people had to get
insurance or pay a penalty), it should not be
blamed on this program since it truly was
one of those unintended consequences of
this legislation. The grade for this section
would therefore be non-credit or no grade.
Increased bureaucracy If you thought
HIPAA (Health Insurance Portability and
Accountability Act) and EHR (electronic
health records) were difficult and expensive
to implement, wait until you have to decide
which ACO (accountable care organization)
to become affiliated with and how to prove
that your practice provides efficient, effective, high-quality care at appropriate cost.
It seems inevitable with the push toward
value-based incentives that more effort will
be required to prove to your ACO the value
of a patient seeing you for dermatologic
care rather than someone else. If all those
werent enough new bureaucratic hurdles to
clear, wait for the creation and implementation of the new IPAB (Independent Payment
Advisory Board) that will determine how to
reduce Medicare costs without impacting
quality of care. My grade for increased
bureaucracy under ACA would be a D.
Providing healthcare of high quality
at a reasonable cost is not only incredibly difficult but also extremely complex.
Having partially accomplished the goal of
increasing the number of Americans with
health insurance coverage, it is time to take
substantial, thoughtful corrective action to
eliminate the errors described above. Otherwise, these goals will never be met and our
patients will continue to suffer the consequences. DT
ADV
Skin is as important to us as it
is to you. So at Celgene, were
bringing our scientific expertise
andinnovative thinking to dermatology.
Its our commitment to help you help
your patients.
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NEWS EAGLE
LEGAL
UPDATE
Teledermatology
fraught with
liability issues
Telemedicine
consulting may not
be covered by your
malpractice insurer.
Ultimately the deceased patients
estate sues for negligence, wrongful
death and practicing telemedicine without a license in Kentucky.
Dr. Cali is horrified and seeks legal
advice. Should he be worried?
Telemedicine is a term that covers
any use of electronic communication
technology to convey medical information. It can be as basic as seeking a
consultation or as advanced as robotic
surgery. Teleradiologists and telepathologists use electronic communication to
send radiographs and specimen images
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Licensure
Negligence liability
Insurance coverage
(i) Most malpractice policies specifically
exclude coverage for unlicensed activities. Some states require insurers to cover
work that extends beyond state borders
and some do not. Know where your state
ADV
Barrier Protection
for the Ages
RxOnly
ELETONE CREAM
NOW AVAILABLE IN
TwinPack
ELETONE CREAM
Nonsteroidal Atopic Dermatitis Therapy
PRODUCT DESCRIPTION:
CAUTION:
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ELE-14107
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ADVANCES
10
http://bit.ly/PMMAclearsacnescars
POLYMETHYLMETHACRYLATE
(PMMA) microspheres in collagen
are effective for treating atrophic acne
scars, results of a recent study suggest.
Investigators from Suneva Medical
gave 147 patients w ith at least four
moderate-to-severe rolling atrophic
acne scars eit her A rteFill (PMM Acollagen, Suneva) or saline injections.
The patients received up to two treatment sessions and were followed up
for six months, according to the study.
Investigators determined efficacy with
a validated rating scale for each scar.
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FDA grants
orphan drug
status for
congenital
ichthyosis
treatment
THE FOOD AND DRUG Administration has granted orphan drug designation to Galdermas trifarotene molecule
for the treatment of congenital ichthyosis.
As a result, Galderma officials say the
company plans to implement a clinical
development plan to explore new treatment options for other rare skin diseases
such as cutaneous T-cell lymphoma and
Gorlin syndrome.
The or pha n dr ug desig nat ion is
reserved for drugs and biologics that
are intended for the effective treatment,
diagnosis or prevention of rare disorders
that affect fewer than 200,000 people in
the United States or that affect more than
200,000 people but are not expected to
generate enough revenue to cover development and marketing costs.
Given the burden of congenital ichthyosis and the lack of effective and easy-touse treatments, this is a condition which
is very difficult to live with, Galderma
President and CEO Humberto C. Antunes
said in a news release. Galdermas objective is therefore not only to provide an efficient and safe medical solution to alleviate
the symptoms of the disease, but also to
improve patients quality of life.
The trifarotene molecule is a selective agonist of the gamma retinoic
acid receptor (RAR-gamma), which is
currently in clinical development for use
in more common dermatological conditions, according to the company. The
drugs retinoid functionality and keratolytic properties make it a potentially viable
treatment for lamellar ichthyosis.
Galderma has initiated the program
for investigating the treatment of lamellar
ichthyosis with trifarotene and is currently
working in collaboration with regulators
to implement a clinical development plan.
The estimated domestic prevalence of
lamellar ichthyosis is in the range of one
per 150,000 persons.DT
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A BREAKTHROUGH
SPOT TREATMENT FOR
COLD SORE OUTBREAKS
www.
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.com
ADV
ADVANCES
12
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FDA clears
Kerydin topical
solution for
onychomycosis
of the toenails
ADV
Same formulation
Same manufacturer
Learn more at www.clodermcream.com
Not a cookie-cutter
topical steroid
Locoid Lipocream and Locoid Lotion are registered trademarks of Astellas Pharma Europe B.V. licensed to Onset Dermatologics
References: 1. Data on le. Study #CDC1303. Bridgewater, NJ: Promius Pharma, LLC; 2013.
2. Data on le. Study #CDC1304. Bridgewater, NJ: Promius Pharma, LLC; 2013.
Cloderm is a trademark of Coria Laboratories, Ltd. 2014 Promius, Pharma, LLC. All rights reserved. CDM-0414-106
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RxOnly
5. Parents of pediatric patients should be advised not to use tight-tting diapers or plastic pants on
a child being treated in the diaper area, as these garments may constitute occlusive dressings.
Laboratory Tests: The following tests may be helpful in evaluating the HPA axis suppression:
Urinary free cortisol test
ACTH stimulation test
Carcinogenesis, Mutagenesis, and Impairment of Fertility: Long-term animal studies have not been
performed to evaluate the carcinogenic potential or the effect on fertility of topical corticosteroids.
DESCRIPTION: Cloderm Cream 0.1% contains the medium potency topical corticosteroid,
clocortolone pivalate, in a specially formulated water-washable emollient cream base consisting of
puried water, white petrolatum, mineral oil, stearyl alcohol, polyoxyl 40 stearate, carbomer 934P,
edetate disodium, sodium hydroxide, with methylparaben and propylparaben as preservatives.
CLINICAL PHARMACOLOGY:
Topical corticosteroids share anti-inammatory, antipruritic and vasoconstrictive actions.
The mechanism of anti-inammatory activity of the topical corticosteroids is unclear. Various
laboratory methods, including vasoconstrictor assays, are used to compare and predict potencies
and/or clinical efcacies of the topical corticosteroids. There is some evidence to suggest that a
recognizable correlation exists between vasoconstrictor potency and therapeutic efcacy in man.
Pharmacokinetics: The extent of percutaneous absorption of topical corticosteroids is determined
by many factors including the vehicle, the integrity of the epidermal barrier, and the use of occlusive
dressings.
Topical corticosteroids can be absorbed from normal intact skin. Inammation and/or other disease
processes in the skin increase percutaneous absorption. Occlusive dressings substantially increase
the percutaneous absorption of topical corticosteroids. Thus, occlusive dressings may be a valuable
therapeutic adjunct for treatment of resistant dermatoses.
(See DOSAGE AND ADMINISTRATION).
Once absorbed through the skin, topical corticosteroids are handled through pharmacokinetic
pathways similar to systemically administered corticosteroids. Corticosteroids are bound to plasma
proteins in varying degrees. Corticosteroids are metabolized primarily in the liver and are then
excreted by the kidneys. Some of the topical corticosteroids and their metabolites are also excreted
into the bile.
INDICATIONS AND USAGE: Topical corticosteroids are indicated for the relief of the inammatory
and pruritic manifestations of corticosteroid-responsive dermatoses.
CONTRAINDICATIONS: Topical corticosteroids are contraindicated in those patients with a history
of hypersensitivity to any of the components of the preparation.
PRECAUTIONS: General: Systemic absorption of topical corticosteroids has produced reversible
hypothalamic-pituitary-adrenal (HPA) axis suppression, manifestations of Cushings syndrome,
hyperglycemia, and glucosuria in some patients.
Conditions which augment systemic absorption include the application of the more potent steroids,
use over large surface areas, prolonged use, and the addition of occlusive dressings.
Therefore, patients receiving a large dose of a potent topical steroid applied to a large surface
area or under an occlusive dressing should be evaluated periodically for evidence of HPA axis
suppression by using the urinary free cortisol and ACTH stimulation tests. If HPA axis suppression is
noted, an attempt should be made to withdraw the drug, to reduce the frequency of application, or
to substitute a less potent steroid.
Recovery of HPA axis function is generally prompt and complete upon discontinuation of the
drug. Infrequently, signs and symptoms of steroid withdrawal may occur, requiring supplemental
systemic corticosteroids.
Children may absorb proportionally larger amounts of topical corticosteroids and thus be more
susceptible to systemic toxicity.
(See PRECAUTIONS-Pediatric Use).
If irritation develops, topical corticosteroids should be discontinued and appropriate therapy
instituted.
Studies to determine mutagenicity with prednisolone and hydrocortisone have revealed negative
results.
Nursing Mothers: It is not known whether topical administration of corticosteroids could result
in sufcient systemic absorption to produce detectable quantities in breast milk. Systemically
administered corticosteroids are secreted into breast milk in quantities not likely to have deleterious
effect on the infant. Nevertheless, caution should be exercised when topical corticosteroids are
administered to a nursing woman.
Pediatric Use: Pediatric patients may demonstrate greater susceptibility to topical corticosteroidinduced HPA axis suppression and Cushings syndrome than mature patients because of a larger
skin surface area body weight ratio.
Hypothalamic-pituitary-adrenal (HPA) axis suppression, Cushings syndrome, and intracranial
hypertension have been reported in children receiving topical corticosteroids. Manifestations
of adrenal suppression in children include linear growth retardation, delayed weight gain, low
plasma cortisol levels, and absence of response to ACTH stimulation. Manifestations of intracranial
hypertension include bulging fontanelles, headaches, and bilateral papilledema.
Administration of topical corticosteroids to children should be limited to the least amount
compatible with an effective therapeutic regimen. Chronic corticosteroid therapy may interfere with
the growth and development of children.
ADVERSE REACTIONS:
The following local adverse reactions are reported infrequently with topical corticosteroids, but
may occur more frequently with the use of occlusive dressings. These reactions are listed in an
approximate decreasing order of occurrence:
Burning, Itching, Irritation, Dryness, Folliculitis, Hypertrichosis, Acneiform eruptions,
Hypopigmentation, Perioral dermatitis, Allergic contact dermatitis, Maceration of the skin,
Secondary infection, Skin atrophy, Striae, Miliaria.
OVERDOSAGE:
Topically applied corticosteroids can be absorbed in sufcient amounts to produce systemic effects
(see PRECAUTIONS).
DOSAGE AND ADMINISTRATION:
Apply Cloderm (clocortolone pivalate) Cream 0.1% sparingly to the
affected areas three times a day and rub in gently.
Occlusive dressings may be used for the management of psoriasis or recalcitrant conditions.
If an infection develops, the use of occlusive dressings should be discontinued and appropriate antimicrobial therapy instituted.
HOW SUPPLIED:
Cloderm (clocortolone pivalate) Cream 0.1% is supplied in 30 gram and 75 gram pump bottles, 45
gram and 90 gram tubes.
30 gram pump bottle
75 gram pump bottle
45 gram tube
90 gram tube
NDC-67857-804-30
NDC-67857-804-51
NDC-67857-804-45
NDC-67857-804-90
STORAGE:
Store Cloderm Cream between 15 and 30 C (59 and 86 F).
Avoid freezing.
Distributed by:
www.promiuspharma.com
Promius Pharma, LLC
200 Somerset Corporate Blvd., Floor 7, Bridgewater, NJ 08807
Cloderm is a trademark of Coria Laboratories, Ltd.
Manufactured by:
DPT LABORATORIES, LTD.
San Antonio, Texas 78215
3. The treated skin area should not be bandaged or otherwise covered or wrapped as to be
occlusive unless directed by the physician.
4. Patients should report any signs of local adverse reactions especially under occlusive dressing.
black
Issued 0711
004158
ADV
ADVANCES
Secukinumab effective
for treating plaque psoriasis
New England Journal of Medicine
July 2014
http://bit.ly/secukinumab
http://bit.ly/acneantibioticsslow
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15
Melanoma
combination
therapy shows
promising
results
ADV
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2014 Novartis
5/14
XDP-1301059
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18
CLINICAL DERMATOLOGY
PROCESS OF ACNE
22 Insights
indicate new
mechanisms by which
bacteria induce lesions
Single-dose tablet
efective for labial herpes
Louise Gagnon | Staff Correspondent
QUICK READ
Quotable
One of our challenges
moving forward is to
try to assess the relative
importance of the
various cytokines
involved in acne.
Diane Thiboutot, M.D.
Hershey, Pa.
On mechanisms of acne
See story, page 22
DTExtra
Content related to dermatology and dermatologic
conditions is widely available on YouTube, but
identifying sources for some of the content remains
a challenge, according to results of a recent study.
The study, conducted by University of Colorado
Cancer Center, Aurora, Colo., examined the type of
content related to dermatology found on YouTube.
Under the search term dermatology, 45 percent of
the content was educational, while 20 percent was
clinical demonstrations by dermatologists. Of the
total number of videos, 35 percent were uploaded
by or included an M.D./D.O./Ph.D. in dermatology
or another specialty or field, researchers found.
READ MORE: DERMATOLOGYTIMES.COM/YOUTUBEVIDEOS
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BASELINE LEG
-FTJPOTEFDSFBTFEJOUIJDLOFTTBOETDBMF
Topicort Topical Spray is a topical corticosteroid indicated for the treatment of plaque psoriasis in patients 18 years of age or older.
Important Safety Information
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is not recommended.
1. Data on le, Taro Pharmaceuticals U.S.A., Inc.
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AD100-0036
June 2014
ADV
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BYJMMBPSHSPJO
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t %POPUCBOEBHFPSPUIFSXJTFDPWFSPSXSBQUIFUSFBUFETLJOTPBTUPCFPDDMVTJWF
t 3FQPSUBOZTJHOTPGMPDBMPSTZTUFNJDBEWFSTFSFBDUJPOTUPUIFQIZTJDJBO
t %POPUVTFPUIFSDPSUJDPTUFSPJEDPOUBJOJOHQSPEVDUTXJUI5PQJDPSU5PQJDBM4QSBZXJUIPVUSTUDPOTVMUJOHXJUI
the physician.
t %JTDPOUJOVFUIFSBQZXIFODPOUSPMJTBDIJFWFE*GOPJNQSPWFNFOUJTTFFOXJUIJOXFFLT
DPOUBDU
the physician.
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Topicort Topical Spray,
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black
ADV
CLINICAL DERMATOLOGY
21
HERPES LABIALIS:
New delivery system for old drug appears safe, efective from page 18
If it cant prevent the outbreak,
it can shorten the duration of the
outbreak, Dr. Tyring says. There are
longer delays between outbreaks, and
when a person has an outbreak, the
outbreak is less severe. The greatest
benefit, however, was applied during
the prodrome.
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22
CLINICAL
DERMATOLOGY
Researchers reconsider
acne development process
Ilya Petrou, M.D. | Senior Staff Correspondent
QUICK READ
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CLINICAL DERMATOLOGY
25
DRUG REACTIONS:
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QUICK READ
Handling severe cutaneous
drug reactions requires quickly
recognizing symptoms and,
where applicable, initiating
treatment, an expert says.
ocular manifestations, which can
lead to blindness.
Unfortunately, he adds, the rarity
of TEN makes it difficult to find
strong studies that can help guide
treatment.
ADV
26
CLINICAL
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
DRUG REACTIONS:
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TEN quickly
progresses over
several days, and
these patients
are at high risk
for systemic
complications.
David R. Adams, M.D., Pharm.D.
Hershey, Pennsylvania
ADV
POWERED BY SCIENCE.
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PATIENT PREFERRED
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*
AVEENO
60%
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Brand A
58.5
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0%
Skin Moisture
Barrier (TEWL)
55.9
Roughness
0
10
20
30
40
50
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Visit our new site for AVEENO product information, to learn more about
ACTIVE NATURALS ingredients in skincare and to order samples.
Johnson & Johnson Consumer Companies, Inc. 2014
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28
COSMETIC DERMATOLOGY
FACIAL REJUVENATION
34 Filler
options expand, with new
products aimed at correcting
midface volume loss
TRUE BEAUTY
36 EMPHASIZING
Self-esteem gets a boost after
cosmetic procedures, which
can lead to increased confidence
PART 1
QUICK READ
Quotable
Te (self-tanner) color
can be lightened by
applying the product to
moist skin or mixing a
small amount of water
with the product ... prior
to application.
Zoe Diana Draelos, M.D.
Durham, N.C.
On how to adjust
self-tanner colors
See story, page 33
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DTExtra
Val Lambros, M.D., Newport Beach, Calif., said in
his presentation at the annual Vegas Cosmetic
Surgery meeting that although he uses fat in every
facelift he performs and has been using it for
more than 20 years, this natural filler can cause
problems in inexperienced hands. Dr. Lambros
emphasized that fat is unpredictable. A rookie
mistake might be to overgraft fat into the face
to smooth away wrinkles, but if the fat grows
over time, it can make the face unnaturally big,
masking the natural contours. Thus, the wrinkles
may be gone, but patients tend not to be happy
when they no longer look like themselves, he said.
READ MORE: DERMATOLOGYTIMES.COM/FATINJECTION
ADV
*A phase 3, randomized, multicenter, double-blind, active- and vehicle-controlled, parallel-group study evaluating the efficacy and safety
of adapalene 0.1%BPO 2.5% fixed-dose combination gel relative to adapalene 0.1% monotherapy, BPO 2.5% monotherapy, and gel
vehicle in a large population for the treatment of acne vulgaris (N=1670).
A multicenter, randomized, vehicle-controlled, double-blind study evaluating the efficacy and safety of adapalene 0.1%BPO 2.5%
fixed-dose combination gel in subjects 9 to 11 years of age with acne vulgaris (N=285).
EPIDUO GEL
The most commonly reported side effects when using EPIDUO gel include
erythema, scaling, dryness, application site irritation, stinging and burning.
Depending upon the severity of these side effects, patients should be instructed
to use a moisturizer, reduce the frequency of the application of EPIDUO gel,
or discontinue use.
Tell your doctor right away if these side effects continue for longer than
4 weeks or get worse, you may have to stop using EPIDUO gel. Tell your doctor
if you have any side effect that bothers you or that does not go away.
These are not all of the possible side effects of EPIDUO gel. For more
information, ask your doctor or pharmacist.
Do not use EPIDUO gel for a condition for which it was not prescribed. Do not
give EPIDUO gel to other people, even if they have the same symptoms you
have. It may harm them.
References: 1. Gollnick HPM, Draelos Z, Glenn MJ, et al; AdapaleneBPO Study Group. Adapalenebenzoyl peroxide, a unique fixed-dose combination topical gel for the treatment of
acne vulgaris: a transatlantic, randomized, double-blind, controlled study in 1670 patients. Br J Dermatol. 2009;161(5):1180-1189. 2. Czernielewski J, Michel S, Bouclier M, Baker M,
Hensby C. Adapalene biochemistry and the evolution of a new topical retinoid for treatment of acne. J Eur Acad Dermatol Venereol. 2001;15(suppl 3):5-12. 3. Tenaud I, Khammari A,
Drno B. In vitro modulation of TLR-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol. 2007;16:500-506. 4. Thiboutot D, Gollnick H,
Bettoli V, et al; Global Alliance to Improve Outcomes in Acne. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am
Acad Dermatol. 2009;60(5)(suppl):S1-S50. 5. Eichenfield LF, Draelos Z, Lucky AW, et al. Preadolescent moderate acne vulgaris: a randomized trial of the efficacy and safety of topical
adapalene-benzoyl peroxides. J Drugs Dermatol. 2013;12(6):611-618.
www.epiduo.com/hcp
COSMETIC
DERMATOLOGY
33
COSMETIC
CONUNDRUMS
Q:
A:
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The pH level of
the skin and the
formulation can
also change the
color of the DHAinduced skin stain.
Q:
A:
I recommend self-tanning
creams for my patients who want
some color, but they tell me the end
result is too dark or too orange.
Self-tanning creams are being
recommended by dermatologists
more frequently as patients are told
to use them to achieve browner
skin without sun exposure. All selftanning creams contain a threecarbon sugar that appears as a white,
crystalline hygroscopic powder
known as dihydroxyacetone (DHA).
DHA is formed when glycerol
is fermented by Gluconobacter
oxydans. It interacts with amino
acids, peptides and proteins to form
chromophobes known as melanoi-
ADV
34
COSMETIC
DERMATOLOGY
QUICK READ
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ADV
In cooperation with the dermatologist, eBx is administered under the supervision of a radiation oncologist.
1
Bhatnagar A. Electronic Brachytherapy for the Treatment of Nonmelanoma Skin Cancer: Results at 3 Years. Int J Radiat Oncol Biol Phys 2013;87:S65
2014 Xoft, a subsidiary of iCAD, Inc. All rights reserved. Axxent, Xoft and Electronic Brachytherapy System (eBx) are registered trademarks of iCAD, Inc.
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ADV
36
COSMETIC
DERMATOLOGY
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QUICK READ
Self-esteem gets a boost after
cosmetic procedures, which
may also lead to an increase in
confdence.
wa rd robe i nclud i ng match i ng
mother-daughter outfits.
I remember thinking about the
t wo of us d ressed a l i ke one, a
full-blown goddess, larger-than-life,
the other, a sk inny, freck le-based
tadpole, an anonymous, unfinished
pencil sketch. As far as my appearance was concerned, I was undefined, except in relation to another
woman, Ms. Monroe says.
It s e a s y t o f a l l s hor t i n s uc h
c ompa r i s on s, s ay s D r. Day a n, a
plast ic su rgeon who pract ices i n
Chicago. A neuropsychiatr y study
re ve a le d t h at s ubt le a nd ba rel y
perceptible alterations in a face can
completely alter another persons
perception of that face (Walker M,
Vetter T. J Vis. 2009;9(11):12).
ADV
NEW
STRENGTH!
Introducing
RETIN-A MICRO
Except as otherwise indicated, all product names, slogans, and other marks are trademarks of the Valeant family of companies.
2014 Valeant Pharmaceuticals North America LLC. DM/RAM/14/0003 06/14 Printed in USA.
NEW
STRENGTH!
Introducing
RETIN-A MICRO
Except as otherwise indicated, all product names, slogans, and other marks are trademarks of the Valeant family of companies.
2014 Valeant Pharmaceuticals North America LLC. DM/RAM/14/0003 06/14 Printed in USA.
COSMETIC DERMATOLOGY
39
TRUE BEAUTY:
Boost of self-esteem after cosmetic procedures can lead to increased confdence from page 36
modulators, fillers or whatever measures we have, we instantly make them
appear more friendly and attractive.
Conversely, aging extracts a toll. In
this regard, Ms. Monroe recounts her
experience greeting patrons at the
door of a friends art exhibit.
If you have
benefited from the
currency of your
looks, when that
currency loses its
value, you can feel
pretty bankrupt.
Valerie Monroe
Beauty director, O, The Oprah Magazine
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Only when
it happens
subconsciously
do you experience
the full pleasure
of something
beautiful.
Steven Dayan, M.D.
Chicago
ADV
40
COSMETIC
DERMATOLOGY
QUICK READ
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ADV
ULTHERAPY IS THE
PRE-TREATMENT
PRE-TREATMENT
PRE-TREATMENT
To Learn More
About Ultherapy:
Visit dt.ultherapy.com
or call 1.866.301.1009
The non-invasive Ultherapy procedure is U.S. FDA-cleared to lift skin on the neck, on the eyebrow and under the chin as well as to
improve lines and wrinkles on the dcollet. For indications in your country, and full product and safety information, including possible
mild side effects, visit www.ultherapy.com/IFU. 2014 Ulthera, Inc. Ultherapy is a registered trademark of Ulthera, Inc. 1001685E
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42
COSMETIC
DERMATOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
LASER PRACTICE:
Ensure your practice spends its money wisely before jumping into laser services from page 28
I star ted in t he laser business
through a chance meeting with the
head of the then ESC Medical who
asked me if I would be interested in
tr ying to remove hair with pulsed
light. That was a novel concept many
yea rs ago. From t here I bega n
work i ng w it h m a ny of t he te c hnologies that we have on the market
today, Dr. Gold says. Lasers and
light sources were a way to introduce my sk ills and my practice to
the people in middle Tennessee, and
this was very helpful in growing my
clinical practice.
But t h i ngs have got ten more
c ompl ic at e d s i nc e t he pione er s
in dermatolog y started their laser
practices.
Finding the financial wherewithal
to start a laser practice with one laser
in 1990 was hard enough, says Dr.
Alster, clinical professor of dermatolog y at Georgetow n Un iversit y
Hospital, Washington, D.C. Today,
laser and other device options are
vast and the costs associated with
ow ning or leasing the technolog y
can financially strain dermatology
practices.
Sta r t i ng a laser prac t ice ta kes
pla n n i ng a nd requ i res der matologists dont try to cut the wrong
corners, Dr. Katz says.
There are specific technologies
for specific conditions. The problem
people get into is they buy one or two
devices and try to use those for things
they really arent indicated for. That
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Laser technology
is so sophisticated
now that if you
dont have lasers
in your practice
youre not going to
be treating a lot
of conditions as
effectively.
Bruce Katz, M.D.
New York
look at the need in their communities, ask ing whether theres room
for a laser practice, says Elizabeth
L. Tanzi, M.D., clinical professor of
dermatology at George Washington
Un i v e r s i t y Me d ic a l C e n t e r a n d
co-director of the Washington Institute of Dermatologic Laser Surgery.
(Having a) really good, solid business plan before engaging in any sort
of investment is a wise thing to do,
Dr. Tanzi says.
Dermatologists should look at the
communities in which t hey practice or plan to practice to see what
technologies are already available,
according to Dr. Gold. Depending on
the supply and demand, a dermatologist might want to open laser practices similar to those in the communit y, but often, the goal is more to
differentiate themselves from whats
already available at other dermatologists offices, he says.
TAP EXISTING PATIENTS
ADV
COSMETIC DERMATOLOGY
49
LASER PRACTICE:
Ensure your practice spends its money wisely before jumping into laser services from page 42
First, define the practice, Dr. Katz
says. Does the dermatologist have
a practice full of older, fair-skinned
patients, with a lot of sun damage
in Florida, for example? Or is it an
urban practice catering to younger
people of all ethnicities, who might
be more interested in having toned,
fit looking bodies than in facial rejuvenation? Still other dermatologists
might focus on patients in the inner
city, who want their tattoos removed.
Starting a laser
practice takes
planning
and requires
dermatologists
dont try to cut the
wrong corners.
You h a v e t o t h i n k a b ou t t he
demographics of your patient base to
determine what kind of laser is going
to be used most frequently, he says.
Medical dermatologists might ask
themselves a different set of questions, according to Dr. Tanzi.
D o y ou f r e q ue nt l y r e f e r t o a
surgeon? Do you see a lot of scars in
your office from skin cancer surgery?
Do you want to be able to treat those
patients? Are you seeing children?
Dr. Tanzi says.
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Maintenance
costs of lasers can
be upwards of
$8,000 to $10,000
a year per laser.
Elizabeth Tanzi, M.D.
Washington, D.C.
ADV
50
CUTANEOUS ONCOLOGY
DERMATOPATHOLOGY REPORTS
64 Margin
comments in nevi
histology reports impact
re-excision rates
Quotable
It looks like most
practicing dermatologists
have come to some good
conclusions regarding
when to re-excise the
lesion, and which types
of lesions (in terms of
their atypia) to re-excise.
Richard L. Spielvogel, M.D.
Newtown Square, Pa.
On re-excision rates
See story, page 64
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DTExtra
Hawaii Gov. Neil Abercrombie signed a bill that
prohibits minors under the age of 18 from indoor
tanning, according to a news release. The bill is
effective immediately. The risk for developing
melanoma increases by 59 percent in individuals
who have been exposed to UV radiation from
indoor tanning devices. ... Since 2.3 million
teens tan indoors in the United States annually,
restricting teens access to indoor tanning is
critical to preventing skin cancer, said Brett
M. Coldiron, M.D., F.A.A.D., American Academy
of Dermatology president, in a news release.
SOURCE: DERMATOLOGYTIMES.COM/HAWAIIBAN
ADV
Its true. Rosacea is complex and its with her for life. Pivotal
clinical studies showed reduction of inammatory papules and
pustules of mild to moderate rosacea and some reduction of
associated erythema. Efcacy for treatment of erythema in rosacea
in the absence of papules and pustules has not been evaluated.
You have made Finacea the #1 Dermatologist-prescribed
topical rosacea brand.1
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ADV
FINACEA
(azelaic acid) Gel, 15%
6 ADVERSE REACTIONS
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates
observed in the clinical trials of a drug cannot be directly compared to rates in the clinical
trials of another drug and may not reflect the rates observed in practice.
In two vehicle-controlled and one active-controlled U.S. clinical trials, treatment safety
was monitored in 788 subjects who used twice-daily FINACEA Gel for 12 weeks
(N=333) or 15 weeks (N=124), or the gel vehicle (N=331) for 12 weeks. In all three
trials, the most common treatment-related adverse events were:
burning/stinging/tingling (29%), pruritus (11%), scaling/dry skin/xerosis (8%) and
erythema/irritation (4%). In the active-controlled trial, overall adverse reactions
(including burning, stinging/tingling, dryness/tightness/scaling, itching, and
erythema/irritation/redness) were 19.4% (24/124) for FINACEA Gel compared to 7.1%
(9/127) for the active comparator gel at 15 weeks.
Table 1: Adverse Events Occurring in 1% of Subjects in the Rosacea Trials by
Treatment Group and Maximum Intensity*
FINACEA Gel, 15%
Vehicle
N=457 (100%)
N=331 (100%)
Mild
Moderate Severe
Mild
Moderate Severe
n=99
n=61
n=27
n=46
n=30
n=5
(22%)
(13%)
(6%)
(14%)
(9%)
(2%)
Burning/
71 (16%) 42 (9%) 17 (4%) 8 (2%)
6 (2%)
2 (1%)
stinging/
tingling
Pruritus
29 (6%)
18 (4%)
5 (1%) 9 (3%)
6 (2%)
0 (0%)
Scaling/
21 (5%)
10 (2%)
5 (1%) 31 (9%) 14 (4%) 1 (<1%)
dry skin/
xerosis
Erythema/
6 (1%)
7 (2%)
2 (<1%) 8 (2%)
4 (1%)
2 (1%)
irritation
Contact
2 (<1%)
3 (1%)
0 (0%) 1 (<1%) 0 (0%)
0 (0%)
dermatitis
Edema
3 (1%)
2 (<1%)
0 (0%) 3 (1%)
0 (0%)
0 (0%)
Acne
3 (1%)
1 (<1%)
0 (0%) 1 (<1%) 0 (0%)
0 (0%)
7 DRUG INTERACTIONS
There have been no formal studies of the interaction of FINACEA Gel with other drugs.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Teratogenic Effects: Pregnancy Category B
There are no adequate and well-controlled studies in pregnant women. Therefore,
FINACEA Gel should be used during pregnancy only if the potential benefit justifies the
potential risk to the fetus.
Dermal embryofetal developmental toxicology studies have not been performed with
azelaic acid, 15% gel. Oral embryofetal developmental studies were conducted with
azelaic acid in rats, rabbits, and cynomolgus monkeys. Azelaic acid was administered
during the period of organogenesis in all three animal species. Embryotoxicity was
observed in rats, rabbits, and monkeys at oral doses of azelaic acid that generated some
maternal toxicity. Embryotoxicity was observed in rats given 2500 mg/kg/day [162
times the maximum recommended human dose (MRHD) based on body surface area
(BSA)], rabbits given 150 or 500 mg/kg/day (19 or 65 times the MRHD based on BSA)
and cynomolgus monkeys given 500 mg/kg/day (65 times the MRHD based on BSA)
azelaic acid. No teratogenic effects were observed in the oral embryofetal developmental
studies conducted in rats, rabbits and cynomolgus monkeys.
An oral peri- and post-natal developmental study was conducted in rats. Azelaic acid
was administered from gestational day 15 through day 21 postpartum up to a dose
level of 2500 mg/kg/day. Embryotoxicity was observed in rats at an oral dose of 2500
mg/kg/day (162 times the MRHD based on BSA) that generated some maternal toxicity.
In addition, slight disturbances in the post-natal development of fetuses was noted in
rats at oral doses that generated some maternal toxicity (500 and 2500 mg/kg/day; 32
and 162 times the MRHD based on BSA). No effects on sexual maturation of the fetuses
were noted in this study.
8.3 Nursing Mothers
It is not known whether azelaic acid is excreted in human milk; however, in vitro studies
using equilibrium dialysis were conducted to assess the potential for human milk
partitioning. The studies demonstrated that, at an azelaic acid concentration of 25
g/mL, the milk/plasma distribution coefficient was 0.7 and the milk/buffer distribution
was 1.0. These data indicate that passage of drug into maternal milk may occur. Since
less than 4% of a topically applied dose of 20% azelaic acid cream is systemically
absorbed, the uptake of azelaic acid into maternal milk is not expected to cause a
significant change from baseline azelaic acid levels in the milk. Nevertheless, a decision
should be made to discontinue nursing or to discontinue the drug, taking into account
the importance of the drug to the mother.
8.4 Pediatric Use
Safety and effectiveness of FINACEA Gel in pediatric patients have not been established.
8.5 Geriatric Use
Clinical studies of FINACEA Gel did not include sufficient numbers of subjects aged 65
and over to determine whether they respond differently from younger subjects.
17 PATIENT COUNSELING INFORMATION
Inform patients using FINACEA Gel of the following information and instructions:
Use only as directed by your physician.
For external use only.
Before applying FINACEA Gel, cleanse affected area(s) with a very mild soap or a
soapless cleansing lotion and pat dry with a soft towel.
Avoid use of alcoholic cleansers, tinctures and astringents, abrasives and peeling
agents.
Avoid contact with the eyes, mouth and other mucous membranes. If FINACEA Gel
does come in contact with the eyes, wash the eyes with large amounts of water and
consult your physician if eye irritation persists.
Wash hands immediately following application of FINACEA Gel.
Cosmetics may be applied after the application of FINACEA Gel has dried.
Avoid the use of occlusive dressings or wrappings.
Skin irritation (e.g., pruritus, burning, or stinging) may occur during use of FINACEA
Gel, usually during the first few weeks of treatment. If irritation is excessive or persists,
discontinue use and consult your physician.
Report abnormal changes in skin color to your physician.
To help manage rosacea, avoid any triggers that may provoke erythema, flushing, and
blushing. These triggers can include spicy and thermally hot food and drinks such as
hot coffee, tea, or alcoholic beverages.
* Subjects may have >1 cutaneous adverse event; thus, the sum of the frequencies
of preferred terms may exceed the number of subjects with at least 1 cutaneous
adverse event.
In patients using azelaic acid formulations, the following adverse events have been
reported: worsening of asthma, vitiligo, depigmentation, small depigmented spots,
hypertrichosis, reddening (signs of keratosis pilaris) and exacerbation of recurrent 2014, Bayer HealthCare Pharmaceuticals Inc. All rights reserved.
herpes labialis.
Local Tolerability Studies
Manufactured for:
FINACEA Gel and its vehicle caused irritant reactions at the application site in human
dermal safety studies. FINACEA Gel caused significantly more irritation than its vehicle in
a cumulative irritation study. Some improvement in irritation was demonstrated over the
course of the clinical trials, but this improvement might be attributed to subject dropouts.
No phototoxicity or photoallergenicity were reported in human dermal safety studies.
Bayer Healthcare Pharmaceuticals Inc.
Whippany, NJ 07981
6.2 Post-Marketing Experience
The following adverse reactions have been identified post approval of FINACEA Gel.
Manufactured in Italy
Because these reactions are reported voluntarily from a population of uncertain size, it
is not always possible to reliably estimate the frequency or establish a causal
relationship to drug exposure:
Eyes: iridocyclitis upon accidental exposure of the eyes to FINACEA Gel
6706806BS2
black
ADV
CUTANEOUS ONCOLOGY
53
BCC:
Determining appropriate treatment strategies for locally advanced disease from page 50
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ADV
54
CUTANEOUS
ONCOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
BCC:
Determining appropriate treatment strategies for locally advanced disease from page 53
must stress the expected benefits of
radiation treatment and the limited
number of treatment sessions when
counseling patients.
ORAL HEDGEHOG PATHWAY INHIBITORS
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On April 3rd, 2014, photobiologist Dr. Curt Cole led an hour-long webinar on the science of
sunscreens for Dermatology Times subscribers. Below are excerpts from that dynamic discussion.
To view the entire Webinar and Q&A session, please visit http://dermatologytimes.com/
Neutrogenasunscreenwebinar.
DERMATOLOGY TIMES
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A u g u s t 2014
ADV
Compare the 2 hypothetical, broad spectrum, SPF 30 sunscreens shown above: both have the same critical
wavelength, yet the amplitude of UVA protection varies dramatically1
The term broad spectrum does not ensure high-amplitude UVA protection
1. Data on file. Neutrogena Corp.
Figure 2. Action spectra from sunlight are very similar and highest in the UVB
Ideal Sunscreen Should Address Damage Proportionately
1. ISO 17166/CIE S007/E. 2. de Gruijl FR, Van der Leun JC. Health Phys. 1994;67(4):319-325. 3. Kligman LH, Syre RM. Photochem Photobiol. 1991;53(2):237-242.
DERMATOLOGY TIMES
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1. ISO 17166/CIE S007/E. 2. J&J Data on file. 3. Cole C. Photodermatol, Photoimmunol, Photomed.
2001;17(1):2-10.
Figure 4. The higher the SPF value, the longer the required
exposure time to reach the same level of sunburn damage1
1. Ou-Yang H, et al. Poster presented at: 68th Annual American Academy of Dermatology Meeting;
March 5-9, 2010; Miami, FL.
A u g u s t 2 014
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DERMATOLOGY TIMES
ADV
Recommending Sunscreen to
Patients
According to a study reported in the
Journal of the American Medical
Association, dermatologists
recommend sunscreen at less than 2%
of office visits.2 If were ever going to
stop the rising epidemic of melanoma
in the United States, this needs to
change. Daily sunscreen protection
should be as routine a behavior for
patients as brushing their teeth.
Q&A
Heather Onorati (Editor,
Dermatology Times): Thank you, Dr.
Cole. Our first question: What is the
significance of the application amount
of 2 mg/cm2? We know that translates
into the recommended 1 ounce of
sunscreen for your body. But how
does this translate into guidelines for
other forms like sticks and sprays?
Dr. Cole: The 2 mg/cm2 is the
magic number that has been codified
in all of the SPF testing protocols that
have been used globally. When the
FDA first started SPF testing they knew
they needed to have a standardized
application dose; 2 mg was the
References
1. Ou-Yang H, Stanfield J, Cole C, et al. High-SPF
sunscreens (SPF 70) may provide ultraviolet
protection above minimal recommended
levels by adequately compensating for lower
sunscreen user application amounts. J Am
Acad Dermatol. 2012;67(6):12201227.
2. Akamine KL, Gustafson CJ, Davis SA, et al.
Trends in sunscreen recommendation among US
physicians. JAMA Dermatol. 2014;150(1):5155.
Dr. Curtis Cole has been involved with photobiology for more than 35 years, participating in numerous
industry collaborative initiatives in sunscreen evaluation method development. He serves as a project
leader of two international standards organizations committees developing international sunscreen
test methods and is a member of the Photomedicine Society and American Society for Photobiology.
Dr. Cole is the former Vice President of Research and Development for Johnson and Johnson Consumer
Companies, Inc. During his 27-year tenure, he has been a key contributor to several sun product
launches and innovations. Dr. Cole has 13 issued US patents and has been featured in more than
30 publications including Forbes Magazine.
A promotional supplement supported by Neutrogena. Copyright 2014 and published by Advanstar Communications Inc. No portion of this publication may be reproduced or
transmitted in any form, by any means, without the prior written permission of Advanstar Communications Inc. The views and opinions expressed in this supplement do not
necessarily reflect the views and opinions of Advanstar Communications Inc. or Dermatology Times.
A u g u s t 2 014
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CUTANEOUS ONCOLOGY
59
BRACHYTHERAPY:
Electronic surface brachytherapy provides safe, efective option for treating NMSC from page 1
not losing hair or weight like patients
with lung cancer or breast cancer.
Therefore, although traditional radiotherapy is effective for NMSC, patient
acceptance proved problematic.
Traditional radiotherapy uses large
linear accelerators to
generate radiation,
so it requires a
lead-lined fault and
heav y shielding
for patients during
t reat ment, says
Dr. Baron
Jonathan Baron,
M.D., a dermatologist and Mohs
surgeon in private practice in Santa Ana,
California. He offers electronic surface
brachytherapy for NMSC.
GREATER CONVENIENCE
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QUICK READ
For selected nonmelanoma
skin cancers, electronic
surface brachytherapy offers
advantages including a high
cure rate and a patient-friendly
regimen, proponents say. But
expert opinions are divided
as to its ultimate role in the
dermatologists ofce.
radiation therapist (using doses calculated by an off-site medical physicist)
in the dermatologists office, he says.
The procedure is noninvasive and
painless, and clinically proven to be
effective, says Ken Ferry, president
and CEO of iCAD. The mobile design
of the system allows dermatologists to
offer this unique treatment option to a
broader patient population and position
their practice as an innovative leader in
their community.
Most dermatology practices offering
this procedure have a radiation oncologist on-site two days weekly, performing
consultations and monitoring treatment,
according to Dr. Baron.
Patients have a comfort level with
that, because theyre familiar with your
office, and they know the staff and
how to get here. We used to have to
send these patients to the hospital for
treatment, he says.
FAST TREATMENTS
ADV
60
CUTANEOUS
ONCOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
BRACHYTHERAPY:
Electronic surface brachytherapy provides safe, efective option for treating NMSC from page 59
risks and benefits of the procedure are
fully explained.
Dermatologists who instead seek
to guard their NMSC turf one day
could find that most skin cancers are
being treated by radiation therapy
not in the dermatologists office, but
in the radiation oncologists office or
comprehensive cancer center, Dr.
Werschler says.
As a specialty, Organized dermatology needs to make a decision how
theyre going to approach this. You dont
want to be the guy whos still championing carburetor technology in the
world of electronic fuel injection.
According to an American Academy
of Dermatology (AAD) position paper
approved in late 2013, the academy
considers surgical treatment (e.g.,
excision, Mohs, destruction) the optimal
primary intervention for basal cell
carcinoma (BCC) and squamous cell
carcinoma (SCC). Moreover, the paper
raises the concern that the rapid growth
in utilization of temporary current
procedural terminology (CPT) codes
related to superficial radiation therapy
and electronic surface brachytherapy
may draw scrutiny from private payers,
federal agencies, including the Centers
for Medicare and Medicaid Services,
members of Congress, and federal
watchdogs.
Presently, the paper states, The
academy believes additional research
is needed on superficial radiation
therapy (SRT) and electronic surface
brachytherapy.
DERMS VERSUS RADIATION ONCOLOGISTS
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62
CUTANEOUS
ONCOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
BCC:
Determining appropriate treatment strategies for locally advanced disease from page 54
Hedgehog pathway inhibitors, such
as sonidegib, are currently undergoing trials and could potentially
offer improved side effect profiles,
increased efficacy or even decreased
resistance potential. 8
Potent ia l hedgehog pat hway
inhibitors such as itraconazole and
arsenic trioxide may play an important role in treatment of vismodegib
resistant tumors.9 Additionally, topical
smoothened inhibitors under current
study may be useful in cases where oral
vismodegib is not tolerated.10
F u t u r e a r t ic l e s i n t h i s s e r i e s
regarding aBCC will review the current
state of research as well as the impact
and management of aBCC in elderly
patients.
T he int roduct ion of new t reatments for metBCC and laBCC was a
pivotal development in dermatology,
translating basic science in to clinical
practice. The focus on laBCC represents an important opportunity for
dermatologists to continue their role
as skin cancer experts. DT
Involves vital
structure
Multiple
recurrences
Extensive/
invasive
tumor
High risk
location
Locally
advanced
BCC
High tumor
burden
(Gorlins)
Surgical
candidate?
Radiation
therapy
candidate?
Hedgehog
pathway
inhibitor
candidate?
Disclosures: Dr. Krishnan reports no relevant financial interests. Dr. Amin has participated on the advisory board for Genentech and is a paid speaker.
References:
Combination
chemotherapy
candidate?
Figure 1 demonstrates an algorithm for identifying and treating locally advanced basal cell carcinoma.
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Fight age.
And win.
Introducing
www.neostratapro.com
800-628-9904
new
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64
CUTANEOUS
ONCOLOGY
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QUICK READ
DIAGNOSTIC DIFFERENCES
I n a not her re t r o s p e c t i v e s t ud y,
researchers evaluated the effect of
surgical excision performed after the
biopsy-diagnosis of dysplastic nevi, in
terms of the final diagnosis, melanoma
prevention and melanoma detection
(Reddy KK, Farber MJ, Bhawan J, et al.
JAMA Dermatol. 2013;149(8):928-934).
Of the 580 dysplastic nevi included in
the study, 196 had a positive biopsy
margin increasing with grade of atypia;
127 of the 196 lesions (65 percent) were
re-excised, performed more often as the
grade of atypia increased.
Data showed that two of the 127
re-excised lesions received a different
diagnosis, changing from biopsydiagnosed moderately to severely
dysplastic nevus to melanoma in situ.
The researchers also found that of the
216 melanomas included in the study, in
situ and superficial spreading subtypes
were more of ten associated w it h
histopathologically dysplastic nevi (20
percent and 18 percent, respectively),
most of them having a moderate-tosevere grade of atypia.
The excision of biopsy-diagnosed
mildly or moderately dysplastic nevi
will not likely result in a clinically
sig n i f ica nt cha nge i n d iag nosis,
Dr. Spielvogel say s, a nd t he r isk
of transformation of these lesions
t o me l a nom a app e a r s v er y lo w.
However, as moderately-to-severely
and severely dysplastic nevi are more
often associated with melanoma, their
timely excision may be prove to be
beneficial for the detection or prevention of melanoma.
There has been a lot of controversy on atypical or dysplastic nevi
regarding their appropriate treatment
and management. I think that despite
the lack of literature in the past, it
looks like most practicing dermatologists have come to some good conclusions regarding when to re-excise the
lesion, and which types of lesions (in
terms of their atypia) to re-excise, as
reflected in these recent studies, Dr.
Spielvogel says. DT
Disclosures: Dr. Spielvogel reports no relevant
financial interests.
ADV
Baseline1,*
Hour 41,*
Instant gratication.
2,
Study results for one application of Neotensil in a 16-hour durability study; 4% of patients saw results within 10 minutes and 70% of patients
sawresults within 1 hour; N=28.
Study results for once-daily application of Neotensil in a 2-week pilot study; N=25.
References: 1.Data on fle, Living Proof, Inc. 2.Draelos ZD, Investigator. Strateris 16-hour durability study, DCS-105-13. Data on fle, Living Proof, Inc.
3.Kauvar A, Kilmer S, Ross EV, et al. A pilot study of a novel non-invasive topical under-eye contouring technology. Poster presented at: 71st Annual
Meeting of the American Academy of Dermatology; March 1-5, 2013; Miami, FL.
Neotensil and Living Proof are trademarks of Living Proof, Inc. used under license.
Except as otherwise indicated, all other product names, slogans and other marks are trademarks of the Valeant family of companies.
Distributedby OMP, Inc.
2014 Obagi Medical Products, Inc., a division of Valeant Pharmaceuticals North America LLC. DM/NEO/14/0008c 03/14
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66
BUSINESS OF DERMATOLOGY
OUTREACH EFFORTS
69 Strengthen
your role in the
population you serve by
connecting with the community
FAN ENGAGEMENT
71 BOOST
Increase interaction on Facebook
by hosting video events and
offering contests, giveaways
QUICK READ
Quotable
If you have a particular
condition that you dont
want shared, providers
are going to look at their
policies and see what
they can accommodate.
Mary Griskewicz
Health Information
Management Systems Society
On data exchange
and patient consent
See story, page 78
Although only some dermatologists currently participate in healthcare exchange plans, he says, Whats
happening in the exchange plans
will be spreading to other commercial insurance products, not at the
gover n ment s behest, but due to
insurers desires.
As of mid-April, 8 million Americans
have signed up for state and federally run
private insurance exchanges, published
accounts say. Generally, Dr. Resneck
adds, most Americans chose the lower
premium Bronze or Silver level plans,
which cover the same services as Gold
plans but include higher deductibles
and copays.
DTExtra
Despite the proliferation of physician ratings
websites in recent years, more Americans still rely
on information from friends and family members
when choosing a doctor, according to a new survey.
The study found that among those (23 percent) who
have gotten information comparing healthcare
providers quality in the past year, two-thirds got
it from friends or family. Other survey findings: 48
percent said it is either very easy or moderately
easy to find trustworthy information about the
quality of care provided by local doctors; 47 percent
said they are extremely confident they could
find information to help in selecting a specialist.
READ MORE: MEDICALECONOMICS.COM/QUALITYDOCTORS
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Proven EFFICACY
in step with
Skin restoration
Only ECOZA FOAM combines the
proven antifungal efficacy of econazole
nitrate with the skin-restoring properties
of patented Proderm Technology
Kills fungi that cause interdigital
tinea pedis1
Unique foam delivery system helps
protect and restore skin2-4
Convenient once-daily dosing1
Nongreasy foam penetrates quickly,
dries rapidly5
Alcohol-free1
INDICATIONS AND USAGE
Ecoza (econazole nitrate) topical foam, 1%, is indicated
for the treatment of interdigital tinea pedis caused by
Trichophyton rubrum, Trichophyton mentagrophytes,
and Epidermophyton floccosum in patients 12 years of
age and older.
NEW
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BUSINESS OF DERMATOLOGY
69
Media opportunities
raise awareness
for the cause and
solidify you and
your practice as
the epicenter of
expertise.
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Community
outreach efforts
strengthen
your role in the
population you serve.
If you feel as though party planning is not in your future, there are
many other opportunities to lend
your ex per t ise for a cause. Loca l
dermatologic societies and national
dermatologic organizations often
organize sk in cancer or pediatric
events that make your time investment m i n i ma l a nd you r posit ive
attitude return high.
Want to do something more unique
and sustainable within your practice?
Then ident if y unmet communit y
needs a nd you r u n ique sk i l l set.
Next, see where these two intersect
and voil your idea for community
outreach is born.
Chambers of commerce and local
charity groups are an excellent place
to star t. If your idea is unique, it
may be suppor ted by communit y
grants through local and national
der matolog ic orga n i z at ions. My
adv ice is to follow your interests,
support the outcome and watch it
grow. The fruits will be well worth
your effort. DT
ADV
70
BUSINESS
OF DERMATOLOGY
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BUSINESS OF DERMATOLOGY
71
dermatoscope
www.canfieldscientific.com
info@canfieldsci.com
phone +1.973.276.0336
(USA) 800.815.4330
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patent pending
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72
BUSINESS
OF DERMATOLOGY
Innovative techniques
for protecting your home
Along with retirement accounts,
the family home is often the most
valuable asset of the affluent. Beyond
its financial value, the home has great
psychological and emotional value. In
fact, we find that most of our clients
who engage in asset-protection planning often begin with the question:
How can I protect my home? That is
why we thought it important to discuss
this asset and how to protect it from
outside threats.
This article will look at the pros and
cons of state homestead laws, tenancy
by the entirety (TBE), limited liability
companies (LLCs), family limited partnerships (FLPs), and the debt shield.
You may be surprised to find out that a
situation you have always feared could
actually be your ally in your quest to
protect your most valuable asset. This
will be another example of a secret of
the affluent that completely contradicts conventional ideas held by many
average Americans.
STATE HOMESTEAD LAW
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End with
relief.
1, 2
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AD100-0037
April 2014
ADV
Rx only
Rx only
Laboratory Tests
The following tests may be helpful in evaluating the hypothalamic-pituitaryadrenal (HPA) axis suppression:
Urinary free cortisol test
ACTH stimulation test
For topical use only. Not for oral, ophthalmic, or intravaginal use.
INDICATIONS AND USAGE
Topicort (desoximetasone cream USP) 0.05% and Topicort (desoximetasone
ointment USP) 0.05% are indicated for the relief of the inammatory and pruritic
manifestations of corticosteroid-responsive dermatoses.
CONTRAINDICATIONS
Topical corticosteroids are contraindicated in those patients with a history of
hypersensitivity to any of the components of the preparation.
WARNINGS
Keep out of reach of children.
PRECAUTIONS
General
Systemic absorption of topical corticosteroids can produce reversible
hypothalamic-pituitary-adrenal (HPA) axis suppression with the potential for
clinical glucocorticosteroid insufciency. This may occur during treatment or
upon withdrawal of the topical corticosteroid.
Because of the potential for systemic absorption, use of topical corticosteroids
may require that patients be periodically evaluated for HPA axis suppression.
Factors that predispose a patient using a topical corticosteroid to HPA axis
suppression include the use of more potent steroids, use over large surface
areas, use over prolonged periods, use under occlusion, use on an altered skin
barrier, and use in patients with liver failure.
An ACTH stimulation test may be helpful in evaluating patients for HPA axis
suppression. If HPA axis suppression is documented, an attempt should be
made to gradually withdraw the drug, to reduce the frequency of application, or
to substitute a less potent steroid. Manifestations of adrenal insufciency may
require supplemental systemic corticosteroids. Recovery of HPA axis function is
generally prompt and complete upon discontinuation of topical corticosteroids.
Cushings syndrome, hyperglycemia, and unmasking of latent diabetes mellitus
can also result from systemic absorption of topical corticosteroids.
Use of more than one corticosteroid-containing product at the same time may
increase the total systemic corticosteroid exposure.
Pediatric patients may be more susceptible to systemic toxicity from use of
topical corticosteroids.
Local Adverse Reactions with Topical Corticosteroids
Local adverse reactions may be more likely to occur with occlusive use, prolonged
use or use of higher potency corticosteroids. Reactions may include atrophy, striae,
telangiectasias, burning, itching, irritation, dryness, folliculitis, acneiform eruptions,
hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary
infection, and miliaria. Some local adverse reactions may be irreversible.
Allergic Contact Dermatitis with Topical Corticosteroids
Allergic contact dermatitis to any component of topical corticosteroids is usually
diagnosed by a failure to heal rather than a clinical exacerbation. Clinical diagnosis
of allergic contact dermatitis can be conrmed by patch testing.
Concomitant Skin Infections
Concomitant skin infections should be treated with an appropriate antimicrobial
agent. If the infection persists, Topicort (desoximetasone cream USP) 0.05% or
Topicort (desoximetasone ointment USP) 0.05% should be discontinued until the
infection has been adequately treated.
Information for the Patient
Patients using topical corticosteroids should receive the following information
and instructions:
1. This medication is to be used as directed by the physician. It is for external
use only. Avoid contact with the eyes.
2. Patients should be advised not to use this medication for any disorder other
than for which it was prescribed.
3. The treated skin area should not be bandaged or otherwise covered or 4.
wrapped as to be occlusive unless directed by the physician.
4. Patients should report any signs of local adverse reactions, especially under
occlusive dressings.
5. Other corticosteroid-containing products should not be used with Topicort
(desoximetasone cream USP) 0.05% or Topicort (desoximetasone ointment
USP) 0.05% without rst consulting with the physician.
black
ADV
BUSINESS OF DERMATOLOGY
75
HOME PROTECTION:
How to guard your most valuable asset from outside threats from page 72
best way to protect a home is probably
the same way we all started owning our
homes with someone elses money.
By not having any, or very little, equity
in your home, the bank owns the home.
A creditor has very little to gain from
trying to attack the home when there
is little to no equity especially when
that small amount of equity is partially
or completely protected through homestead exemptions in many states.
Because we cant go back in time
and stop paying down our mortgages,
we have to find a way to address this
issue in the present. Unfortunately,
most advisers cant even tell you how
to do this. Affluent Americans have to
decipher financial information that is
directed toward average Americans.
C on s ide r t h i s e x a m ple : I nd ividuals and firms in the securities
and insurance industries have been
the subject of a number of a rising
number of complaints and lawsuits
over the past 15 years. As a result, the
regulatory agencies and compliance
depa r t ments of t hese compa nies
have forbidden their representatives
from recommending that their clients
remove equity from real estate and
invest it into either securities or insurance products. These advisers cannot
even accept loan proceeds from a
refinanced property. These companies adopted t his polic y because
t he y fea red t hat less f i na nc ia l ly
sophisticated homeowners wouldnt
understand the risk of this maneuver
and might lose their homes if the
investments they made with the loan
proceeds didnt perform well.
We approve of protec t i ng less
sophisticated investors and of protection against unscrupulous salespeople
(and there are many of both). However,
to threaten to terminate advisers who
want to help aff luent clients whose
asset-protection concerns outweigh
the investment risks that they and their
teams understand is ridiculous. In this
situation, the affluent cant even get the
advice they require. Lets discuss that
technique that most advisers cant share
but the savvy affluent know and implement on a regular basis: the debt shield.
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The debt shield can be the most effective way to shield the equity of the home.
Essentially, using a debt shield means
getting a loan against most of the equity
in your home. For many clients, this
is counterintuitive; they want to pay
down the mortgage as much as possible.
While this may have an emotional
appeal, for asset-protection purposes,
it is simply bad strategy.
For example, to help people protect
the equity in their home, one financial
institution we examined for a client
designed an interesting debt-shield
program. The bank loaned the client
funds equal to up to 90 percent of the
value of the home and then filed a mortgage first, second or even third in
order to consume any remaining equity.
The home was then protected.
The loan funds were placed in an
asset-protected trust, one drafted
for the client by an asset-protection
attorney. Those funds were owned by
the trust and, under the loan documents, were required to be placed in
the banks certificate of deposit (CD)
account. Further, the bank contractually guaranteed that its loan rate would
be only 1 percent greater than its CD
rate, meaning that this structure cost
participants just 1 percent of the home
equity to implement (plus legal fees).
When the client retires or feels that the
threat to the home has diminished, the
CD account pays off the loan and the
mortgage is released.
THE ENHANCED DEBT SHIELD
ADV
76
BUSINESS
OF DERMATOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
PRESSURE MOUNTING:
Dermatologists must be proactive in documenting value of their services from page 66
If we put our heads in the sand,
however, theres a huge risk to the
specialty of being marginalized, he says.
ACO ADJUSTMENTS
208
330
156
146
156
113
108
5
1/31/2013
5
12/31/2012
32
9/30/2012
31
6/30/2012
27
5
3/31/2012
22
2
12/31/2011
19
1
9/30/2011
15
1
71
6/30/2011
30
12
1
45
3/31/2011
22
10
0
44
12/31/2010
16
7
0
91
9/30/2010
31
19
8
3
0
86
142
6/30/2010
22
15
5
2
0
59
65
138
167
3/31/2010
10
5
3
2
0
46
27
14
5
0
91
71
48
160
202
189
Q1
2010
Q2
2010
Q3
2010
Q4
2010
Q1
2011
Q2
2011
Q3
2011
Q4
2011
Q1
2012
Q2
2012
Q3
2012
Q4
2012
Jan
2013
Total
Physician Group
Hospital System
Insurer
Community-Based Organization
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BUSINESS OF DERMATOLOGY
SAVE UP TO $4,980
When You Purchase MTIs 430
Procedure Table and MI-1000 LED
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78
BUSINESS
OF DERMATOLOGY
OPT-IN OR OPT-OUT?
Patient consent rules in the United States
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ND
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NV
VT
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AZ
MA
WI
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NY
MI
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Opt in
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* Other indicates the state has both opt-in and opt-out rules, a hybrid system, pending rules, or
no rules identifed yet.
Source: 2013 self-reported data by HIE grantees to the Offce of the National Coordinator for Health Information Technology
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BUSINESS OF DERMATOLOGY
79
...................................................................
ON THE FUTURE
Since the DF was established in 1964, dermatology has emerged
as a vibrant and vital specialty in the house of medicine.
For fve decades, the Foundation has provided funding that
has helped to develop and retain new generations of teachers,
researchers and mentors, enabling advancements in patient care.
Individual physician support has always been at the core of the
DFs ability to support progress. In an era of fat NIH funding,
and ever-changing economic, social and health care trends,
dermatologists participation is more crucial than ever.
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80
BUSINESS
OF DERMATOLOGY
DERMATOLOGY
AUGUST 2014
2013 DERMATOLOGYTIMES.COM
PATIENT CONSENT:
Be aware of state, federal legal requirements for secure exchange of data from page 79
frequently requested exclusions in
Indiana, but some patients may not
want to disclose information on other
health conditions either.
Even if providers want to accommodate these patient requests, todays
EHRs make it difficult for healthcare
organizations to do so. Experts say that
EHRs have difficulty segregating sensitive information, partly because much
of the data is embedded in free text,
rather than structured fields that can
be manipulated.
Beyond these categories, providers
are not legally required to withhold
certain data in patient records when
they exchange them with other treating
providers.
Under HIPAA, the patient has the
right to segregate some things only
if the provider is willing to do it, Mr.
Harlow says. Most providers are not
willing to customize anything, because
they dont have the tools to do it easily
and reliably. So theyre just going to say
no, except for some things that must be
segregated and not go to a payer if the
patient so desires.
Partly because of the difficulty of
sequestering specific information,
Mary Griskewicz, senior director of
health information systems for the
Healt h Informat ion Management
Systems Societ y, says its simpler
from a legal standpoint to ask the
patient to allow having all of his or
her records exchanged.
From a risk assessment perspective,
thats the way to go, she says. A lot of
providers say, basically, that if you want
to get treated, you have to agree.
LIABILITY ISSUES
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U lt i m at e l y, he a lt h i n f or m at ion
exchange is about enabling physi-
ADV
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82
TRADE TOOLS
THREE-IN-ONE TREATMENT
TACKLES ACNE, BLEMISHES
FIRST CRUSH SKIN
CARE has launched
a multitasking
product for acne and
other blemish breakouts.
The 3-in-1 Acne/
Blemish Treatment
includes a cleanser
to eliminate dirt and
oil; a treatment to get
rid of dead skin cells
and blemish-causing
bacteria; and a toner
to freshen, firm and
invigorate the skin,
according to the company.
The treatment is appropriate for
all skin types and does not contain
benzoyl peroxide. The formulation
includes grape seed extract, salicylic acid, tea tree oil, lavender oil
and ginseng extract.
The products can be ordered
individually in 6-ounce tubes, or as
part of a four-piece display set.
FIRST CRUSH SKIN CARE
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TWO-PHASE BODY
CREAM FIGHTS CELLULITE
PURACAP PHARMACEUTICALS
CELLUENCE
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REGIMEN IMPROVES
SIGNS OF HAIR LOSS
THE HAIR REGROWTH SYSTEM
by BrandMD uses a novel threestep daily regimen to improve the
signs of hair loss, according to the
company.
The treatment
system includes
BrandMD's
HRS-10, a biomimetic peptide
that is combined
with red clover
extract. The Hair
Regrowth System's
ingredients and
technology work to stimulate hair
growth and improve hair follicle
anchoring, giving users fuller,
thicker hair.
The HRS-10 technology uses
peptides, essential oils and
extracts, and is safe for use in men
and women.
The hair system is available exclusively to medical professionals for
in-office dispensing.
BRANDMD
www.brandMDskincare.com
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VISCOT
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86
TRADE TOOLS
Resurfacing peel
fights signs of photoaging
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LUXURY SKINCARE
LINE USES NATURAL
INGREDIENTS
SOBO SKIN CARE
has introduced a
new luxury collection of anti-aging
creams, serums
and moisturizers that include
natural ingredients, aimed at
health-conscious
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The skincare
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The product line is free of parabens, sulfates, triclosan, phthalates, GMOs and synthetic dyes and
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upcoming
events
Kansas Society of
Dermatology & Dermatologic
Surgery 2014 Conference
www.kanderm.org
Aug. 23, 2014
Sheraton Hotel
Overland Park, Kansas
XV World Congress
on Cancers of the Skin
www.aad.org
Aug. 6-10, 2014
Hyatt Regency Chicago
Chicago
www.wccs2014.org
Sept. 3-6, 2014
Edinburgh International Conference Centre
Edinburgh, Scotland
Pacific Dermatologic
Association 66th Annual
Meeting
www.pacificderm.org
Aug. 13-17, 2014
Fairmont Hotel Vancouver
Vancouver, British Columbia
LaserInnsbruck 2014
www.laserinnsbruck.com/1/1/english/1/3/
index.htm
Sept. 3-6, 2014
Messe Innsbruck
Innsbruck, Austria
2014 CalDerm
Annual Meeting
CALENDAR/ AD INDEX
www.asds.net/rejuvenation
Sept. 13-14, 2014
Renaissance Chicago Downtown Hotel
Chicago
www.laserskintherapyboston.com
Oct. 10-12, 2014
Seaport Hotel & World Trade Center
Boston
www.teledermatology2014.com
Sept. 18-20, 2014
IDEC-Universitat Pompeu Fabra
Barcelona, Spain
www.globalacademycme.com
Oct. 10-12, 2014
Island Hotel
Newport Beach, California
www.fsds.org/event.php
Sept. 19-21, 2014
Ritz-Carlton Orlando, Grande Lakes
Orlando, Florida
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Oct. 25-26, 2014
Adolphus Hotel
Dallas
World Cutaneous
Malignancies Congress
www.ohderm.org
Sept. 26-28, 2014
Hilton Columbus at Easton
Columbus, Ohio
www.calderm.org
Sept. 12-14, 2014
La Costa Resort & Spa
Carlsbad, California
www.cutaneousmalignancies.com
Oct. 29-31, 2014
San Francisco Marriott Marquis
San Francisco
American Society
of Dermatopathology
51st Annual Meeting
www.montagnasymposium.org
Oct. 9-13, 2014
Salishan Spa & Golf Resort
Gleneden Beach, Oregon
www.asdp.org
Nov. 6-9, 2014
Chicago Hilton and Towers, Chicago
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DESOXIMETASONE
37 - 38
87
88 THE
TAKEAWAY
THE IMPORTANCE
OF PATIENT ADHERENCE
ELAINE SIEGFRIED, M.D
DR. SIEGFRIED: In a recent issue of The Dermatologist, you wrote in your editors message
about giving your cell phone number to patients to
encourage adherence.1, 2 Can you talk more about
that? Do you take calls on evenings and weekends?
A:
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Giving
people my
cell phone
number
is one of
my most
powerful
tools to encourage
patients to use
medications.
Steven Feldman, M.D.
Winston-Salem, N.C.
A:
ADV
THE
VIDEO
TAKEAWAY
89
dermatologytimes.com
Dr. Feldman discusses how patient psychology is part of
practicing good dermatology. He cites the importance of having
a plan for encouraging patients to begin their medications and
helping patients to continue their medications as use drops
off. View the video and read more at: dermatologytimes.com/
medicationadherence
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Presumably, you
should be able to
clear up any child
of atopic dermatitis
with triamcinolone
if you can get the
parents to follow
the treatment at
home.
Steven Feldman, M.D.
Winston-Salem, N.C.
A:
A:
DR. SIEGFRIED: Do you use any measures of adherence and do you document adherence in any way
in your EMR?
A:
ADV
90
Dermatology Times |
ShowcaSe
Go to:
August 2014
products.modernmedicine.com
education
>VUKLY^OH[[OLZLHYL&
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Go to products.modernmedicine.com and enter names of
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marketers, fnd out more at:
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August 2014
91
DermatologyTimes.com
Go to:
products.modernmedicine.com
ShowcaSe
services
LEAVITT
Search
Search for the company name you see in each of the ads in this section for FREE INFORMATION!
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92
Marketplace
Dermatology Times |
August 2014
SEEKING DERMATOLOGY
SALES REPS/GROUPS
FOR WELL KNOWN
SKIN CARE LINE.
PLEASE CALL
WAYNE (800) 738-0256
OR (915) 593-7500
eqUiPmenT fOR Sale
kenTUCky
We Buy Practices
Retiring
Monetization of your practice
Locking in your value now
Succession planning
Sell all or part of your practice
Please call Jeff Queen at
(866) 488-4100 or
email WeBuy@MyDermGroup.com
www.MyDermGroup.com
flORiDa
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SOLD
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www.TransitionConsultants.com
Call 561-276-3111
or email:
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PRODUCTS
steven@dermasurgerygroup.com
OTC PRODUCTS
M A R K E T P L A C E A d v E RT i s i n g
Repeating an ad
ensures
it will be seen
and remembered!
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August 2014
marketplace
DermatologyTimes.com
93
ReCRUiTmenT
aRiZOna
Busy General/Surgical Dermatology
& MOHS practice in Phoenix, AZ area
looking for a 3rd dedicated, caring
and ambitious BE/BC dermatologist
for gen & surg derm w/ MOHS. Great
earning potential w/ partnership path.
CalifORnia
PORTERVILLE, CA
Partnership available. Established practice.
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com
COnneCTiCUT
Central ConneCtiCut
Dermatology opportunity
Seeking Dermatologist for well established
general and cosmetic practice with two ofces.
Full time with partnership track available.
Would also consider part time candidate.
Competitive salary and benets.
flORiDa
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OCALA, FLORIDA
illinOiS
dermatologist BC/Be
to join 4 full time
Certified dermatologists
Retired?
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nevaDa
RENO, NEVADA
Partnership available. Established practice.
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com
Fax CV to 845-359-0017 or
email:dermcr18@gmail.com
new jeRSey
BERGEN COUNTY, NJ
Email: bayshore.derm@gmail.com
nORTh CaROlina
DERMATOLOGIST
General/Cosmetic/Surgical Dermatology
Medford, NJ (near Philadelphia, PA and
Cherry Hill, NJ). Brand new state of the art
offce, fabulous opportunity, benefts offered.
FT/PT position available.
Email inquiry or CV to:
suzanne@accentderma.com
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94
Marketplace
Dermatology Times |
August 2014
ReCRUiTmenT
ORegOn
wiSCOnSin
EUGENE, OREGON
CONNECT
with qualifed leads
and career professionals
viRginia
FAIRFAX, VIRGINIA
Partnership available. Established practice.
Contact Karey, (866) 488-4100 or
www.MyDermGroup.com
NORFOLK, VIRGINIA
EOE/AA/LEP
DERMATOLOGIST
Gundersen Health System in La Crosse,
Wisconsin, is seeking a BC/BE dermatologist
to work in our new state-of-the-art facility.
Your practice will consist of general
medical dermatology with opportunities
for dermatologic surgery (regular and
cosmetic), medical education and clinical
research within one of the nations largest
multi-specialty group practices. Services
currently oered include MOHS Surgery,
Photodynamic Therapy, PUVA, Broad and
Narrow Band UVB, Vascular Laser
Treatment and multiple IPLs.
Call
Joanna Shippoli
www.modernmedicine.com/physician-careers
Joanna Shippoli
RECRUITMENT MARKETING ADVISOR
(800) 225-4569, ext. 2615
jshippoli@advanstar.com
to place your
Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd.
La Crosse, Wisconsin
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ext. 2615
jshippoli@advanstar.com
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August 2014
marketplace
DermatologyTimes.com
95
ReCRUiTmenT
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96 THE
TAKEAWAY
ADDITIONAL TAKEAWAYS
A CHANGING LANDSCAPE
The landscape of dermatology
is rapidly changing and every
practicing dermatologist will
almost certainly be affected.
Dermatology Times asked Dirk Elston,
M.D., president of the American Academy
of Dermatology, to address some of these
issues so that we may all have a better
idea of what lies ahead for the specialty.
DermatologyTimes.com/changinglandscape
TAKEAWAY:
Steven Feldman, M.D., ofers techniques for encouraging
patient adherence from page 89
example, you would think that a
patient with psoriasis so bad he
needs a biologic, would take it regularly. They dont. You can tell by
asking the patient, Are you keeping
the extra syringes youve accumulated refrigerated like youre
supposed to? If he says, Yes and
Ive got about six or eight of them
in the drawer, then you know he
is not using it regularly because he
wouldnt have accumulated any
extras.
When it comes to topical medications, one of the problems we have
is that its very hard to quantify how
much you should go through in a given
period of time. If the patient comes
back for a return appointment three
When it comes
to topical medications, one of the
problems we have
is that its very
hard to quantify
how much you
should go through
in a given period
of time.
Steven Feldman, M.D.
Winston-Salem, N.C.
Next month: There are a number of factors that infuence whether a patient will
adhere to a treatment regimen. In part 2 of our discussion on adherence,
Drs. Siegfried and Feldman discuss physician-patient relationships as a critical
component and patient satisfaction measurements.
VALUE OF COSMECEUTICALS
Among the diffculties faced
by consumers is the blitz of
advertising of new and presumably
revolutionary products that can
rejuvenate and preserve the youthful appearance
of the skin. Many products make what sound
like medical claims about effcacy. Zoe Draelos,
M.D. the foremost authority on this subject
discusses these issues with Dermatology Times.
DermatologyTimes.com/cosmeceuticals
DOES GLUTEN
DRIVE SKIN DISEASE?
Gluten and gluten-sensitive
enteropathy have become hot
topics among the lay public and in
medical practices. Dermatologists
have historically concerned themselves
with gluten only as it relates to dermatitis
herpetiformis. This may be changing. John Zone,
M.D., from the University of Utah, Salt Lake City,
discusses how gluten sensitive enteropathy
may impact many areas of dermatology.
DermatologyTimes.com/gluten-sensitivity
ADVANCEMENTS IN
PSORIASIS TREATMENT
The past few years have been
an exciting time for those
who treat psoriasis and for
many patients with severe
disease because of excellent new therapies
for this often intractable problem. Alan
Menter, M.D., Baylor University Medical
Center, Dallas, shares insight into recent
developments in the treatment of psoriasis.
DermatologyTimes.com/psoriasisadvances
STRATEGIES FOR
MANAGING LEG ULCERS
Leg ulcers are a common and
diffcult management problem
for all dermatologists. Robert S.
Kirsner, M.D., professor and vice
chairman of dermatology, University of Miami
Miller School of Medicine, and director of the
University of Miami Hospital Wound Center,
elucidates the diagnosis and management
of these challenging skin problems.
DermatologyTimes.com/legulcers
Hear more at: dermatologytimes.com/takeaway-podcasts
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ADV
Mirvaso
BRIEF SUMMARY
This summary contains important information about MIRVASO (Mer-VAY-Soe)
Gel. It is not meant to take the place of the full Prescribing Information.
Read this information carefully before you prescribe MIRVASO Gel. For full
Prescribing Information and Patient Information please see package insert.
WHAT IS MIRVASO GEL?
MIRVASO (brimonidine) Topical Gel, 0.33% is a prescription medicine that
is used on the skin (topical) to treat facial redness due to rosacea that does
not go away (persistent).
WHO IS MIRVASO GEL FOR?
MIRVASO Gel is for use in adults ages 18 years and older.
WHAT WARNINGS AND PRECAUTIONS SHOULD I BE AWARE OF?
MIRVASO Gel should be used with caution in patients that:
have depression
have heart or blood vessel problems
have dizziness or blood pressure problems
have problems with blood circulation or have had a stroke
have dry mouth or Sjgrens Syndrome
have skin tightening or Scleroderma
have Raynauds phenomenon
have irritated skin or open sores
are pregnant or plan to become pregnant. It is not known if MIRVASO Gel
will harm an unborn baby.
are breastfeeding. It is not known if MIRVASO Gel passes into breast milk.
You and your female patient should decide if she will use MIRVASO Gel or
breastfeed. She should not do both.
Ask your patient about all the medicines they take, including prescription
and over-the-counter medicines, skin products, vitamins and herbal
supplements. Using MIRVASO Gel with certain other medicines may affect
each other and can cause serious side effects.
Keep MIRVASO Gel out of the reach of children.
If anyone, especially a child, accidentally swallows MIRVASO Gel, they
may have serious side effects and need to be treated in a hospital. Get
medical help right away if you, your patient, a child, or anyone else
swallows MIRVASO Gel and has any of these symptoms:
MIRVASO Gel can lower blood pressure in people with certain heart or
blood vessel problems. See What warnings and precautions should I be
aware of?
These are not all of the possible side effects of MIRVASO Gel. Remind your
patients to call you for medical advice about side effects.
You are also encouraged to report negative side effects of prescription drugs
to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
HOW SHOULD MIRVASO GEL BE APPLIED?
Remind your patients to use MIRVASO Gel exactly as you instruct them.
They should not use more MIRVASO Gel than prescribed.
Patients should not apply MIRVASO Gel to irritated skin or open wounds.
Important: MIRVASO Gel is for use on the face only. Patients should not
use MIRVASO Gel in their eyes, mouth, or vagina. They should also avoid
contact with the lips and eyes.
Instruct your patients to see the detailed Instructions for Use that come
with MIRVASO Gel for information about how to apply MIRVASO Gel
correctly.
GENERAL INFORMATION ABOUT THE SAFE AND EFFECTIVE USE OF
MIRVASO GEL
Remind your patients not to use MIRVASO Gel for a condition for which it
was not prescribed and to not give MIRVASO Gel to other people, even if they
have the same symptoms. It may harm them.
WHAT ARE THE INGREDIENTS IN MIRVASO GEL?
Active Ingredient: brimonidine tartrate
Inactive Ingredients: carbomer homopolymer type B, glycerin,
methylparaben, phenoxyethanol, propylene glycol, puried water, sodium
hydroxide, titanium dioxide.
WHERE SHOULD I GO FOR MORE INFORMATION ABOUT MIRVASO GEL?
Go to www.mirvaso.com or call 1-866-735-4137
GALDERMA LABORATORIES, L.P.
Fort Worth, Texas 76177 USA
Revised: August, 2013
HCP
black
References: 1. Fowler J Jr, Jackson JM, Moore A, et al; Brimonidine Phase III Study Group. Efcacy
and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe
facial erythema of rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies.
J Drugs Dermatol. 2013;12(6):650-656. 2. Mirvaso [package insert]. Galderma Laboratories, L.P.
Fort Worth, TX; 2013.
ADV
Not an actual patient. Individual results may vary. Results are simulated to show a 2-grade improvement of erythema. At hour 12 on day 29, 22% of subjects
using Mirvaso Gel experienced a 2-grade improvement of erythema compared with 9% of subjects using the vehicle gel.*
M I R V A S O ( b r i m o n i d i n e ) T O P I C A L G E L , 0 . 3 3 %
The rst and only FDA-approved topical treatment specically developed and indicated for the facial erythema of rosacea1
Fast results that last up to 12 hours1
The most commonly reported adverse events in controlled clinical studies included erythema (4%), ushing (2%), skin-burning
sensation (2%), and contact dermatitis (1%)2
Important Safety Information
Indication: Mirvaso (brimonidine) topical gel, 0.33% is an alpha-2 adrenergic agonist indicated for the topical treatment of persistent (nontransient) facial erythema
of rosacea in adults 18 years of age or older. Adverse Events: In clinical trials, the most common adverse reactions (1%) included erythema, ushing, skin-burning
sensation, and contact dermatitis. Warnings/Precautions: Mirvaso Gel should be used with caution in patients with depression, cerebral or coronary insufciency,
Raynauds phenomenon, orthostatic hypotension, thromboangiitis obliterans, scleroderma, or Sjgrens syndrome. Alpha-2 adrenergic agents can lower blood pressure.
Mirvaso Gel should be used with caution in patients with severe or unstable or uncontrolled cardiovascular disease. Serious adverse reactions following accidental
ingestion of Mirvaso Gel by children have been reported. Keep Mirvaso Gel out of the reach of children. Not for oral, ophthalmic, or intravaginal use.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
Please see brief summary of full Prescribing Information on the following page.
Each gram of gel contains 5 mg of brimonidine tartrate equivalent to 3.3 mg of brimonidine free base.
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ADV
UNDERSTANDING
THE
PSORIASIS
PATIENT:
A Practical Approach
to Patient Care
EXPERT DISCUSSION CHAIRED BY
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ADV
This promotional supplement is based on a discussion that psoriasis experts had during
the Maui Derm Conference in Hawaii on January 29, 2014. Andrew Blauvelt, MD, chaired
the meeting, which also included Bruce Strober, MD, PhD, Arthur Kavanaugh, MD, and
1HDO%KDWLD0'7KHSDQHOPHPEHUVH[DPLQHGQGLQJVIURPD1DWLRQDO3VRULDVLV
Foundation report on undertreatment and treatment dissatisfaction among patients
with psoriasis and offered insights into ways of optimizing care for these patients. Other
discussion topics were how to establish a good dermatologist-patient relationship and
how to identify and manage the physical and emotional impact of psoriasis on patients.
Funding and content assistance provided by Novartis. Copyright 2014 and published by Advanstar Communications Inc. No portion of this publication may be reproduced or
transmitted in any form, by any means, without the prior written permission of Advanstar Communications Inc. The views and opinions expressed in this supplement do not
necessarily reect the views and opinions of Advanstar Communications Inc. or Dermatology 7imes.
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Psoriasis Undertreatment
and Patient Dissatisfaction
In a 2013 report, the National Psoriasis Foundation (NPF)
highlighted undertreatment and treatment dissatisfaction
rates among patients with psoriasis in the United States.14 Te
reported study, which was based on NPF surveys conducted
biannually from 2003 to 2011, analyzed data from 5604
patients with psoriatic disease who were randomly sampled
from the NPF database and who completed the survey. Of
these 5604 patients, 1286 had mild disease (self-defned as <3
palms of psoriasis), 2031 had moderate disease (3-10 palms),
and 1894 had severe disease (>10 palms). (Tese criteria correspond to the BSA criteria described earlier.)
Psoriasis Undertreatment
Figure 1 shows that 49.2% of patients with mild psoriasis,
23.6% with moderate psoriasis, and 9.4% with severe psoriasis
were not treated for the disease.14 In addition, although a higher percentage of patients with moderate or severe psoriasis
received topical treatment in 2011 than in 20032005, 29.5%
of moderate-disease patients and 21.5% of severe-disease
patients in the 2011 survey received topical treatment alone.
Te NPF guidelines recommend the use of phototherapy, a
systemic agent, or phototherapy plus a systemic agent as treatment for moderate and severe psoriasis.7,8,16 Panel member Dr.
Andrew Blauvelt noted that these data indicate signifcant undertreatment of psoriasis in the United States: Te numbers
may be even worse than they appear, considering that they are
based on responses from members of the NPF registry, who
likely represent more highly motivated and informed patients compared with those generally encountered in clinical
practice.
Figure 1. Proportions of National Psoriasis Foundation survey respondents (patients with psoriasis) receiving no treatment or using topical medications alone by severity level.
Psoriasis severity was categorized as mild (<3% body surface area [BSA] psoriasis involvement), moderate (3%10% BSA), or severe (>10% BSA).14 Reprinted with permission.
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Improving Dermatologist-Patient
Communication
You want to be their cheer leader and their
advocate, as well as their sounding board.
Neal Bhatia, MD
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Figure 3. Proportions of National Psoriasis Foundation 20032011 survey respondents (patients with different grades of psoriasis severity) who reported treatment
dissatisfaction.14 Reprinted with permission.
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season-inappropriate clothing, and not looking the dermatologist in the eye are some of these signs. Lesions on the face
or scalp may be disrupting patients lives more than lesions
on other body areas are. Because many nonverbal signs difer
from person to person, the same sign does not necessarily mean the same thing, but signs do ofer suggestions or
opportunities for further probing. Although not technically
nonverbal, some indirect signs may be informative as well. For
example, a new patient who had seen 2 or more dermatologists before coming to you may have been dissatisfed with the
care received earlier.
Nonverbal signs may be helpful in identifying social
or emotional issues that are affecting the patient
with psoriasis. However, a sign may mean one thing
for patient A but something different for patient B.
Some dermatologists are reluctant to probe a patient with
psoriasis for emotional issues because they perceive it as opening Pandoras box, panel members said. Once an issue is out,
it must be addressed. Other dermatologists are uncomfortable
talking with patients about social stigmatization, depression,
or sexual intimacy issues: Is the dermatologists ofce really
the best place for this discussion? Perhaps most important for
many dermatologists, starting a discussion may give a patient
an opening to bring up many other issues, and there is not
enough time in the schedule to take them all on and have the
practice function properly and remain proftable. Although we
can talk about the ideal from a patient perspective, the reality is that many dermatologists do not have the time to fully
examine and discuss patients emotional issues.
Given such time constraints, yet knowing the benefts of
identifying and managing social or emotional issues in patients with psoriasiscare optimization and increased patient
satisfactiondermatologists should consider other creative
ways to identify and address patients concerns. Te panel suggested 2 possible approaches: enlistment of other dermatology
clinicians and use of patient-reported outcomes and objective
measurement tools.
DErmAtoLogy CLiNiCiANS
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REFERENCES
1.
2.
3.
4.
5.
6.
7.
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11.
12.
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Its our commitment
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TREATING
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Patient pictured was not a participant in the Phase 3 clinical studies for Topicort Topical Spray. Individual results may vary. Photos and notes provided by J. Bikowski, M.D.1
BASELINE LEG
Topicort Topical Spray is a topical corticosteroid indicated for the treatment of plaque psoriasis in patients 18 years of age or older.
Important Safety Information
Topicort Topical Spray is a topical corticosteroid that has been shown to suppress the hypothalamic-pituitary-adrenal (HPA) axis.
Systemic absorption of topical corticosteroids can produce reversible HPA axis suppression with the potential for glucocorticosteroid
insuciency. This may occur during treatment or upon withdrawal of the topical corticosteroid.
Because of the potential for systemic absorption, use of topical corticosteroids may require that patients be periodically evaluated for
HPA axis suppression.
Local adverse reactions may be more likely to occur with occlusive use, prolonged use or use of higher potency corticosteroids. Reactions
may include atrophy, striae, telangiectasias, burning, itching, irritation, dryness, folliculitis, acneiform eruptions, hypopigmentation, perioral
dermatitis, allergic contact dermatitis, secondary infection, and miliaria. Some local reactions may be irreversible.
Safety and eectiveness of Topicort Topical Spray in patients younger than years of age have not been studied therefore use in pediatric
patients is not recommended.
1. Data on le, Taro Pharmaceuticals U.S.A., Inc.
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13 (8.7%)
18 (13.3%)
4 CONTRAINDICATIONS
None
4 (2.7%)
7 (5.2%)
4 (2.7%)
5 (3.7%)
3 (2.0%)
5 (3.7%)
BRIEF SUMMARY
1 INDICATIONS AND USAGE
Topicort Topical Spray is a corticosteroid indicated for the treatment of plaque psoriasis in patients 18 years of
age or older.
Systemic absorption of topical corticosteroids can produce reversible HPA axis suppression with the potential
for glucocorticosteroid insuciency. This may occur during treatment or upon withdrawal of the topical
corticosteroid.
In a study including 21 evaluable subjects 18 years of age or older with moderate to severe plaque psoriasis,
adrenal suppression was identied in 1 out of 12 subjects having involvement of 10-15% of body surface area
(BSA) and 2 out of 9 subjects having involvement of >15% of BSA after treatment with Topicort Topical Spray
twice a day for 28 days. [see Clinical Pharmacology (12.2)]
Because of the potential for systemic absorption, use of topical corticosteroids may require that patients be
periodically evaluated for HPA axis suppression. Factors that predispose a patient using a topical corticosteroid
to HPA axis suppression include the use of high potency steroids, larger treatment surface areas, prolonged use,
use of occlusive dressings, altered skin barrier, liver failure and young age.
An ACTH stimulation test may be helpful in evaluating patients for HPA axis suppression.
If HPA axis suppression is documented, an attempt should be made to gradually withdraw the drug, to reduce
the frequency of application, or to substitute a less potent steroid. Manifestations of adrenal insuciency may
require supplemental systemic corticosteroids. Recovery of HPA axis function is generally prompt and complete
upon discontinuation of topical corticosteroids.
Cushings syndrome, hyperglycemia, and unmasking of latent diabetes mellitus can also result from systemic
absorption of topical corticosteroids.
Use of more than one corticosteroid-containing product at the same time may increase the total systemic
corticosteroid exposure.
Pediatric patients may be more susceptible to systemic toxicity from use of topical corticosteroids. [see Use in
Specifc Populations (8.4)]
5.2 Local Adverse Reactions with Topical Corticosteroids
Local adverse reactions may be more likely to occur with occlusive use, prolonged use or use of higher potency
corticosteroids. Reactions may include atrophy, striae, telangiectasias, burning, itching, irritation, dryness,
folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary
infection, and miliaria. Some local adverse reactions may be irreversible.
5.3 Allergic Contact Dermatitis with Topical Corticosteroids
Allergic contact dermatitis to any component of topical corticosteroids is usually diagnosed by a failure to heal
rather than a clinical exacerbation. Clinical diagnosis of allergic contact dermatitis can be conrmed by patch
testing.
5.4 Concomitant Skin Infections
Concomitant skin infections should be treated with an appropriate antimicrobial agent.
If the infection persists, Topicort Topical Spray should be discontinued until the infection has been
adequately treated.
Corticosteroids have been shown to be teratogenic in laboratory animals when administered systemically at
relatively low dosage levels.
Desoximetasone has been shown to be teratogenic and embryotoxic in mice, rats, and rabbits when given by
subcutaneous or dermal routes of administration at doses 3 to 30 times the human dose of Topicort Topical
Spray based on a body surface area comparison.
8.3 Nursing Mothers
Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with
endogenous corticosteroid production, or cause other untoward eects. It is not known whether topical
administration of corticosteroids could result in sucient systemic absorption to produce detectable quantities
in breast milk. Because many drugs are excreted in human milk, caution should be exercised when Topicort
Topical Spray is administered to a nursing woman.
If used during lactation, Topicort Topical Spray should not be applied on the chest to avoid accidental ingestion
by the infant.
8.4 Pediatric Use
Safety and eectiveness of Topicort Topical Spray in patients younger than 18 years of age have not been
studied; therefore use in pediatric patients is not recommended. Because of a higher ratio of skin surface area to
body mass, pediatric patients are at a greater risk than adults of HPA axis suppression and Cushings syndrome
when they are treated with topical corticosteroids. They are therefore at greater risk of adrenal insuciency
during andor after withdrawal of treatment. Adverse eects including striae have been reported with
inappropriate use of topical corticosteroids in infants and children. [see Warnings and Precautions (5.1)]
HPA axis suppression, Cushings syndrome, linear growth retardation, delayed weight gain, and intracranial
hypertension have been reported in children receiving topical corticosteroids. Manifestations of adrenal
suppression in children include low plasma cortisol levels and absence of response to ACTH stimulation.
Manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema.
[see Warnings and Precautions (5.1)]
8.5 Geriatric Use
Clinical studies of Topicort Topical Spray did not include sucient numbers of subjects aged 65 years and over
to determine whether they respond dierently from younger subjects. Other reported clinical experience has
not identied dierences in responses between the elderly and younger patients. In general, dose selection for
an elderly patient should be cautious, usually starting at the low end of the dosing range, reecting the greater
frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
10 OVERDOSAGE
Topicort Topical Spray can be absorbed in sucient amounts to produce systemic eects. [see Warnings and
Precautions (5.1)]
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More than
sKin dEEp
PHOTO: GETTYIMAGES/BALLYSCANLON/ PHOTOGRAPHERS CHOICE RF
AU G U ST 2014
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seem to be more affected than their older counterparts with psoriasis. Among the striking findings: 84
percent of those ages 20 to 39 said they felt angry or
frustrated by psoriasis, versus 69 percent of respondents older than 40, according to the NPF.
AU G U ST 2014
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EmErging rEsEarch
Experts agree that more research needs to be done on
the psychosocial impacts of psoriasis and how to better
manage patients. Researchers are making headway,
however, in causes and potential treatments.
Francisco Tausk, M.D., professor of dermatology
and psychiatry, University of Rochester, New York, and
former president of the Association of Psycho-neurocutaneous Medicine of North America, and colleagues
presented a recent mouse study looking at the effect
of stress on psoriasis. His research, Dr. Tausk says,
supports the idea that not all patients psoriasis gets
a worldwide issue
The psychiaTric comorbidiTies associated
with psoriasis deserve more attention from physicians
around the globe, experts say.
In a large population-based study published in
Archives of Dermatology, researchers reported people
with psoriasis have increased risks of depression,
anxiety and suicidality. They estimated that psoriasis in
the United Kingdom is responsible for more than 10,400
diagnoses of depression, 7,100 diagnoses of anxiety
and 350 diagnoses of suicidality (Kurd SK, Troxel
AB, Crits-Christoph P, Gelfand JM. Arch Dermatol.
2010;146(8):891-895).
The authors, including researchers from the
University of Pennsylvania, concluded its important for
clinicians to evaluate psoriasis patients for these conditions to improve outcomes. They recommend future
research focus on mechanisms by which psoriasis is
associated with psychiatric outcomes, as well as how
to prevent psychiatric comorbidities.
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But how?
Dermatologists can help patients address psychosocial
needs simply by recommending they join the NPF. Dr.
Feldman suggests all his patients continued on next page
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Dr. Feldman
AU G U ST 2014
www.ncbi.nlm.nih.gov/pubmed/20462664
get involved. The foundation offers credible information, support and comfort in knowing theyre not alone,
he says.
Simple and quick strategies can help a dermatologist determine the extent to which a psoriasis patient is
psychosocially affected by the skin disease.
Dr. Feldman says he screens his psoriasis patients
for depression at every visit. He assesses their mood,
in part, by watching their behavior. Lack of eye contact
and paucity of movement are clues they might be
depressed.
If you get the sense theyre depressed, you can
quickly ask them a screening question or two, Dr.
Feldman says.
He says his favorite questions (because theyre not
very confrontational) are asking patients if theyve
had trouble sleeping and about their energy level. If
those issues are problems, hell follow up with the more
pointed questions, asking if patients think theyre
depressed or if they feel suicidal.
If you identify signs of depression, then you need
to get them to their primary care doctor for treatment,
and, if its severe, perhaps psychiatry, Dr. Feldman
says.
The dermatologists treatment plan should include
getting the disease under better control, giving the
person affected a sense of enhanced control and
offering more information and opportunity for them to
address some of the psychologic or psychiatric morbidi-
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15
Patients
pErspEctivE
A patient with psoriasis asks dermatologists to
put themselves in their patients shoes and look
at the condition from that viewpoint.
lisette hilton | senior staff Correspondent
rian Lafoy, 44, of Plano, Texas, was diagnosed with psoriasis in his
early 20s. He says it wasnt until about five years ago, when he went
on etanercept (Enbrel, Amgen) and got the condition under control,
AU G U ST 2014
that he realized how the disease was a burden on his everyday life.
16
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physical impact
Still, it wasnt the psychosocial
aspects of the disease that led Mr.
Lafoy to want a stronger medication it was the physical impact of
the disease. Mr. Lafoy, who is active
in sports, lost most of the use of his
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There were never any discussions about how are you feeling?
Are you having problems at
work because of the flakes? Mr.
Lafoy says. I dont think I was
waiting for somebody to bring
it up. It wasnt until the last
few years that I realized, if we
dont start talking about this,
were not going to be able to help
other people in understanding
that this isnt just a skin disorder
or just arthritis. This is a lot
deeper and more involved.
His message to dermatologists:
Put yourselves in your patients
shoes and look at it from that
perspective. DT
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psoriasis
strEss
rEsponsE
IN VITRO
lisette hilton | senior staff Correspondent
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information, support, research, advocacy and more now has a peer mentoring program
that pairs psoriasis patients who are trained to mentor others with the disease with those who
are newly diagnosed or struggling with psoriasis. The program, called the Psoriasis One to
One peer mentor program, can be found at www.psoriasis.org or at http://www.psoriasis.org/
newly-diagnosed/one-to-one/mentors/find-a-mentor.
The NPF holds More than Skin Deep events and webcasts for patients with psoriasis to
educate consumers about the latest research, how to better control psoriasis and psoriatic
arthritis, manage stress and more (https://www.psoriasis.org/sslpage.aspx?pid=628)
Another good resource, according to clinical health psychologist Madelyn Petrow-Cohen, M.A.,
L.C.S.W., is Inspire.com, billed as a safe place where people can chat about different problems,
including psoriasis. Theres a group called Talk Psoriasis; the group is connected with the NPF and
can be found at https://www.inspire.com/search/?query=talk+psoriasis&submit.x=0&submit.y=0.
The Look Deeper campaign in the U.K. looks at the association between psoriasis and mental
health: http://www.seepsoriasislookdeeper.co.uk/
In June 2014, the NPF launched a new project to improve diagnosis, care and treatment for people
with psoriatic arthritis. The NPF Psoriatic Arthritis Project, at www.psoriasis.org/PsAProject, aims
to give healthcare providers new tools to better serve patients. Among the areas of focus: to
improve the understanding of psoriatic arthritis symptoms, disease management and impact on
patient quality of life among healthcare providers, according to an NPF news release. DT
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2014
peptides vasoactive intestinal polypeptide and pituitary adenylate cyclase-activating polypeptide and
allowing the Langerhans cells to present antigen
in vitro to responsive T cells, the result is skewed
towards the generation Th17-type helper T cells.
The reason this is relevant to psoriasis is it is
believed that Th17 cells and the interleukin (IL)-17
family of cytokines are important in the pathogenesis of psoriasis, he says.
Furthermore, the researchers have shown that
treating human endothelial cells with norepinephrine (a sympathetic nerve transmitter) and
adenosine-5-triphosphate (or ATP, also a sympathetic nerve transmitter) causes the cells to produce
the cytokine IL-6.
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MAKE A CONNECTION.
MAKE A DIFFERENCE.
Find out how you can help at PsOmuchmore.com
References: 1. Data on fle. Kantar Health 2013. Novartis Pharmaceuticals Corp; 2014. 2. Gupta MA, Gupta AK, Watteel GN. Perceived deprivation of social touch in
psoriasis is associated with greater psychologic morbidity: an index of the stigma experience in dermatologic disorders. Cutis. 1998;61(6):339-342. 3. Schmid-Ott G, Jaeger
B, Kuensebeck HW, Ott R, Lamprecht F. Dimensions of stigmatization in patients with psoriasis in a Questionnaire on Experience with Skin Complaints. Dermatology.
1996;193(4):304-310. 4. Armstrong AW, Schupp C, Wu J, Bebo B. Quality of life and work productivity impairment among psoriasis patients: fndings from the National
Psoriasis Foundation survey data 2003-2011. PLoS One. 2012;7(12):e52935.
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