Proceedings of the Fifth SKIN SPECTRUM SUMMIT

SSS-2019 02-10-20_Layout 1 2/12/2020 5:17 PM Page 1

Proceedings of the Fifth

The Chronicle

of SKIN & ALLERGY

Supplement to

The Chronicle of

Skin & Allergy,

February 2020


From the

SKIN

SPECTRUM SUMMIT

CURRUCULUM

CHAIRS

February 2020

Will you join us in supporting diversity and inclusiveness in dermatologic care?

Dear Colleague:

D R. GARY

SIBBALD DR R. DANIELLE MARCOUX DR. JASON RIVERS

Derma tologist and Internist

Professor of Medicine and

Public Health, University of Toronto

Derma tologist

CHU Sainte-Justine

University of Montréal

Dermatologist

Clinical Professor of Dermatolog

y

University of British Columbia

We welcome you to this annual edition of the Proceedings of Skin Spectrum Summit.

As these Proceedings are being distributed, we are preparing the sixth annual iteration of the Summit,

a live Continuing Medical Education event. This year’s conference will be national in scope and will

be held at the Chestnut Conference Centre of the University of Toronto on Saturday, April 18. You are

encouraged to register and attend this accredited session.

It strikes us that several things have changed since the first Summit was held in 2014. Interest in the

clinical subject of Ethnodermatology has grown demonstrably over these years, and we are gratified to

have played a role in raising awareness. Practitioners and researchers are gaining practical therapeutic

knowledge, through observation, trials, and genomic research, about the traits shared across our different

lineages -- as well as some factors that may somewhat distinguish us.

Our primary goal has been to facilitate better care for our Canadian communities.

The celebration of diversity and inclusiveness are key to the Canadian character, and the provision

of access to care for all has become the principle that in several ways defines who we are as a nation. Yet,

we note with concern from watching the evening newscasts that there is by no means universal acceptance

of these humanitarian values; moreover, in certain jurisdictions there are controversies affixed to

providing clinical care to immigrants and refugees.

As we have stated in previous editions of this publication: as physicians, we know that levels of

melanin may represent in several meaningful ways the least of our differences. We are all ethnic, and we

are all continuously learning from, and teaching each other.

We hope you will join our eminent faculty for the 2020 Skin Spectrum Summit in Toronto for a lively

and rewarding exploration and exchange of knowledge

concerning the treatment of cutaneous disorders

in different populations, particularly those

with Fitzpatrick skin types III through IV.

Please enjoy this monograph, and do consider

attending this year’s national Skin Spectrum Summit.

You may register at the conference website,

www.skinspectrum.ca

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ACNE

Acne management

DR. AFSANEH AlAvi ..............................................................................................................4

Topical clindamycin-tretinoin an effective Tx option for acne

DR. MONiCA K. li ........................................................................................4

Treating hormonal acne in women

DR. RENiTA AHluwAliA................................................................................5

Conveying the rationale of acne Tx to patients

DR. ANDREw F. AlExiS..................................................................................6

Topical scar management

DR. JERRY TAN ............................................................................................7

Mitigate acne scarring by treating it immediately

DR. CATHERiNE MAARi..................................................................................7

intermediate systemic acne treatment

DR. JERRY TAN ............................................................................................8

Choosing appropriate acne therapy

DR. JERRY TAN ............................................................................................9

ATOPIC DERMATITIS

Clinical presentation of AD in children with skin of colour

DR. DANiEllE MARCOux ..................................................................................................10

Myths and misconceptions in AD

DR. KEviN PEHR..................................................................................................................10

Skin barrier function plays an important role in AD

DR. AFSANEH AlAvi ..........................................................................................................11

Optimizing topical therapy in AD

DR. MAHA DuTil ................................................................................................................12

Steroid sparing and reducing flares in AD

DR. KATiE BElEzNAY..........................................................................................................12

Morphologic variants of AD in skin of colour

DR. MARiSSA JOSEPH ........................................................................................................13

Patients with AD are genetically predisposed

DR. iSABEllE DElORME ....................................................................................................14

Educating patients about AD, complications

DR. MARCiE ulMER............................................................................................................14

AESTHETICS & HAIR

Safe, effective aesthetic Tx in skin of colour

DR. HANEEF AHiBHAi ........................................................................................................16

How does skin aging differ among races?

DR. MARiSSA JOSEPH ........................................................................................................16

Grooming practices for Afro-textured hair

DR. RENéE A. BEACH..........................................................................................................17

Traction alopecia in men wearing turbans

DR. RENéE A. BEACH..........................................................................................................17

Diagnostic dilemmas and treatment options in Afro-textured hair

DR. RENéE A. BEACH..........................................................................................................18

HYPO- & HYPERPIGMENTATION

Diagnosing and Tx options for hyperpigmentation

DR. JAGGi RAO ....................................................................................................................20

CONTENTS

Hyperpigmentation and scarring

DR. KATiE BElEzNAY..........................................................................................................21

light patches on the trunk may turn out to be progressive

macular hypomelanosis

DR. ANDREw F. AlExiS ......................................................................................................21

Tyrosinase activity contributes to hyperpigmentation

DR. RENéE A. BEACH..........................................................................................................22

Scleroderma has a similar presentation to vitiligo

in patients with skin of colour


KELOIDS & MYCOSIS

Controlling onychomycosis and toe web bacteria

DR. GARY SiBBAlD ............................................................................................................24

Treatment of keloids

DR. RENéE A. BEACH..........................................................................................................25

PSORIASIS

How to spot psoriasis in Fitzpatrick skin types v and vi


Common areas, modalities of treatment and subtypes of Pso

DR. GARY SiBBAlD ....................................................................................26

Treating mild, moderate and severe psoriasis

DR. CATHERiNE MAARi ..............................................................................27

Clearing of psoriasis plaques may not mean the

end of treatment for patients with skin of colour

DR. ANDREw F. AlExiS ..............................................................................28

Signs of psoriasis

DR. JAGGi RAO ..........................................................................................28

Treating scalp Pso in women of African ancestry

DR. ANDREw AlExiS ..................................................................................29

ROSACEA

Treatment options for rosacea

DR. KEviN PEHR..................................................................................................................30

Rosacea management: Early Dx reduces morbidities

DR. MAHA DuTil ......................................................................................30

Rosacea underreported, underdiagnosed in patients with skin of colour

DR. MONiCA K. li ......................................................................................31

MELANOMA, SUN PROTECTION

when brown patches are not melasma


The three basic methods for sun protection

DR. SuNil KAliA........................................................................................33

WOUND MANAGEMENT

Sickle cell disease may complicate ulcers in patients of colour

DR. BRiAN KuNiMOTO ......................................................................................................34

Risk factors for diabetic foot ulcers and

what to look for in an initial foot exam

MARiAM BOTROS ....................................................................................35

in cooperation with JOURNAL OF ETHNODERMATOLOGY • 3


ACNE

Acne management

Dr. Afsaneh Alavi

4 • Proceedings of 2019 SKIN SPECTRUM SUMMIT

According to Dr. Afsaneh

Alavi, the key to determining

the best course of action

for acne treatment and management

is consulting with patients

on how they feel and their perception

of their condition. Dr.

Alavi discussed acne management

strategies at Skin Spectrum Summit

in Toronto.

Acne has four pathogenic factors:

an alteration in the keratinization

process, sebum production by

the sebaceous gland, release of inflammatory

mediators into the skin

and P. acnes follicular colonization.

Studies have shown that a certain

phenotype of acne responds

better to topical treatment. Dr. Alavi

suggests a combination of retinoids

and benzoyl peroxide as a single

agent for the first line of therapy for

comedonal and inflammatory acne.

During her presentation, Dr.

Alavi alluded to a survey of 3,000 to

4,000 dermatologists and non-dermatologists,

which showed that only

50% of dermatologists use retinoids

in the management of acne. For

non-dermatologists, fewer than 30%

were using retinoids as a treatment

option.

“Retinoids are a great treatment

in the management of acne,” she

said. “What may be the barrier for

treatment using retinoids is dryness

of the skin and irritation that counselling

and using moisturizer can resolve.”

For pregnant women, azelaic

acid, either 15% gel or 20% cream, is

an option when treating post-inflammatory

hyperpigmentation.

Topical and systemic antibiotics

should not be used as a monotherapy

in the management of acne, said

Dr. Alavi.

“Experts use neither topical

[nor] systemic antibiotics as a single

agent as a treatment for a patient

with acne,” Dr. Alavi said, “because of

resistance.”

Isotretinoin is the first line of

therapy for very severe acne, such as

cystic and conglobate acne.

“The recommendation is that if

you have a patient [who] at the end

of treatment … still has acne, you

proceed [with isotretinoin] until the

final clearance,” said Dr. Alavi.

Acne flares can also be eliminated

by initiation of a low dose of

isotretinoin.

For maintenance, Dr. Alavi recommends

topical retinoids with or

without benzoyl peroxide. Topical

antibiotics should not be used as

acne maintenance therapy.

Laser, intense pulsed light and

photodynamic therapy should not

be considered first-line therapy for

inflammatory acne.

“If other treatments fail, [these

therapies are] an option,” she added.

Topical

clindamycintretinoin

an effective

Tx option

for acne

Dr. Monica K. Li

Topical combination treatment

options are now being

recommended in North

America and Europe as one of the

first-line therapies for patients

with acne, said Dr. Monica K. Li

during her presentation at Skin

Spectrum Summit in Vancouver.

“There are different synergistic

and additive mechanisms of action

when using a topical combination approach,

which will then target multiple

pathogenic factors underlying the

progression of the acne,” said Dr. Li.

“The topical combination approach

allows for better patient compliance

because there are less

ingredients and less products that

they have to use as part of their skin

care and acne management,” stated

Dr. Li. A topical combination treatment

can also help practitioners achieve desired

treatment outcomes, according

to Dr. Li, because of a higher likelihood

of increased patient compliance.

One of the most effective topical

combination treatment options is a


Dr. Monica K. Li

clindamycin-tretinoin gel (Biacna,

Bausch Health).

During her presentation, Dr. Li

discussed a clinical study that looked

at the safety, efficacy and tolerability

of clindamycin-tretinoin as a treatment

option for acne. After a 12-week

period, patients saw a significant reduction

in papules and pustules, with

results seen as early as two weeks.

Compared to tretinoin alone, the

combination treatment had a faster

onset of action by six weeks.

“Studies have shown that clindamycin

can improve the effectiveness

of retinoids,” said Dr. Li.

“Topical retinoids can improve the

penetration of other active agents,

allowing for better concentration

and penetration into the pilosebaceous

unit, where the formation of

the microcomedone first starts.”

Dr. Li also talked about how the

combination of a topical clindamycintretinoin

gel with a benzoyl peroxide

wash was an effective treatment option

for a patient who was uncomfortable

with systemic treatment options.

The patient was a 43-year-old female

with severe papulopustular

acne on her face and upper back.

“The severity of her presentation

warranted a course of isotretinoin....

This patient declined all of the systemic

options because she was not

comfortable with their potential

side-effect profiles,” said Dr. Li.

After four months, the patient

had some papules and pustules but

also showed significant improvement.

According to Dr. Li, the takehome

point from this case is that

“benzoyl peroxide can be added to

the combination of a topical clindamycin-tretinoin

for a triple-modality

approach where we are targeting

different pathogenic factors underlying

acne development.”

“If we look at phase III studies on

the effectiveness of the combination of

clindamycin with tretinoin across all

skin types, we can see that not only are

fairer-skinned patients doing very well

with this medication, but also those

with skin types IV to VI,” said Dr. Li.

Dr. Li’s presentation was supported

through an unrestricted educational

grant from Bausch Health.

Treating hormonal

acne in women

Dr. Renita Ahluwalia

The prevalence of acne in females is on the rise, Dr. Renita Ahluwalia

reported during her presentation at Skin Spectrum Summit in

Toronto.

“Fifty per cent of women in their 20s and 35 per cent of women in their

30s experience acne,” said Dr. Ahluwalia. “The main age of referral for women

with acne has increased by eight years over the last decade, from 18.5 to

26.5.”

During her talk on acne in the female patient, Dr. Ahluwalia spoke about

how it is important to consider hormonal factors when treating female patients

with acne. “Up to 85 per cent of adult women complain that their acne

flares a week before their period, with hormonal flares higher in women over

age 30 compared to younger women.”

When treating hormonal acne, it can be helpful to consider the etiology of

the acne. Prior to a woman’s menstrual period, a woman experiences an increase

in her progesterone and estrogen, which can stimulate the premenstrual

acne flare.

Dr. Ahulwalia talked about how a combination topical regimen of clindamycin

phosphate 1.2%/tretinoin 0.025% [Biacna, Bausch Health] and topical

dapsone 5% [Aczone, Bausch Health], along with an over-the-counter benzoyl

peroxide cleanser and supported with the hormonal birth control spironolactone,

was an effective treatment for a patient with severe hormonal acne.

“What is really unique about the tretinoin in this [topical combination product]

is that there are two forms of it: one that is immediately available and one

that solubilizes slowly by going into the skin and into the follicle to increase

penetration,” said Dr. Ahluwalia. “Another key point about the tretinoin in this

product is that it is not degraded by sunlight or benzoyl peroxide.... The delayed

release of the second form [of tretinoin] and its small particle size [allow]

it to enter into the pilosebaceous unit and target those resistant P. acnes.”

In a three-week head-to-head trial, patients treated with the

clindamycin/tretinoin combination product had less stinging, scaling and erythema

compared to those receiving a combined product of adapalene and

benzoyl peroxide. There was also a 50 to 60% decrease in both inflammatory

and non-inflammatory lesions after 12 weeks.

“[Topical dapsone 5%] works better in female patients,” said Dr. Ahluwalia.

“Studies have shown that 48.6 per cent of women achieve clearer skin [compared



to] 34.4 per cent of men.” Dr.

Ahluwalia also stated that this product

works on both inflammatory and noninflammatory

lesions and patients are

sustaining treatment results for over a

year.

A Canadian study on topical

dapsone 5% treatment in 101 female

patients showed very effective

results. Using the global acne grading

score as a measuring tool, 69%

of patients achieved success.

After three months of the topical

combination regimen, Dr.

Ahluwalia's patient had noticeably

improved skin but was not completely

clear of acne. It was to further

target the hormonal

component of her patient’s acne

that Dr. Ahluwalia prescribed 100

mg daily of spironolactone.

“When there is a hormonal component,

we have to address that.”

Dr. Ahluwalia’s presentation was

supported through an unrestricted

educational grant from Bausch

Health.

Dr. Renita Ahluwalia

Conveying the rationale of acne Tx to patients

Dr. Andrew F. Alexis

Explaining the rationale behind

choices in a therapeutic

regimen for acne can help

patients be more confident in a

doctor’s recommendations and

encourage better adherence to

treatment, said Dr. Andrew F.

Alexis in a presentation at Skin

Spectrum Summit in Montreal.

“It helps to very briefly tell the

patient that acne is caused by four

key factors, including overproduction

of sebum — oil, in layman’s

terms for the patient; follicular hyperkeratinization,

which to the patient

you can describe as blocked

follicles; overgrowth of bacteria —

P. acnes or the new name, C.

acnes; and inflammation,” said Dr.

Alexis.

That then allows a practitioner

to explain to patients how their particular

presentation of acne is being

driven by those factors and how the

combination of recommended treatments

works to correct the situation.

He noted that benzoyl peroxide

(BPO) is frequently used in acne

treatments because not only is it antimicrobial

— without encouraging

antimicrobial resistance — it also

has some comedolytic effects. BPO

also works well in conjunction with

other agents, allowing for fixed-dose

combination products that simplify

administration while addressing multiple

pathogenic factors of acne at

the same time.

“Topical dapsone, one of the recent

additions to our topical acne armamentarium,

has a range of

anti-inflammatory effects and is

available as an aqueous gel. It tends

to be very well tolerated,” Dr. Alexis

said. He noted that studies have

looked at the efficacy of combining

topical dapsone with BPO or with a

fixed-dose combination of BPO and

the retinoid adapalene.

“When we do it like this, we use

[topical dapsone] once a day — offlabel

instead of … twice a day — and

use the retinoid formulation in the

evening, typically,” he said.

“One word of caution is when

you combine topical dapsone directly

with a benzoyl peroxide,” Dr.

Alexis said. “You want to do that at

separate times, not in the same

place and time. Otherwise, you can

get a tan-brown discolouration.”

Topical retinoids are one of the

most important classes of medication

in managing acne, said Dr.

Alexis. “They help to normalize follicular

desquamation but also have the

added benefit of reducing hyperpigmentation,

which, of course, is very

relevant to patients with skin of

colour.”

This class of medications is also

valuable as a maintenance therapy,

used in conjunction with another

therapy, such as an oral antibiotic, to

bring acne under control and then

used alone after the antibiotic is

stopped to prevent acne flares, he

said.

Antibiotics, although they are

effective at reducing microbial

overgrowth and have anti-inflammatory

properties, should not be

used as monotherapy due to the

risk of encouraging antimicrobial

resistance, he said. As well, the

choice of antibiotic — based on efficacy,

safety and cost — should be

explained to the patient. Minocycline,

for example, is extremely efficacious

and has a low risk of

inducing photosensitivity but can

potentially induce some unusual

side effects, including drug hypersensitivity

syndrome and pigmentation

of scars and mucous

membranes.

“There is even evidence from a

French study that patients of African

ancestry were more likely to develop

this drug hypersensitivity syndrome

from minocycline,” Dr. Alexis said.

“So when thinking about patients of

colour, this, coupled with the pigmentation

concern, makes this a

second-line agent. So we depend

more on doxycycline [in darkerskinned

patients].”



Topical scar management

Dr. Jerry Tan

Facial scars have a strong negative impact on

quality of life and can be frequent after inflammatory

acne, noted Dr. Jerry Tan in a presentation

at Skin Spectrum Summit in Toronto.

Fortunately, there are a growing range of treatments,

including topical approaches, for not only reducing

the appearance of scars but also helping to prevent

their formation.

For atrophic scars, one treatment that has been investigated

in a study of patients with acne scars but no

active acne is adapalene 0.3% gel.

“The vast majority of patients had moderate or

greater improvement in terms of overall scar severity,”

said Dr. Tan of that study. “What we saw is that the patients

also had increased deposition of collagen and procollagen,

which is what we expect if this product is going

to be able to enhance repair.”

For hypertrophic scars, which are more common in

reactive, darker skin, there are more options.

Treatments for hypertrophic scars

that have already formed include silicone

sheets and sometimes intralesional triamcinolone

acetonide injections, said Dr.

Tan. “And there are a lot of other options

now, including some of the vascular

lasers..”

However, when a lesion is progressing

from macular erythema into the beginnings

of hypertrophy, only a few

options are available for which there is

level 1 or 2 scientific evidence, he said.

These include silicone sheets and onion

extract, the latter of which has been

shown to produce good results on surgical

scars.

Another new option is a topical for-

Dr. Jerry Tan

mulation of putrescine. It has been studied in all sorts of

hypertrophic scars in a cosmetic surgery clinic, as well as

in the prevention of hypertrophic scars post-breast reduction,

said Dr. Tan.

“This product reduces the activation of tissue transglutaminase,

an enzyme that enhances cross-linking of collagen,”

he said. Excess cross-linking of collagen can make

the tissue very hard, forming a lump, hypertrophic scar or

keloidm which is undesirable.

“You want the soft [collagen] that helps to elevate and

gives you tissue structure, but you do not want excessive

cross-linking. And this agent seems to help with that.”

Crucial to preventing acne scars is getting inflammation

under control quickly, Dr. Tan said. “In acne, the

analoyg is that of a forest fire: as long as the fire is burning,

you are going to get stumps in the forest. So put out

the fire quickly.”

It is also valuable to think about the nature of an individual

patient’s scar risk. If it is mostly atrophic, there is

evidence for topical

retinoids. If there is

concern about hypertrophic

scars and the

patient already has

some, still has active

acne and is receiving

surgery on areas at

high risk of hypertrophic

scars — particularly

a patient of

colour — “then you

may really want to consider

some of these

topical options to help

mitigate [the] risk of

scar formation.”

Mitigate acne

scarring by

treating it

immediately

Dr. Catherine Maari

It is important to treat acne immediately

when you see that

some scarring is occurring to mitigate

potential life-long scars. This

was a point made by Dr. Catherine

Maari during her presentation at

Skin Spectrum Summit in Montreal.

“Even if the acne is not severe

but the presence of scars is seen, we

need to intervene and treat aggressively

because once there are scars,

they are very difficult to remove,”

said Dr. Maari.

During her presentation, Dr.

Maari described the case of a patient

she was not initially seeing for

acne but who had acne with scarring

that had not been treated. The patient

was initially resistant to treatment.

However, after completing a

course of isotretinoin, his acne

cleared, but he was still left with permanent

scars. “I wish I had seen this

patient earlier,” said Dr. Maari. “Any

time you see severe acne scarring

but are not comfortable prescribing

oral medication or isotretinoin, make

sure to refer the patient [to a dermatologist]

right away.”

It is also important to treat milder

acne, according to Dr. Maari, espe-



cially in patients with skin of colour

when post-inflammatory hyperpigmentation

is seen. “Even if the scars

are not punch-out, hyperpigmentation,

once there, can last for months

or even years,” she said.

In addition, the importance of

treating acne in skin that is prone to

hyperpigmentation, regardless of the

severity, was emphasized by Dr.

Maari. “If the patient has one to two

papules or pustules a month but

each leaves a hyperpigmented macule,

they eventually add up and can

cause cosmetic concern to the patient.

This type of patients are the

ones we want to treat earlier to try to

better contral the acne. I will be more

aggressive with these patients to try

and control pigmentation.”

Dr. Maari outlined potential

treatment options for various types

of acne. For comedonal lesions, she

recommended the use of topical

retinoid. For inflammatory lesions,

she suggested either antibiotics or

benzoyl peroxide. Patients who have

sebum secretion should be treated

with isotretinoin or oral contraceptive,

and patients who have a mixed

acne can be treated with a combination

treatment, such as clindamycintretinoin

(Biacna, Bausch Health) or

other combination treatments.

“Do not underestimate the impact

of acne. I tailor my treatment

according to the needs of the patient,”

she said.

Dr. Maari’s presentation was supported


grant from Bausch Health.

Intermediate systemic acne treatment

Dr. Jerry Tan

Systemic therapy for acne represents an array of

effective treatments beyond antibiotics and

retinoids, but some of the “common wisdom”

regarding their use is incorrect, according to Dr. Jerry

Tan, who spoke at Skin Spectrum Summit in Toronto.

During an intermediate overview on acne, Dr. Tan

talked about systemic treatments, including oral antibiotics

and isotretinoin, but also spironolactone oral contraceptive

pills for female patients, antihistamines and

lifestyle changes.

Regarding oral antibiotics, he suggested avoiding

minocycline in favour of tetracycline or doxycycline. “The

problem with minocycline [is that] it is one of the only … cyclines

that has been associated with a high risk of [issues

such as autoimmune hepatitis and drug-induced lupus]….

Of the different moieties of cyclines, this seems to be the

most allergenic of them all. So if you can avoid it, why not?”

Avoiding this antibiotic is also supported by a lack of

evidence that it works any better than the other cyclines,

Dr. Tan said.

“If you are looking to reduce the risk of antibiotic resistance,

add BPO washes, add BPO gels. Limit [antibiotic]

use to three months.”

For female patients, spironolactone-based oral contraceptives

are another effective option, he said.

“The overall quality of evidence we have for spironolactone

in acne is low,” said Dr. Tan. “But I have to tell you,

based on the sessions with other acne experts and people

who treat a lot of acne, this is one of those unheralded

heroes in our toolkit. And the reason is it works so

well; it is so smooth and has so few side-effects.”

He mentioned a hybrid systematic review that found

spironolactone 100 to 200 mg/day reduces inflammation

and inflammatory lesion counts. Higher dosing was associated

with an increased risk of side–effects — breast

tenderness and irregular menstrual periods — so Dr. Tan

recommended starting patients at 50 mg/day, slowly increasing

to 200 mg and then slowly lowering the dose if

the acne comes under control.

Contrary to common thought, routine potassium

monitoring is largely unnecessary when treating acne with

spironolactone, he said, except in patients with diabetes

or kidney disease, such as type 4 renal tubular acidosis.

A Korean study from 2014 showed that adding the

antihistamine desloratadine to oral isotretinoin improves

results, Dr. Tan said. “It makes the isotretinoin work

faster, it makes it work more thoroughly and when you

actually evaluate the effect of the desloratadine, it reduces

inflammation and sebum secretion.”

As desloratadine is available over the counter in

Canada, practitioners can feel confident that it is reasonably

safe. This is particularly true for patients with premenstrual

acne flares, who would only need to take it for

a week or two at a time, he said. It could also be used to

augment another treatment for patients on topicals who

do not want to move to other systemics or for patients

concerned about antibiotic resistance.

Oral isotretinoin has a bit of a bad reputation, Dr. Tan

said, in part because some patients develop severe cheilitis.

But the frequency and severity of cheilitis are partly

due to outdated ideas about dosing the medication, he

said. Recommendations to treat to a total cumulative

dose of 120 to 150 mg/kg are a legacy of an era when

isotretinoin treatment was limited to four months, he said.

As that is no longer the case, it makes more sense to treat

to clearance rather than to a fixed total dose.

Starting a patient at a 10 mg dose and gradually increasing

it to achieve clearance, and using lower maintenance

dosing such as 0.1 to 0.5 mg/kg, can avoid or

reduce many side-effects, including cheilitis.

“It is still going to get you there. It is still going to get

the patient where they want to go.”



Choosing appropriate acne therapy

Dr. Jerry Tan

“At the end of the road, all

you want is to maximize

outcomes, so it starts

with appropriate selection of

treatment,” said Dr. Jerry Tan in

his presentation on acne at Skin


Dr. Tan believes that successful

treatment begins with providing patients

with anticipated timelines so

that their mindset can be “based on

practical reality.” Then it is important

to select a type of treatment that is

available to each patient and follow

through with the proper application.

Dr. Tan noted that acne starts

with hormonal triggers. Some of

these hormonal triggers may include

a Western diet, dairy intake and

changes in pubertal sensitivities.

These triggers can influence sebocytes

in terms of the amount and

quality of sebum that is made. In

fact, Dr. Tan reported that “sebum

by itself can trigger acne.” Sebum

has the ability to activate inflammatory

mechanisms, leading to increased

inflammation. However, in

other cases, hormones can increase

sebum, which increases proliferation

of P. acnes, which generates lipases.

After identifying acne and its

triggers, Dr. Tan suggested the use

of a combination of treatments that

have already been proven to be successful.

Retinoids are one of the only

products that stop the development

of microcomedones. Dr. Tan emphasized

that “comedones are technically

inflammatory, and when

biopsied, inflammatory infiltrates can

be found.” To treat these, he advised

the use of a combination of topical

retinoids and benzoyl peroxide, both

of which have been known to work

against the proliferation of comedones.

However, Dr. Tan described

the importance of certifying that the

treatment is both available and affordable

to the patient.

Dr. Tan related the application

of a topical treatment to playing a

sport: “When you are thinking about

topical treatments, I want you to

think about defence. You have to

cover the field. You don’t know

where the next spots might come

from.” He emphasized the need to

engage with patients through positive

reinforcement as adherence to

the treatment requires reminders.

Dr. Tan discussed a study that discovered

that the first week after

prescription, only 60% of patients

are opening the tube; however,

when they are reminded by their

doctor, the percentage increases to

100%.

Even when the treatment has

been stabilized, Dr. Tan recommends

that patients continue with

persistent treatment as trials have

shown that maximum improvement

plateaus only at 20 weeks, after

which patients should move forward

with healthy lifestyles.

TORONTO

APRIL 18, 2020

8 am to 4 pm

You are invited to join us

at the 2020 Summit and

receive a discount on

registration fees.

See back cover



ATOPIC

DERMATITIS

Clinical presentation of AD

in children with skin of colour

Dr. Danielle Marcoux

Atopic dermatitis (AD) is more prevalent in children with skin of

colour, specifically children who are of African-American, Asian or

Pacific Islander decent, compared to children with Caucasian skin,

noted Dr. Danielle Marcoux during her presentation at Skin Spectrum

Summit in Montreal.

“Right now, around the world, one in five children have some manifestation

of atopic dermatitis. Fortunately, less than 10 per cent have moderate-severe,”

said Dr. Marcoux.

The clinical presentation of AD is different in both children and adults

with skin of colour compared to patients with Caucasian skin, she said. Different

clinical characteristics include erythema that is more grey, violet or

brown in colour; dyschromia; follicular accentuation, particularly in African-

Americans; and lichenification in Asians, and there is often extensor involvement.

Erythema is an important factor when using the SCORing Atopic Dermatitis

(SCORAD) scale to rate the severity of a child’s AD, said Dr. Marcoux. “If you

adjust the erythema score ... the child could be six times more likely to be

rated as having severe AD.” For example, “if you say there is no erythema, you

lower the score of the child.”

Dyschromia is “a source of anxiety for parents because they see changes

in colour on their children’s skin,” said Dr. Marcoux. “It is all the post-inflammatory

hyperpigmentation. When it is more round and white, we label it pruritus

alba, which [means] white scales.”

“As far as phenotypes, Asians have more well-demarcated lesions with

increased scaling and lichenification,” she noted. However, “in African

Americans, there is more extensor involvement; there is also more perifollicular

accentuation and scattered distinct papules on the extensors and

trunk.”

Dr. Marcoux went on to point out the importance of education:

“Therapeutic education, in all chronic disease, is fundamental; you

don’t just hand out a prescription. [Atopic dermatitis] is disturbing to

parents; they are worried. They really need reinforcement and education.”

Myths and

misconceptions

in AD

Dr. Kevin Pehr

There are a number of ideas

about atopic dermatitis (AD)

that are outdated but are

still being referenced in practices.

Some of these were described by

Dr. Kevin Pehr at Skin Spectrum

Summit in Montreal.

“We used to say, ‘Don’t worry;

the child will outgrow [AD] when he

is a teenager’ or ‘Don’t worry; she will

outgrow it when she is an adult,’”

said Dr. Pehr. In truth, he said, 40%

of pediatric AD cases persist into

adulthood.

With as many as 10% of children

experiencing AD, that means

4% of all people could have the condition

last through their whole

childhood.

Another idea Dr. Pehr would like

abandoned is the use of antihistamines

to treat itching in AD and to

help children sleep.

“I will probably get arguments on

this. Every textbook will tell you ‘antihistamines’!

No, no, no.”

“There is no histamine release

involved [in AD],” he said. “Yes, if

you give [children] enough at bedtime,

they will fall asleep because

you drugged them with the anti-



histamine.... It will not stop them

from scratching. If you put somebody

to sleep with whatever, and if

you do infrared cinematography,

you will see them scratching in

their sleep.”

AD often flares in the winter in

Canada due to how dry the air gets,

but practitioners should not assume

this is the season when patients’ AD

will be the worst. “The air has zero

per cent humidity; it is functionally a

desert here in winter. On the other

hand, for some people, it is the excessive

heat. So you have to ask your

patient: Is it the hot? Is it the cold? Is

it the dry? Is it the wet?” said Dr.

Pehr.

A misconception many parents

have is that being conservative in

their use of medications such as

topical steroids will help address

their children’s AD while using less

medication, he said. However,

treating to clearance is the better

choice.

“The reason I will go back to

‘treat to clear’ is they will use less

medicine overall in the long run.

Most parents—especially parents

of young children—will treat until

the child is sorta-kinda-almostmaybe-sorta

clear or perhaps a little

bit better, which means they are

constantly on and off treatment.

Treat them hard, treat them until

they are completely clear; you will

use less medicine. Even if you have

to wait until the lichenification goes

down.”

Skin barrier function plays an important role in AD

Dr. Afsaneh Alavi

Impairment to the barrier function

of the skin plays an important

role in the path o-

physiology of atopic dermatitis

(AD), Dr. Afsaneh Alavi reported

during her presentation at Skin

Spectrum Summit in Toronto.

“If you look at the pathophysiology

of the disease, even in non-lesional

skin, there is an impairment in

barrier function,” said Dr. Alavi.

“The first line of treatment for

atopic dermatitis ... is emollients,”

said Dr. Alavi. “Emollients help the

barrier to function.”

During her intermediate AD

overview presentation, Dr. Alavi

posed two questions to the delegates

in attendance: “If barrier function

is that important in terms of

[the] pathophysiology of atopic dermatitis,

could [we] prevent atopic

dermatitis if we help the barrier

function of the skin? Could we help

our patients to have less severe disease?”

She answered these questions

by discussing the findings of

the Horimukai, et al. study published

in The Journal of Allergy and Clinical

Immunology (2014; 134(4):824–830).

During the study, 59 neonates

who were considered at high risk for

AD had an emollient moisturizer applied

twice daily for the first 32

Dr. Afsaneh Alavi

weeks of life. The results showed

that approximately 32% fewer

neonates developed AD when compared

to the control group. “If we

can help maintain the barrier function,

we can prevent some degree of

AD. That is why [barrier function] is

so important,” said Dr. Alavi.

Current AD guidelines suggest

using an emollient moisturizer and

avoiding triggering factors as the first

line of AD management. Dr. Alavi

stressed the importance of proper

moisturization: “Lots of times, patients

come and say, ‘I use moisturizer,

but it doesn’t get better.’ In

most cases, [moisturizers] are underused.”

In adults, the recommended

amount of moisturizer per

week is 250 grams; however, according

to Dr. Alavi, most patients are not

using this amount.

The two moisturizers that are

typically prescribed to patients are

hydrophilic moisturizers and

lipophilic emollients. Both should be

fragrance free. “Lipophilic emollients

are suggested to be applied after

[active disease] to maintain moisture,”

stated Dr. Alavi.

Dr. Alavi also discussed other

treatment options for AD, including

topical anti-inflammatory agents

such as steroids and calcineurin inhibitors,

phototherapy, PDE4 inhibitors

and topical JAK inhibitors.



Optimizing topical therapy in AD

Dr. Maha Dutil

Topical treatment of atopic dermatitis (AD) involves

a multi-angle approach for both managing

flares and ongoing maintenance, but there

are both well-established therapies and new agents

for this condition that can produce improvement.

That was one message Dr. Maha Dutil included in her

presentation on AD at Skin Spectrum Summit in

Toronto.

The basis of any care regimen is emollient use, Dr.

Dutil said, noting that studies have shown that moisturizing

alone can improve the eczema score. Bathing habits,

too, are a non-medical factor that can impact AD symptoms,

she said, recommending that patients with AD only

bathe once every two to three days to reduce the drying

effect.

Topical treatments for AD include topical steroids,

topical calcineurin inhibitors (CNIs) and PDE4 inhibitors.

Steroid phobia is common even though, when used

properly, steroids are very valuable, she said.

“If you counsel the patient and use low- to mediumpotency

steroids, you do not really have many side effects,”

Dr. Dutil said. “There is a long history of safety

when used correctly, and they are very effective at cooling

inflammation down quickly. They relieve the itch, and

they are inexpensive.”

She recommends prescribing low-potency steroids

for the face and folds and mid-potency steroids for the

body, arms and legs. “I leave the high-potency [steroids]

… for the palms and soles.”

For patients who do not respond to a topical steroid,

have developed a side-effect or an intolerance or have

become dependent due to overuse, Dr. Dutil says switching

to a topical CNI or a PDE inhibitor could be a good

choice.

Topical steroids should also be avoided in adolescents

or preadolescents. “If you happen to hit them during

their growth spurt with a topical steroid, you increase


the risk of sideeffects,”

she said.

CNIs “suppress

inflammation

by inhibiting

calcineurin-dependent

T-cell activation.

They are

anti-inflammatory

without being antiproliferative.

They improve

skin barrier function,

and they reduce

Staph.

carriage.” With these products, patients should be counselled

that approximately 20% of patients experience a

transient burning sensation on application, lasting

roughly 10 minutes, for the first few days of treatment. Although

there is a safety warning in the monographs of

these products, Dr. Dutil noted that in 20 years of clinical

experience with topical CNIs, no link has been found between

use of these products and skin cancers or lymphomas.

The newest option is PDE4 inhibitors, one of which,

crisaborole, was approved in Canada in late 2018. “Phosphodiesterase

degrades cyclic AMP and is overactive in

patients with atopic dermatitis. So by decreasing phosphodiesterase,

cyclic AMP goes up in the cell, and it reduces

inflammation,” said Dr. Dutil.

She mentioned a four-week study of PDE4 inhibitor

treatment in patients aged 2 and older with mild-to-moderate

AD. In that study, by day 29, a third of patients were

clear or almost clear, with a two-grade improvement. “It

helps the itch within a week. It is probably because cyclic

AMP goes up in all the cells, not just the skin cells. It also

goes up in nerve cells. That may be an effect.”

Steroid sparing and

Dr. Katie Beleznay

Individuals with very dark skin

may be at elevated risk of developing

atopic dermatitis

(AD). That, combined with the

chronic nature of AD and the tendency

for darker skin to develop

difficult-to-treat post-inflammatory

pigment changes, suggests

that encouraging treatment adherence

and reducing the frequency

and severity of AD flares

are particularly important in this

population.

This was a point brought up by

Dr. Katie Beleznay in a talk at Skin


Dr. Beleznay said that on presentation

many patients expect she

will be able to cure their eczema.

“And I say, This is a chronic condition,

similar to high blood pressure

or diabetes,’” she said. “Some conditions,

some people get them despite

everything you do. What we are

going to do is try to help you manage

it better.”

She said she often illustrates the

cycle of AD to patients by drawing a

sinusoidal curve, explaining that the

peaks of the curve represent AD

flares. She tells patients, “Our goals

with treatment [are] to reduce the

peaks—the severity of the flares—

and … increase the time between

the flares.”

The cornerstone of any treat-


and reducing flares in AD

ment program, however, is adherence,

Dr. Beleznay said.

“I … ask people about vehicle

preference because the best cream

is the one that a patient will actually

use. If I give them an ointment, but

they are never going to use it because

it is too greasy, even though

it may be a little bit more potent

[than a cream] or might work a bit

better in a specific area, it is not

going to do any good if it sits on

their shelf.”

Another factor impacting patient

adherence is fears—warranted or

not—patients have regarding some

active ingredients.

“In my practice, I mention

steroids, and people sometimes say,

‘No, there is no way I am using that.

It is terrible; it thins the skin,’” she

said.

One way to address this concern

is to use a topical calcineurin inhibitor

(TCI) for milder AD or for

maintenance between flares, Dr.

Beleznay said.

“With the flare, when things are

quite bad, at that stage a physician

may want to consider using a corticosteroid

to calm things down. Put

the fire out, per se. Then at the

first sign a new flare is starting,

that is when a physician might

want to use pimecrolimus ... to try

and stop the flare before it gets

too extreme and harder to control.”

TCIs such as pimecrolimus and

tacrolimus have equivalent anti-inflammatory

potency to a low- to

mid-potency steroid, she said.

They can also be safely used on

the eyelids as they do not present

a risk of skin thinning the way

steroids do.

AD frequently occurs on very

visible parts of the body, such as

the face. This is particularly bothersome

in patients with skin of

colour, Dr. Beleznay said, because

even if the flares can be controlled,

they may have induced post-inflammatory

pigment changes that can

persist for a significant amount of

time.

Dr. Beleznay cautiously suggested

that there may be a lower

risk of pigment changes with TCIs.

“There are some studies that say

that steroids themselves can contribute

to hypopigmentation. Most

commonly, I think that is actually related

to the dermatitis itself not

being treated.”

“But we do use the calcineurin

inhibitors for treating some conditions

where there may be some hypopigmentation

or depigmentation,

so that is a consideration.

Dr. Beleznay’s talk was sponsored

by Bausch Health.

Morphologic variants

of AD in skin of colour

Dr. Marissa Joseph

Atopic dermatitis (AD) has different morphologic variants in patients

with skin of colour in comparison with individuals with Caucasian

skin.

This was the key message from Dr. Marissa Joseph’s presentation on AD

in skin of colour at Skin Spectrum Summit in Toronto.

According to Dr. Joseph, it is important to be aware of how AD presents itself

in skin of colour patients. “Sixty per cent of Canadians are visible minorities,

and we have the highest per capita immigration rate in the world. You

really have to think about disease processes in unique patient populations

that are becoming, to be honest, not that unique,” stated Dr. Joseph.

She described a case of a three-year-old girl who was referred to her with a

rash. Dr. Joseph said the rash had very little to no red and was more of a “dusky

grey.” She went on to say that her patient had follicular accentuation and a

lichenoid presentation. In addition, the rash was present on her extensor surfaces.

In darker skin types, “less erythema, violaceous-greyish hue [and] hypo- or

hyperpigmentation may actually be the main indicators of severity. Follicular

accentuation is quite common,” said Dr. Joseph. “Classically, we are taught that

[AD] will occur on flexor surfaces, but very commonly in darker skin types, it is

prevalent on extensors, … so that makes it a little bit difficult to differentiate it

from psoriasis.”

Another case Dr. Joseph described was of a young girl referred to her for

acne. “When we look very carefully, those aren’t comedones; those are just little

follicular bumps.” According to Dr. Joseph, eliciting specific information

from the patient was extremely important, especially in this case. “This was

super itchy for her. Very, very itchy. She was scratching, making it difficult for

her to concentrate. This would represent more of a follicular variant,” said Dr.

Joseph. She prescribed a calcineurin inhibitor, which cleared the rash, something

that would not likely happen if it was simple acne.

In another case, Dr. Joseph saw a young man with no acutely visible rash

but very itchy skin. Upon inspection, the patient had very fine flat-topped little

bumps. “This would represent a lichenoid sort of presentation,” said Dr. Joseph.

“It is not just the usual suspect of an ill-defined eruption on the flexor

areas,” said Dr. Joseph. In patients with skin of colour, AD can have “perifollicu-



lar presentations, [and there can be]

dyspigmentation in the presentation,

a lack of erythema, lichenoid presentations

and the presence [of AD] on

extensor surfaces,” said Dr. Joseph.

Patients

with AD are

genetically

predisposed

to it

Dr. Isabelle Delorme

Patients with atopic dermatitis

(AD) are genetically predisposed

to the disease,

reported Dr. Isabelle Delorme

during her talk at Skin Spectrum

Summit in Montreal.

“Atopy is when people have a

predisposition with hyperreactivity,”

said Dr. Delorme.

AD is the first manifestation of

diseases in the atopic march, followed

in order by food allergies,

asthma and rhinitis, said Dr. Delorme.

However, not all people with

atopy will have all of the diseases.

“Some people will have one; others

will have all of them. But, in general,

there is a link that exists between

the diseases,” said Dr. Delorme.

“It appears that the skin barrier

plays a role, not only in atopic dermatitis

but also in the development of food

and airborne allergies,” said Dr. Delorme.

“There is a sensitization through

the skin barrier, which is defective, and

that is where the sensitivity to food allergens,

such as peanuts or eggs, for

example, would appear to pass

through the defective skin barrier.”

AD and the remaining diseases

in the atopic march are more likely

to develop at a young age, according

to Dr. Delorme. Children who develop

food allergies are also at risk of

developing more diseases in the

atopic march. Current treatment

Providing patients with atopic dermatitis (AD), or

a family history of the condition, with good information

can help them prevent flares and

identify signs of complications.

This was part of the message Dr. Marcie Ulmer presented

during a talk at Skin Spectrum Summit in Vancouver.

“I have had a lot of patients come into my practice

very frustrated that they still have their condition,” said

Dr. Ulmer. “They will say, ‘When I was a child, my doctor

told me I would grow out of it.’ So I think it is important

we do not tell our patients that they will grow out of it because

a lot of them do not.... Up to 25 per cent of pediatric

patients have symptoms into adulthood.”

Educating patients about how vital emollient use is in

managing AD is important. Dr. Ulmer described a randomized

controlled trial of emollient use from birth in infants

with a family history of AD, which showed that daily

full-body moisturization could reduce the cumulative risk

of AD by 50% by six months.

“The conclusion was that the skin barrier enhancement

from birth is really a feasible strategy for reducing

the incidence of atopic dermatitis in high-risk neonates,”

she said. “I do recommend it to families.”

“In general, moisturizers are really the cornerstone of

guidelines recommend applying an

emollient to the skin if a child has

food allergies, regardless of AD development,

in order to protect the

barrier function.

Dr. Delorme also discussed the

role of diet in AD. “There is still a lot

of conflicting data. Currently, there is

not enough evidence to recommend

a specific diet to patients as a form

of prevention for atopic dermatitis,”

she said. However, some foods

might aggravate or exacerbate AD,

such as fast food, fruit and fish.

Dr. Delorme stressed the importance

of providing patients not only

with information but also a treatment

plan for AD. “We give patients a lot of

information, but it is good to provide

them with a treatment plan with

things clearly written down to help

them treat themselves [or their children]

properly,” noted Dr. Delorme.

Educating patients about AD, complications

Dr. Marcie Ulmer

atopic dermatitis treatment. If you only recommend one

thing, this is a very good thing to recommend. They help

prevent itch, … help reduce flare frequency and help restore

the lipid balance and skin barrier integrity. They are

shown to have a steroid-sparing effect.”

Sometimes treatment-resistant eczema may not just

be AD, Dr. Ulmer said, describing one of her own patients

with both AD and acne who presented with a tight cluster

of inflamed lesions on her chin. The lesions turned out to

be due to a herpesvirus infection.

“[Patients with AD] are prone to secondary infections

because they have reduced immunity and impaired skin

barrier function,” she said. “Staph is what we will most

commonly see. It can be methicillin sensitive or methicillin

resistant.”

Herpes infections can become disseminated—

eczema herpeticum—which can be very serious and require

hospitalization, said Dr. Ulmer. “But if caught early,

it can usually be treated orally with [valacyclovir].”

The molluscum contagiosum and human papilloma

viruses can also be easily spread by individuals scratching

their itchy AD. Fungal infections such as dermatophytes

and yeasts can also be spread this way. They are all

harder to treat in patients with AD, she said.


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IN DERMATOLOGIC CARE


AESTHETICS

& HAIR


Safe, effective aesthetic Tx in skin of colour

Dr. Haneef Alibhai

Using the correct tools and techniques for aesthetic

dermatology in darker skin can produce

good results while minimizing the risk of inducing

unwanted pigment changes, explained Dr. Haneef

Alibhai at Skin Spectrum Summit in Vancouver.

One technology Dr. Alibhai advocated for skin rejuvenation

in Fitzpatrick skin types IV through VI was picosecond

pulsed lasers.

“The beauty of the picosecond laser is it does not work

photothermally, as other lasers do. Picosecond lasers work

photoacoustically, creating a pressure wave to break down

pigment,” he said.

Rather than heating a target point, these devices cause

a phenomenon known as laser-induced optical breakdown,

which causes a pressure wave that spreads through the tissue,

reaching deeper into the dermis than the lasers could

themselves, Dr. Alibhai said. The pressure waves temporarily

alter the permeability of the cell membranes, which increases

production of elastin and collagen.

This process leads to very little downtime, “and there is

no risk of hyperpigmentation because these laser-induced

optical breakdowns are located below the dermal-epidermal

junction,” he said.

“This is a very good device to lighten unwanted pigment.

It has become my go-to to treat pigmentation on skin

types IV, V, and VI, such as your typical solar lentigines, very

safely.”

Dr. Marissa Joseph began her

talk at Skin Spectrum Summit

in Toronto by examining

the belief that there is a

difference in how individuals of

different races age.

“Is that really true?” she asked before

going on to contrast the features

of aging seen in different skin types.

Thinking about mechanisms of

Of the picosecond lasers, Dr. Alibhai said he prefers a

755 nm device as energy at that wavelength is much more

preferentially absorbed by melanin rather than oxyhemoglobin.

“If you compare it to 532 nm, where the melanin-toblood

ratio is about 2.5, or 1,064 nm, where

melanin-to-blood absorption is about 16 times, at 755 nm,

the difference between melanin and oxyhemoglobin absorption

is actually 50 times.”

This results in very limited risk of pinpoint bleeding,

minimal side-effects and less downtime while lightening pigment

and increasing collagen, he said.

Dr. Alibhai and his colleagues have begun pre-treating

darker-skinned patients with hydroquinone compounds for

the four weeks prior to their picosecond laser appointments,

he said. “That is just for our comfort and safety, so

we can sleep well at night. Just to minimize the risk of [postinflammatory

hyperpigmentation].

Many patients with darker skin have also asked about

correcting dark circles under their eyes, he said. For those

patients, particularly those with hollows under their eyes,

Dr. Alibhai has been treating them with very fine, low-cohesivity,

low-viscosity hyaluronic acid fillers, administered using

a cannula.

“You have to choose the right patient,” he noted, saying

that only three of every 10 patients are a candidate for

treating this way. “If you have the right patient, the right

product and the right technique, you get great results.”

How does skin aging differ among races?

Dr. Marissa Joseph

aging is important across all skin

types, she said.

She spoke about intrinsic aging

and extrinsic aging, making note of the

extrinsic causes of aging, such as UV


Dr. Marissa Joseph

exposure and smoking.

But, she said, when comparing

Fitzpatrick skin types, darker skin types

tend to experience facial aging at a decreased

rate due to intrinsic factors.

Grooming practices for Afro-textured hair

Dr. Renée A. Beach

When it comes to grooming

practices for those with

Afro-textured hair, you

are considering another type of

normal, according to Dr. Renée

Beach, who presented on hair and

scalp disorders at Skin Spectrum

Summit in Montreal.

Whereas non-Afro-textured hair

types may require washing two to

three times a week, with Afro-textured

hair, weekly washing is generally

adequate enough.

“The hair can be quite fragile for

manipulation, so you really want to

According to a survey of women

aged 18 to 75, “African-American

women reported advanced signs of facial

aging on average 10 to 20 years

later than their Caucasian counterparts,”

she said.

Forehead lines in African-American

women were reported in their

50s, tear troughs did not appear until

their 60s and crow’s feet finally appeared

in their 70s, she said.

Approximately 70% of African-

American women aged 70 to 79 reported

that they still had not observed

lines around their mouths.

“There really is a delayed onset of

things like wrinkles,” she said.

Dr. Joseph went on to rank the

rate of wrinkle onset by race: black patients

experienced the slowest onset,

followed by Hispanic patients, Asian

patients and, finally, white patients.

The reason that darker-skinned patients

experience a decreased rate of

onset may be due to “a protective effect

of increased fibroblast activity,” she said.

This may also explain the increased

risk of keloids in darkerskinned

patients, she said.

This does not mean that patients

with darker skin tones don’t seek or

require treatments or improvements

for anti-aging, she said.

Dermatosis papulosa nigra, small

dark keratoses that appear on the

face and neck, was one of the examples

she gave of an aging condition

specific to people with darker skin.

“There are nuances to addressing

their specific aging concerns,” she said.

have patients [be] careful with regards

to styling practices,” explained

Dr. Beach. “The hair growth is generally

less than other hair types, and

this can be approximately half or

three-quarters of the rate of other

hair types.”

Patients in this cohort prefer to

use conditioners over shampoos

mainly because some of the slipping

agents in conditioners help

Afro-textured hair be more manageable

after it is shampooed.

As a result of the decreased

growth rate in patients with Afrotextured

hair, trimming frequency

should be reduced to twice a year

on average, according to Dr.

Beach.

Additionally, the bedtime routine

for patients with Afro-textured

hair is significant for two reasons:

first, to preserve a certain hairstyle,

and second, to minimize trauma to

the existing hair. Some patients will

apply moisturizing products but will

also protect the hair with something

silky or satiny, such as a bonnet

or particular wrap, to minimize

friction.

Traction

alopecia in men

with turbans

Dr. Renée A. Beach

Traction alopecia is a scalp

disorder that occurs commonly

in women. But as Dr.

Renée A. Beach discussed during

her presentation on hair and

scalp disorders at Skin Spectrum

Summit in Vancouver, a minority

of men, particularly men who

wear turbans, report symptoms

of the condition.

“As a dermatologist, we often

look before we ask, and when we

look, we see that there is loss of the

frontal hairline, with a fringe pattern

[of hair] remaining at the edge of the

front,” Dr. Beach said, describing the

symptoms of traction alopecia.

Female patients will show signs

of gradual hair loss as a result of a

history of wearing swept-back hairstyles,

sleek ponytails and top knots.

According to Dr. Beach, when you

question these patients, they will

admit that when the hairstyles go in,

they are painful. But both female

and male patients often accept the

pain as part of the styling process.

Signs of traction alopecia include

the fringe hair loss along the

edge of the frontal scalp. There is retained

vellus or small terminal hairs

that simply do not get swept up into



the style. A trichoscopy can show

specific features, but this is a clinical,

bedside diagnosis that doesn’t require

further investigation.

Male patients, who are observing

Sikhs wearing turbans, are at a

greater risk for traction alopecia.

During her talk, Dr. Beach showed

examples of a dermatologist based

in India using the process of inserting

hair grafts and hair plugs in an

attempt to cure a case of traction

alopecia in male patients.

Dr. Renée A. Beach

To avoid further hair loss, patients

need to undergo significant

modification to the way they wear

the turban so that the condition

does not recur.

“Patients who are wearing turbans

or hijabs are encouraged not

to pull them tightly along the hair,”

said Dr. Beach. “Hairstyle modification

is paramount, but there is offlabel

use of minoxidil 5 per cent

foam, which can certainly help in a

subacute situation.”

Traction alopecia is a reversible

form of hair loss; however, at later

stages, a hair transplant may be the

only option for patients.


Diagnostic dilemmas and treatment

options in Afro-textured hair

Dr. Renée A. Beach

Patients with Afro-textured (AT) hair can have a

variety of issues, including seborrheic dermatitis,

traction alopecia and androgenetic alopecia.

During a talk on hair and scalp disorders at Skin

Spectrum Summit in Toronto, Dr. Beach discussed diagnostic

and treatment options for patients with

conditions related to AT hair.

Seborrheic dermatitis mainly affects the scalp, causing

scaly patches, red skin and dandruff. For treatment,

Dr. Beach recommends the use of a triple-threat therapy

including an anti-yeast, anti-inflammatory medication

and, in some cases, debris removal.

“I have a discussion with [patients] about increased

washing, at least temporarily. I ask them to wash their

scalp twice a week, which I know is really a lot for Afrotextured

hair types,” she said. “Also, [I ask them to] consider

the use of ciclopirox lotion, if they need to, a few

nights a week.”

Mometasone lotion is an option to aid with itching,

and scaling can be done with a 2% salicylic acid compound.

Although the recurrence of seborrheic dermatitis

can be limited by washing and rinsing the scalp, traction

alopecia requires patients to modify their hairstyle.

Traction alopecia is the gradual receding of the hairline.

There is hair at the front of the hairline and then

there are patches of hair with a noticeable regression.

The condition can be caused by wearing the hair in

slicked-back updos and top-knot buns.

“Patients will admit, sometimes reluctantly, to

headaches, tenderness, sometimes broken hairs with

certain hairstyles. And typically, they get a fringe sign [of

hair loss]. Patches of hair along the hairline [are] a dead

ringer for traction alopecia,” said Dr. Beach.

In addition to hairstyle modifications to reduce tension

on the scalp, Dr. Beach recommends the off-label

use of a 5% minoxidil foam. Traction alopecia is reversible

if diagnosed and treated in the early stages.

Weathering and trichorrhexis nodosa—defects in the

hair shaft—occur when there is a lack of hair growth. Hair

strands appear like broomstick hair. Patients also have

broken shafts, simple knots and complex knots throughout

the scalp. The hair has been weathered, which is

caused by heating the hair strands with a blow dryer or

ceramic straightener.

“When we heat the hair strands, they literally get air

bubbles in the shaft, and the air bubbles are tied to

breakage,” said Dr. Beach. “When patients with Afro-textured

hair dry comb their hair without any sort of product

on their hair, it can amount to a daily haircut in terms of

the breakage that they sustain.”

She suggests air-drying the hair and minimizing

the friction with a seamless comb. Products with

“slip” that contain ingredients such as glycerine, as

well as trimming off dead ends, can be helpful in

treatment.

Androgenetic alopecia is a type of hair loss common

in middle age. Affecting 40% of females and 50% of

males, androgenetic alopecia is gradual and progressive

and can be described as follicular miniaturization. Thicker

hairs turn into vellus hairs and whisk away.

This type of hair loss is a combination of genetics,

heritage and androgen activity.

Dr. Beach suggests a 5% minoxidil foam for treatment

and notes that if spironolactone is prescribed to

patients, there is a dosage difference between men and

women.


SKIN

SPECTRUM SUMMIT

CHAIRS &

FACULTY

Dr. Renita Ahluwalia is a staff dermatologist

at Women’s College Hospital

in Toronto.

Dr. Afsaneh Alavi is a dermatologist at

York Dermatology Clinic and Research

Centre in Richmond Hill,

Ont., and is the Past President of

the Canadian Hidradenitis Suppurativa

Foundation.

Dr. Andrew F. Alexis is Chair of the

Department of Dermatology at

Mount Sinai West in New York, and

Director of the Skin of Color Center

at Mount Sinai St. Luke’s. He is also

an associate professor of Dermatology

at the Icahn School of Medicine

at Mount Sinai.

Dr. Haneef Alibhai is the Medical Director

of MD Cosmetic & Laser clinic in

Vancouver, and a Clinical Instructor

in the University of British Columbia’s

Faculty of Medicine.

Dr. Renée A. Beach is Head of the

Alopecia Clinic at Women’s College

Hospital in Toronto.

Dr. Katie Beleznay is Director of the

Vancouver Acne & Rosacea Clinic

and a dermatologist at Carruthers

& Humprey Cosmetic Dermatology

and Seymour Health Centre in

Vancouver.

Mariam Botros is the Chief Executive

officer of Wounds Canada (formerly

known as the Canadian Association

of Wound Care).

Dr. Isabelle Delorme is a dermatologist

based in Drummondville, Que.

In addition to her clinical activities,

she devotes time to Continuing

Medical Education and

operates her own research centre

dedicated to clinical research in inflammatory

diseases.

Dr. Maha Dutil is a dermatologist in

private practice, a consultant at

Women’s College Hospital in

Toronto, and Assistant Professor of

Medicine in the Dermatology Department

at the University of

Toronto.

Dr. Marissa Joseph is a pediatrician

and dermatologist and is the Medical

Director of the Ricky Kanee

Schachter Dermatology Centre at

Women’s College Hospital in

Toronto. She also works at the

Hospital for Sick Children where

she manages children with complex

dermatologic disease.

Dr. Sunil Kalia is a dermatologist and

the Co-Director of the Clinical Trials

Unit at the Skin Care Centre in

Vancouver.

Dr. Brian Kunimoto is the founding

Director of the Vancouver General

Hospital Wound Healing Clinic

from 1990 to present. He has a special

interest in wound bacteriology.

Dr. Monica K/ Li is a dermatologist

practicing at City Medical Aesthetics

Center in Vancouver and at The

Skin Doctor/Enverus Medical in

Surrey, B.C.

Dr. Catherine Maari is Associate Professor

at the Faculty of Medicine at

the University of Montreal and

practices dermatology at the

CHUM (University of Montreal

teaching hospital) and Saint-Justine

Hospital in that city.

Dr. Danielle Marcoux is a Clinical Associate

Professor at the University

of Montreal and dermatologist at

CHU Sainte-Justine in Montreal.

She is a founder and past-president

of the Camp Liberte Society, a

camp for children with dermatologic

disorders.

Dr. Kevin Pehr teaches at Jewish General

Hospital/McGill University in

Montreal, where he is Chief of Cutaneous

Lymphoma, and operates a

private practice that encompasses

medical, surgical and aesthetic

dermatology.

Dr. Shafiq Qaadri is a Toronto-based

family physician, Continuing Medical

Education (CME) lecturer,

medical writer and broadcaster.

Dr. Jaggo Rao is founder of the Rao

Dermatology Centre in Edmonton

and a full Clinical Professor of

Medicine at the University of Alberta.

Dr. Jason Rivers is a Clinical Professor

of Dermatology at the University of

British Columbia. He practices

medical and cosmetic dermatology

at Pacific Derm in Vancouver, and

is President of the Acne and

Rosacea Society of Canada.

Dr. Gary Sibbald is a dermatologist

and internist with a special interest

in wound care and education.

He is a Professor of Medicine and

Public Health at the University of

Toronto and an international

wound care key opinion leader (educator,

clinician and clinical researcher).

Dr. Jerry Tan is an Adjunct Professor at

Western University, Windsor campus

and practices general dermatology

in Windsor, Ont. He is the

Medical Director of Healthy Image

Centre for Aesthetic Dermatology

and Windsor Clinical Research Inc.

Dr. Marcie Ulmer is a dermatologist at

Pacific Derm in Vancouver where

she has a comprehensive medical

and aesthetic dermatology practice.

She is a Clinical Instructor in

the Department of Dermatology

and Skin Science at UBC.



Diagnosing and Tx options for hyperpigmentation

Dr. Jaggi Rao

HYPO- &

HYPER-

PIGMENTATION

When dealing with patients

suffering from hyperpigmentation,

Dr. Jaggi Rao

recommends that practitioners

start by looking at why the skin is

hyperpigmented. Dr. Rao discussed

the consultation process

and treatment options for patients

with hyperpigmentation

during his presentation at Skin


There are two different categories

of hyperpigmentation:

melanotic or melanocytotic, according

to Dr. Rao. Melanotic hyperpigmented

conditions have too many

melanosomes compared to the

baseline, whereas melanocytotic hyperpigmentation

occurs when there

are excess melanocytes.

Melanotic conditions include

freckles, melasma and facultative

pigmentation. Melanocytotic symptoms

include different types of

Dr. Jaggi Rao

moles, nevus of Ota and Ito, blue

nevus and lentigines.

Using the Fitzpatrick skin phototype,

Dr. Rao suggests that doctors

begin the consultation process

by assessing the patient’s baseline

pigment, the level of pigmentation

without the disorder.

“This is reflective of the constitutive

epidermal pigmentation

that a person would have,” Dr.

Rao explained. “People who have

darker skin types … have more labile

melanocytes, and if you are

too aggressive with the treatment,

you can cause more pigmentation

or post-inflammatory hyperpigmentation.

Typically, this will happen

for Fitzpatrick skin type III to

VI.”

To achieve synergy in treatment,

Dr. Rao suggests a multiproduct

approach to effectively

treat hyperpigmented skin.

“If you can go ahead and both

prevent further pigment gain and

promote loss and do it in multiple

levels, then we will be able to have

better and safer therapy,” Dr. Rao

said.

Multi-layer therapy is another

treatment option for hyperpigmentation

Dr. Rao discussed.

Utilizing enzyme inhibitors of

the melanin pathway as well as

melanin transfer, exfoliants and antioxidants

can treat the pigments

that are excess not only in the epidermis

but also in the dermis.

“We now know that infrared radiation

can also cause free-radical

accumulation, and that might contribute

to damage,” said Dr. Rao.

Although Dr. Rao focused his

presentation on topical agents for

the treatment of hyperpigmentation,

he acknowledged that different

types of sunscreens as well as multimodality

therapy can be used to

treat the disorder.

“You can use a lot of this with

other modalities, such as laser therapies,

peels and so forth, as long as

you know how to do it properly,

you’re well trained and you have

that comfort level,” suggested Dr.

Rao.

Dr. Rao’s presentation was supported


grant from Vivier Pharma.



Hyperpigmentation and scarring

Dr. Katie Beleznay

hyperpigmentation is one of the top reasons

that skin of colour patients seek dermatological care,” said Dr.

“Post-inflammatory

Katie Beleznay a presentation at Skin Spectrum Summit in

Vancouver.

Dr. Beleznay emphasized how early and effective intervention is essential to

prevent pigmentary issues and scarring. Specifically, she discussed how keloid

scarring is more common in skin of colour. In addition, for skin of colour patients,

some hair-grooming products may cause or worsen acne, leading to what Dr.

Beleznay described as “pomade acne.”

After inflammatory wounds, the pigmentation of skin can occur. Post-inflammatory

hyperpigmentation is more common in darker-skinned patients,

whereas post-inflammatory erythema is more common in patients with

lighter skin types. Dr. Beleznay stressed that these skin discolourations, although

they are not true scars as the skin is not pitted or depressed, can

last for years. Therefore, “it is important to set up expectations, how to treat

this, when will it fade, so [patients] are not thinking it is going to be gone the

next day,” said Dr. Beleznay.

Epidermal lesions may persist for up to six to 12 months, but dermal hyperpigmentation

can last for years and may be more disconcerting than acne. Facial

acne scarring occurs in 95% of patients and develops within 12 weeks. Dr.

Beleznay described how facial acne scars can manipulate the perception of an

individual, presenting a survey that found that people with clear skin are more

often associated with positive traits.

Dr. Beleznay suggested the use of oral antibiotics, which can be less irritating

to the skin than topical therapies. She named isotretinoin as a potentially

remissive treatment for acne, which was found to be safe and effective

in African-American, Middle Eastern, Asian and Asian-Indian populations.

Isotretinoin reduces sebum production by 70%, reverses follicular hyperkeratosis

to normalize epidermal differentiation, reduces P. acnes and inhibits

the inflammatory reaction, which reduces the amount of neutrophils attracted

to the troubled site.

In terms of scarring with the use of isotretinoin, Dr. Beleznay advised

that “less scarring develops in those receiving isotretinoin early in their disease

process.”

Dr. Beleznay stressed that it is important to be clear with patients as treating

acne and acne scarring can be an expensive and lengthy endeavour.

Light patches on the trunk

may turn out to be progressive

macular hypomelanosis


In his presentation titled “Diagnoses

Not to Miss” at Skin

Spectrum Summit in Montreal,

Dr. Andrew F. Alexis provided information

on several tricky skin

conditions that can easily be mistaken

for something else.

Many of these conditions, he said,

are not “everyday” conditions that dermatologists

encounter in their practice.

However, one of the more

common, although often misdiagnosed,

conditions he spoke about was

progressive macular hypomelanosis

(PMH).

This condition usually appears as

white or light-coloured patches on the

patient’s trunk.

“Usually, when we see these little

hypopigmented macules that coalesce

to patches on the trunk, the diagnosis

is pretty straightforward: we think

tinea versicolor,” said Dr. Alexis.

But not all of these types of

patches on the trunk are tinea versicolor,

he said.

PMH also presents as hypopigmented

macules that coalesce to

patches that appear on the chest and

back.

“You often try to treat it as tinea

versicolor. You give [patients] every

antifungal known to man, and it just

doesn’t go away,” he said.

With tinea versicolor, fine scales

are often observed, but not with PMH.

In cases where no scale is observed

and antifungals are ineffective,

it’s often PMH, he said.

Unlike tinea versicolor, the condition

is not caused by yeast, which triggers

a fungal infection. Instead, PMH is

a bacterial infection, which he said is

thought to be mediated by the bacteria

P. acnes, also known as C. acnes.

The P. acnes bacteria can be found

using a Wood’s lamp, under which it

fluoresces.

According to Dr. Alexis, treatment

should be directed at the P. acnes

bacteria, which means using either a

topical benzoyl peroxide wash or topical

clindamycin formulations.

Resolution should happen in approximately

12 weeks, he said.

For best results, Dr. Alexis recommends

phototherapy, such as narrowband

UVB, in addition to topical

antimicrobial therapy.

“With that I hope that I have

helped to broaden the differential of

common presentation of dark spots

and light spots and patients of colour,”

he said.



Tyrosinase activity contributes to hyperpigmentation

Dr. Renée A. Beach

Increased activity of the tyrosinase enzyme

is a contributing factor to skin dyspigmentation

according to Dr. Renée A. Beach, who

spoke at Skin Spectrum Summit in Montreal.

“When we think about hyperpigmentation, what

we are really thinking about is the enzyme tyrosinase,”

said Dr. Beach. If a person’s trigger is ultraviolet

light, for example, this “activates the tyrosinase

enzyme to enhance or increase melanin production....

Our bodies are actually doing this as a means

of trying to protect our skin; however, what happens

is, in a sense, overcompensation, which leads to dyspigmentation.”

Dr. Beach spoke about ways to inhibit tyrosinase,

resulting in an overall more even skin tone.

According to Dr. Beach, benzene-1,4 diol (hydroquinone)

is the most effective treatment option

for improving dyspigmentation. “It is used for a variety

of conditions,” she said. “I use it in practice for

Scleroderma has a similar

presentation to vitiligo in

patients with skin of colour


Vitiligo is not the only cause of hypopigmentation in patients with

skin of colour, said Dr. Andrew F. Alexis in a presentation at Skin


“When there is a striking contrast of normal and involved skin and it has that

sort of milk-white appearance, it is usually vitiligo. However, not all depigmented

patches on the skin are vitiligo. We have to keep an open mind and consider

other diagnoses,” he said.

“Light patches, loss of pigment on the face, [are] a pretty common scenario


post-inflammatory hyperpigmentation; it is also

used under supervision for melasma.” Benzene-1,4-

diol is an aromatic organic compound, and when

used in the range of 2 to 4%, it inhibits the activity of

tyrosinase.

“Two per cent [benzene-1,4-diol] can be used on

all skin types to help prevent and treat hyperpigmentation,”

stated Dr. Beach. She emphasized the importance

of educating patients on the process of

benzene-1,4-diol treatment, stating that patients

need to understand that the effects are gradual and

it can take anywhere from three to four months to

produce results.

Dr. Beach also said that “patients with olive,

brown or black skin will probably notice a greater

benefit because they are generally starting off from a

higher level of dyspigmentation in many cases because

their skin depigments more readily.”

She also mentioned the importance of properly

using sunscreen to both prevent further damage

and to inhibit tyrosinase. “When we use something

like sunscreen or sunblock, tyrosinase activity is alleviated

or decreased. You get a decreased melanin

production; you get skin protection and an overall

more even skin tone,” said Dr. Beach.

Dr. Beach recommends that patients use at

least a broad-spectrum SPF 45 sunscreen because

she feels most people do not apply their sunscreen

thickly enough. “My rule is SPF 30 does not really

manifest as an SPF 30,” said Dr. Beach, meaning that

a higher SPF is needed.

“We want to help [a patient’s] pigmentation, but

part of the issue is making sure we prevent further

dyspigmentation, which is why sunscreen is an important

element,” said Dr. Beach.

Dr. Beach’s presentation was supported

through an unrestricted educational grant from

Vivier Pharma.

when treating patients with skin of colour,” noted Dr. Alexis. “While vitiligo can certainly

affect the periorificial areas of the face, ... you have to look at the whole patient,”

not just the affected areas.

During his presentation, Dr. Alexis described the case of a patient who was

referred to him with a diagnosis of vitiligo; however, further evaluation revealed

that she actually had scleroderma.

The patient, an African-American woman, had patches of hypopigmentation

on her face and trunk, but, most importantly, she had taut, bound-down skin and

a tapering of her digits.

Noted Dr. Alexis: “When scleroderma presents in darker skin, it often presents

with an associated pigment change, which might be the first thing the patient

notices, and the thing that would drive the patient to a physician or, specifically, a

dermatologist.”

Systemic sclerosis has a higher rate of prevalence in women of African-American

ancestry, usually with a worse prognosis compared to other groups, said Dr.

Alexis.

Dr. Alexis provided another example of a patient who was also diagnosed


Dr. Andrew F.

Alexis

Dr. Danielle Marcoux

Dr. Isabelle Delorme

with vitiligo prior to seeing him, but

clinical examination, biopsies and a

serological workup were consistent

with scleroderma.

After looking at the whole patient,

he saw “areas with some hyperpigmentation

and hypopigmentation.... In

the area with the loss of pigmentation,

there is some follicular sparing, creating

a salt-and-pepper appearance,”

said Dr. Alexis. According to Dr. Alexis,

“this salt-and-pepper appearance, especially

involving the trunk, is a very

striking and common presentation of

scleroderma in darker-skin patients.”

Dr. Alexis also stressed palpating

the skin. “Don’t forget the importance

of palpation. Don’t just stand at the

edge of the bedside or doorway when

diagnosing what seems to be a pigmentary

concern.”

Dr. Marcie Ulmer

Dr. Kevin Pehr

Dr. Katie Beleznay

Dr. Haneef Alibhai

Dr. Shafiq Qaadri



KELOIDS,

MYCOSIS


Controlling onychomycosis

and toe web bacteria

Dr. Gary Sibbald

In his presentation at Skin Spectrum Summit in Toronto, Dr. Gary Sibbald

spoke about preventing diabetic foot ulcers by first outlining

treatment for onychomycosis and toe web bacteria.

“The average wear and tear in the foot for someone who lives an average

lifespan is the equivalent of walking 115 thousand miles,” said Dr. Sibbald.

It is no surprise, then, that 75% of the population experiences foot pain at

some point, said Dr. Sibbald.

Many other physical ailments can first manifest in the foot, he said. Those ailments

include arthritis, peripheral vascular disease, cardiac disease and diabetes.

“A foot out of alignment results in discomfort and pain in the ankle, the knee,

the hip and the back,” he said.

For patients with diabetes, 85% of amputations begin with a foot ulcer, said

Dr. Sibbald. For this population, an onychomycosis infection can be especially

concerning.

“In a population of persons with diabetes, 1 per cent of them have gangrene,”

said Dr. Sibbald. For those with diabetes and onychomycosis, 5% have gangrene,

he said.

He noted that 2% of persons with diabetes and a foot ulcer will develop gangrene.

If they have diabetes, a foot ulcer and onychomycosis, the incidence goes

up to 6%.

When taking a nail clipping for culture, the most important part is to get the

subungual debris, said Dr. Sibbald.

“This is really where most of the fungus is. About 30 per cent can be falsely

negative on culture, so you may need three cultures. But if we see a KOH [test]

with fungal filaments, that’s enough,” he said.

There are 22 different conditions that can mimic fungus, Dr. Sibbald said. He

offered a piece of advice for identifying tricky cases.

“The most important pattern is distal streaking where it’s wider distally than

proximally,” he said.

If unsure about the diagnosis, he recommends 1% hydrocortisone powder

and antifungal cream.

Dr. Sibbald also talked briefly about bacteria between the toes. The tightest

toe web is typically between the fourth and the fifth toe, he said.

In patients with diabetes, this can become a problem area for bacterial and

fungal infections, so he recommends

checking in this area first before going

proximally to check the others.

“Bacteria, specifically Staph and

Strep, can get in. That causes lymphangitis

and subsequent cellulitis,

and these people end up in emergency

departments,” he said.

He recommends using 10% povidone-iodine

on this area by applying it

with a cotton applicator.

“It’ll control gram-positive, gramnegative

and anaerobic bacteria; it

will treat dermatophyte fungus,

yeast and viruses. This is a way to

keep that space clean,” he said. He

also recommends breathable

footwear for patients with this condition

Dr. Gary Sibbald


Treatment of keloids

Dr. Renée A. Beach

The best treatment for keloids is to try to avoid them altogether, according

to Dr. Renée A. Beach, who presented on scarring at Skin


“The problem with keloids is that we do not have great treatments,” Dr.

Beach explained. “We have treatments that help and treatments that work for

a subacute period, whether that is three to six months, but I always tell people

prevent it so that we do not have to have this conversation.

“If you know it is in your family or you know you have a tendency, try to

prevent it or avoid practices that are going to help form keloids.”

On top of there being no permanent removal of the scar, it is also difficult

to find surgeons who will excise keloids because they can recur in some capacity.

For a cost-effective treatment option, Dr. Beach suggests using clobetasol.

She prescribed twice-daily applications of clobetasol cream to a 19-year-old

female patient without extended health benefits.

“This is an instance where you want to use your side-effects as your therapeutic

effect,” Dr. Beach said. “Often times you will hear a patient say, ‘Oh, I

don’t want to use a steroid because it is going to thin my skin.’ This is the time

we say, ‘Exactly; this is what we are hoping for.’”

Patients using this regimen for three to five months will not improve the

colour of the scar. A Caucasian patient will end up with a flat, red scar but will

not have a keloid anymore. A patient with brown, olive or black skin can experience

hypopigmentation, according to Dr. Beach.

“Clobetasol treatment is certainly OK, as long as your patient understands

you are not doing anything to improve the colour of the keloid, and that is

across skin colours,” she said.

For a patient with an unlimited budget, Dr. Beach suggests consulting a

plastic surgeon to see if the keloid can be removed cosmetically. Therapy with

pulsed dye laser can be used to mitigate some of the redness. CO2 ablation is

also an option.

Additionally, for a patient not concerned with costs, Dr. Beach recommends

a three- to six-month course of imiquimod.

“I usually ask them to use it about four to five days a week and see them

back in about four to six weeks,” she said. “The patient needs to understand it

is going to look worse before it starts to look better. [The prescription] will

need a couple of refills; depending on their drug plan, that can get expensive.”

Dr. Jason Rivers



PSORIASIS

How to spot psoriasis in

Fitzpatrick skin types V and VI


As part of his talk on psoriasis

in skin of colour at Skin

Spectrum Summit in

Toronto, Dr. Andrew F. Alexis detailed

a number of ways that the

skin condition can present differently

in darker skin.

This was part of a larger talk debunking

myths surrounding the prevalence

of psoriasis in darker skin and

comparing the disease’s colour presentation

and shape across skin

shades.

He began his talk by discussing

how psoriasis in darker skin has come

to be understood better over the

years. Although it was once considered

a “rare” skin condition in people

of colour, Dr. Alexis debunked that

myth.

“This was due to underreporting,”

he said. “Thankfully, more recent studies

have shown that the prevalence of

psoriasis in darker skin is far from

rare; in fact, these studies have shown

the prevalence rate [to be] in the one

to two per cent range.”

As far as psoriasis in darker skin

types goes, Dr. Alexis said that sometimes

the presentation is classic; it is

usually sharply demarcated, brick red

or pink, and can have plaques with silvery

scales.

“However, once we get into the

more darkly pigmented ranges of the

spectrum, including Fitzpatrick type V

and type VI, the redness may be

masked by melanin and may start to

look a little more purple or violaceous

than red,” he said.

The sharp lines of demarcation

and characteristic scale will still be

present, he said, but because of the

purplish hue, it can be difficult to distinguish

from lichen planus, another

papulosquamous disorder.

One factor that can help differentiate

the two disorders is the location

on the body where it is found.

“Lichen planus tends to favour the

flexural side of extremities, including

the wrist and forearm, while psoriasis

will be more extensor,” he said.

The shapes of the lesions of the

two disorders differ as well, he said.

“In lichen planus, plaques tend to

be more flat topped and polygonal.”

Hyperpigmented lesions ranging

from dark brown to red brown may

appear on darker skin as opposed to

red lesions on lighter skin.

Certain skincare practices may

also hide the character of the scale. In

his presentation, Dr. Alexis gave the

example of a patient who had a nightly

routine of applying petrolatum ointment

on his scaly plaques and scraping

off the scales with a kitchen knife.

“This is a lesson to be learned as

far as asking about what patients are

doing and considering how that might

impact the clinical appearance of the

plaques in front of us,” he said.

Common areas,

modalities of

treatment and

subtypes of Pso

Dr. Gary Sibbald

In his presentation at Skin Spectrum

Summit in Toronto, Dr.

Gary Sibbald spoke about topical

treatments for psoriasis. He

discussed the “many faces of psoriasis,”

including the subtypes; the

different modalities of treatment;

and the common areas at which

psoriasis tends to manifest itself.

Psoriasis subtypes include plaque

psoriasis, guttate psoriasis, pustular

psoriasis and erythrodermic psoriasis,

said Dr. Sibbald. He went on to point

out that there is “‘A’ evidence for most

of what we do in psoriasis,” referring

to randomized controlled trials.

He said that for any patient with

5% or less psoriasis coverage, he

would recommend starting with



Treating mild, moderate and severe psoriasis

Dr. Catherine Maari

Dr. Catherine Maari

In her presentation at Skin Spectrum

Summit in Montreal, Dr.

Catherine Maari spoke about

treating psoriasis in its different

forms: mild, moderate and severe.

Topical treatments can work best

for mild psoriasis, whereas moderate

psoriasis can respond well to phototherapy,

she said. For severe psoriasis,

she recommends biologics.

She outlined a few topical treatment

options.

“Corticosteroids are still the gold

standard,” she said.

She also mentioned a topical vitamin

D analogue, calcipotriene. “[Calcipotriene]

cream does not exist

anymore; there is only the ointment.

For the patient who does not like

greasy treatment but says, ‘I do not

want a cortisone,’ this is the only thing

you can offer,” she said.

She also said that doctors can try

a mix of betamethasone dipropionate

and calcipotriol.

For hands and feet, she recommended

using a “very strong” cortisone,

such as halobetasol propionate, clobetasol

or betamethasone dipropionate.

She also emphasized that doctors

should tell their patients to pay no attention

to the percentages listed on the prescription

packaging as the potency of the

individual corticosteroid matters more.

“They will see .05 per cent [of a

high-potency corticosteroid] and think

it must be weak and apply that on

their face. Or they will see 1 per cent

hydrocortisone and … will think that is

stronger and apply that on their body,

and it does not work.”

Be very clear about which topical

is to be used on which part of the

body, she said.

That said, Dr. Maari expressed

her frustration with topical psoriasis

treatments in general.

“We have not had any great topical

treatments … come on the market

in the last 20 years,” she said.

Dr. Maari said that for her, the

unmet need in psoriasis is more in the

mild to moderate range.

“For extensive psoriasis patients,

we have great treatment,” she said.

For scale psoriasis, which she said

can be difficult to treat, she has found

good results with fluocinolone in oil

form, although she noted that it is a

very greasy treatment.

Finally, she touched on biologic

treatments for more extensive cases.

Biologics are very effective treatments

with minimal side-effects, she

said. The downside is that they are

very expensive.

“The problem is they cost $20,000

a year, and the patient needs to be on

the treatment forever,” she said.

Despite the cost, biologics can almost

completely clear severe psoriasis,

she said.

topical corticosteroids.

“They only work for a very short period

of time,” said Dr. Sibbald. Salicylic

acid increases penetration, and he even

recommended using petrolatum, which

he said has an antipsoriatic effect.

He also suggested that additional

supplemental treatments should include

local physical modalities, ultraviolet

light, biologics and systemic agents.

In his list of treatments, he also mentioned

methotrexate, although he

noted it has B rather than A evidence.

Dr. Sibbald went on to describe

the differences between the various

topical treatment vehicles for psoriasis:

lotions, creams, ointments,

patches, pastes and gels.

“We always talk about these

terms, but do we really know what

they mean?” he asked the audience.

A lotion is a powder in water, a

cream is composed of oil in a continuous

water base, an ointment is water

with a continuous oil base, a patch is

occlusive delivery, a paste is a powder

in an ointment and a gel is a powder

in a lattice, said Dr. Sibbald.

Ointment vehicles do have an

antipsoriatic effect, he noted. He also

warned against compounding a gel.

“A gel is an unstable modality that

must not be compounded,” he said.

Common sites where psoriasis

manifests or “areas of trauma,” said Dr.

Sibbald, include the elbows, knees, scalp

and torso. Less common sites include

the genitals and the nails. If the nails are

involved, he said, be aware that this

could point to psoriatic arthritis.



Clearing of psoriasis plaques may not mean the

end of treatment for patients with skin of colour


In a presentation on psoriasis in pigmented

skin delivered at Skin Spectrum Summit in

Montreal, Dr. Andrew F. Alexis asked his audience

to keep an open mind while diagnosing

the skin disorder and to take into account the

patient’s concerns about hyperpigmentation.

“You need to really look head to toe at the patient

and, if it just does not fit, have a low threshold

for biopsy,” he said while referring to a patient with

sarcoidosis, which he called “one of the great imitators”

of psoriasis in darker-skinned patients.

The quality of life impact of psoriasis can be

greater in people with skin of colour, he said, which

makes it even more important for a dermatologist to

get the diagnosis right the first time and to take into

account some cultural and aesthetic concerns as

well.

Dr. Alexis explained why the quality of life is impacted

more so in people with skin of colour.

“It is probably that the associated pigmentary alterations

contribute to a greater quality of life impact,”

he said.

Some cultural aspects to perceiving the disease

may also play a role, he explained.

To demonstrate this, he showed an example of

a patient whose psoriatic scaling had improved with

treatment, along with redness and other symptoms,

but who was left with hyperpigmented patches on

her legs.

“In a research study, she might be considered a

treatment success, but in real life, she doesn’t think

the treatment is even working because functionally

she still can’t comfortably expose her skin.”

Clearing up both plaques and pigment alteration

can become part of the treatment in darkerskinned

patients, he said. This persistent pigment

alteration may lead to a much longer treatment period

for patients with skin of colour.

He stated that after clearing the psoriasis, he will

start working on the hyperpigmentation with topical

bleaching agents.

When it comes to data on the treatment of psoriasis

in skin of colour, Dr. Alexis said they are quite

limited.

“When you look at all of the studies, there is one

consistent theme: the demographics hover around

90 per cent Caucasians.”

For this reason, there are fewer data for patients

with skin of colour.

Dr. Alexis said has worked with the data that do

exist and has not found any safety or efficacy differences

in any of the treatments for psoriasis.

Regarding his clinical impression of treating hyperpigmentation

before it becomes a problem, Dr.

Alexis said this: “Early and appropriately aggressive

treatment might reduce the impact of the severity

and duration of hyperpigmentation.”

Signs of psoriasis

Dr. Jaggi Rao


changes may indicate

psoriatic arthritis

“Nail

as nails are an extension

of the skin itself,” said Dr.

Jaggi Rao in a presentation at Skin


Dr. Rao described psoriasis as

an immune-mediated chronic inflammatory

skin condition that impairs

the physical and emotional aspects

of an individual’s life. He states

that “nothing is destroying or attacking

the skin; it has to do with the influence

of the immune system to

create the reaction we see.” Dr. Rao

lists the five main types of psoriasis

as psoriasis vulgaris, guttate psoriasis,

pustular psoriasis, inverse psoriasis

and erythrodermic psoriasis.

Psoriasis vulgaris is the most common

as it is seen in 80 to 90% of all

psoriasis cases. Guttate psoriasis is

caused by the presence of group A

streptococcus. Pustular psoriasis,

identified through the studded pustules

commonly found on palms and

soles, and erythrodermic psoriasis,

which involves blood vessel dilation

(which can change thermal regulation),

are both types that require

emergency urgent care.

Psoriatic arthritis can be identified

through the change in appearance

of the nails. Dr. Rao explained

that nails “do not have blood vessels

but have keratin and different forms

of skin cells.” Some changes that

occur can be pits and grooves,

white-yellow discolouration, separation

of the nail from the nail bed, a

thickened plate, scales of the nail

bed, splinter hemorrhages, pustules


and more fungal infections. He reported

that these symptoms are

usually not unilateral and would be

visible on the hands and feet.

With psoriatic arthritis, Dr. Rao

advised that topical treatments do

not work particularly well as the nail

functions as a barrier to the treatment.

Instead, Dr. Rao suggested injection-based

or oral treatments.

Dr. Rao said that in the past,

psoriasis would be treated with a series

of topical, systemic and phototherapy

treatments; however, he

now believes in using more aggressive

therapies earlier, as long as

they’re safe. He cautioned that patients

need to qualify for these more

extreme treatments, which he does

by first using systemic treatments

plus light therapy. “If that fails, they

qualify to move on to the more intensive

treatments,” said Dr. Rao. As

with any treatment process and

plan, Dr. Rao emphasized that the

main goal is patient satisfaction.

Treating scalp Pso in women of African ancestry


When treating a woman

of African ancestry with

psoriasis of the scalp,

Dr. Andrew F. Alexis recommends

that doctors take into account

differences in hair

structure and in hair-care practices.

“When prescribing topical

therapy in particular, we have got

to go an extra step and think

about prescribing something that

will be compatible with this patient’s

hair type and hair-care regimen,

especially hair-washing

frequency,” said Dr. Alexis in a

presentation at Skin Spectrum

Summit in Vancouver.

Generally, he said, hair-washing

frequency is lower in women of

African ancestry, for a variety of

practical and cultural reasons.

Once-weekly or once-everyother-week

washing is common, he

said.

“To prescribe something that involves

washing the hair every single

day would not be aligned with this

patient’s normal hair-care practices,

so we have to come up with a regimen

that involves a good compromise.”

He said that this compromise

could be something such as onceweekly

washing with a medicated

shampoo and using potent topical

leave-on products on the scalp for

the rest of the week.

It is best to get the patient’s

feedback on what they would prefer

as far as dosing regimen and

Dr. Alexis

vehicle, whether they prefer a

water-based, an oil-based or

some other formulation, said Dr.

Alexis.

“Breaking down the various options

and getting the patient’s own

input on the selection goes a long

way for adherence and better outcomes,”

he said.

One product that is particularly

well suited for treating scalp

psoriasis in this population, he

said, is a fixed-combination formulation

of calcipotriene and betamethasone.

Among its advantages are that it

does not dry out the hair and is easy

to leave in without washing.

“However, particularly in more

severe cases of scalp psoriasis, we

may need to consider non-topical

therapies,” he said.

One treatment that is particularly

effective against scalp psoriasis

is secukinumab, he noted.

In summary, Dr. Alexis said

that he advises doctors not to forget

to convey to the patient that

“you are in with them for the long

haul” and to give them realistic

timelines.

“Take into account hair-care

practices and query patients about

traditional cultural practices that

may influence the presentation of

their disease,” he said.



ROSACEA

Treatment options for rosacea

Dr. Kevin Pehr

Although there is no lab test

to diagnose rosacea, there

are several treatment options,

which Dr. Kevin Pehr discussed

during his talk at Skin


“If the patient understands

therapy-quality conditions, they’re

not expecting cure,” Dr. Pehr said.

“It is chronic. It is not adult acne.”

To begin with, Dr. Pehr recommends

asking questions to gain an

understanding of what is most worrisome

to the patient.

“Ask, ‘What aspect bothers you?

Is it the flushing? Is it the broken

blood vessels? Is it the itchy feel? Is

it the papules and pustules? Is it the

eyelids?’ Maybe they all bother the

patient, but find out what bothers

them the most and focus the treatment

on that to start,” he said.

When treating the nose area,

Dr. Pehr recommends spraying

oxymetazoline nasal spray on the

skin twice a day. The relatively inexpensive

treatment works about a

third of the time, according to Dr.

Pehr. Additionally, patients can use

brimonidine gel, an alpha-2 agonist,

which is applied in the morning and

works roughly 80% of the time. The

gel lasts about 12 to 13 hours before

wearing off.

For erythrotelangiectatic and

background erythema, Dr. Pehr suggests

laser therapy or intense

pulsed light, but cautions that this

treatment is expensive and is not

permanent.

There are various options when

it comes to treating papules and

pustules, including ivermectin,

which is expensive but effective.

Azelaic acid can be used for treatment

and is also good for post-inflammatory

hyperpigmentation but

can be a little irritating.

Although, in theory, low doses

of systemic antibiotics, such as

tretinoin or benzoyl peroxide, will

work for the treatment of papules

and pustules, Dr. Pehr avoids these

treatment options because they are

irritating for the patient.

With phyma, or bulging nose,

Dr. Pehr says isotretinoin may work

as a treatment option, but surgery

may be required.

When it comes to ocular

rosacea, Dr. Pehr says often patients

won’t think to ask their dermatologist

about the condition.

“Ask them about it,” he said.

“The patient will not volunteer. They

do not feel it is their business, especially

in my case. They say, ‘Well,

you’re a skin doctor; this is my eye

problem. Why say something to

you?’”

Dr. Pehr suggests that with

“good, hard treatment,” the patient

should see a response within the

first two months, but it could take

up to six months. It is important

that patients understand that the

treatment could clear their rosacea

symptoms for the rest of their life

but that they could also relapse

once the treatment stops.

Rosacea

management:

Early Dx

reduces

morbidities

Dr. Maha Dutil

Education and open dialogue

are crucial for doctors helping

their patient manage

rosacea symptoms, according to

Dr. Maha Dutil, who discussed

treatment options and things to

avoid during her talk on rosacea

management at Skin Spectrum

Summit in Toronto.

“Early diagnosis and treatment

will reduce morbidities,” Dr. Dutil

said. “Counsel on skin care, sun protection

and [avoiding] triggers. It

takes a lot of time, but unless [patients]

do all these things, your therapeutic

options do not work well.”

There are many topical treatments

available to patients, such as

metronidazole gel and 1% cream



and azelaic acid gel 15%, which can

be used for both acne and rosacea.

Ivermectin 1% cream and brimonidine

gel, which restricts the blood

vessels to help reduce redness, can

also be used. Benzoyl peroxide, an

acne medication, helps papulo, pustular

rosacea.

When the disease is more severe,

Dr. Dutil suggests using systemic

antibiotics. To avoid altering

the microbiomes, she says to use

only anti-inflammatory doses of

doxycycline. Isotretinoin can also be

used in treatment. For phymatous

rosacea and vascular lesions, lasers

can be used. Surgical interventions

are also an option for phymatous

rosacea.

Dr. Dutil says to avoid using an

acne wash with salicylic or glycolic

acid as it will aggravate rosacea

symptoms. Instead, use a gentle

cream. Additionally, sun protection

is important. Dr. Dutil suggests

using chemical-free sunscreens as

chemical sunscreens tend to aggravate

rosacea. Also, makeup can help

cover the redness of rosacea symptoms.

There is a study showing that

an antimicrobial dose of doxycycline

can produce similar efficacy and

safety in skin types IV to VI as well

as skin types I to III.

“Prescribe effective treatments,

topically and systemically, if

needed,” said Dr. Dutil. “Let’s reduce

the disparities in rosacea management.”

Rosacea underreported, underdiagnosed

in patients with skin of colour

Dr. Monica K. Li

The management of rosacea in light and dark

skin types is very similar according to Dr. Monica

K. Li, who presented on strategies to manage

rosacea symptoms at Skin Spectrum Summit in Vancouver.

“Unfortunately, because the entity itself is underreported

and underdiagnosed in those with skin of colour,

there is not a lot of data specifically looking at management,

and the efficacy of management strategies for this

patient population,” Dr. Li explained.

With the increased risk of post-inflammatory hyperpigmentation

in darker-skinned patients, physicians and

clinicians need to be vigilant when implementing lasers

and light-based therapies to ensure that this patient

population does not experience potential adverse effects

as much as possible.

The goal of rosacea management is to reduce papules

and pustules in patients, which can reduce the chronic inflammation

occurring on the face, leading to potential

scarring and post-inflammatory hyperpigmentation.

When using laser and light therapies, the goal is to

reduce superficial capillaries and to resurface the possible

phymatous changes that can result as rosacea progresses.

Dr. Li cautions practitioners to be careful when

choosing laser and light therapies for darker skin phototypes

because there is an increased risk of post-inflammatory

hyperpigmentation that can result as a sequela

of these interventions.

“I use a long-pulse 1064 nm laser, Nd:YAG. We can

also use a 595 nm pulsed dye laser to reduce the diffused

redness that can be seen on the face,” said Dr. Li.

“Because of the chronic nature of rosacea, usually a series

of treatments are required every one to two years

to improve some of the facial redness and symptoms

experienced by darker-skinned patients.”

For supportive measures to help both fair- and

dark-skinned patients, it is important to avoid triggers

such as spicy foods, alcohol and sun exposure when

possible.

Additionally, dermatologists should be advising and

helping patients to use photoprotection, particularly

with physical agents containing zinc oxide and titanium

dioxide, consistently. The use of bland emollients and

moisturizers is important because essentially all patients

with rosacea have hypersensitive skin.

When using a new skin-care product, patients

should apply the product to a test-spot area for a week

to determine tolerance prior to more generalized application

of the product on the entire face.

Patients should be counselled to use physical blockers

as opposed to chemical blockers. Chemical blockers

can be more irritating to rosacea patients with sensitive

skin. Also, patients should avoid alcohol-based exfoliating

products (astringents), which can further drive the

redness and irritation on facial skin.

Established options for rosacea management include

an oral 40 mg subantimicrobial-dose doxycycline

taken once daily. Studies show that this treatment

method has similar efficacy and safety for skin phototypes

I to III, as well as those with phototypes IV to VI. In

the U.S., a topical oxymetazoline cream is available for

the treatment of facial redness in both lighter and

darker skin phototypes.



When brown patches are not melasma


MELANOMA,

SUN

PROTECTION

In a presentation titled “Diagnoses

Not to Miss” at Skin Spectrum

Summit in Toronto, Dr.

Andrew F. Alexis sorted through a

number of cases in which his patients

exhibited pigmentation

symptoms that could easily be

misinterpreted as more common

diseases at first glance due to

their fairly standard appearance.

In some cases, skin hyperpigmentation

can be brought on by unusual

skin-care regimens or

reactions to other therapies, he

said.

“When one is presented with symmetrical

brown patches on the face,

the diagnosis is usually melasma, but

not always.”

He outlined a number of cases in

which these brown patches turned

out to be something different than expected.

Dr. Alexis proceeded to discuss a

case involving a 53-year-old African-

American woman with brown patches

on her face, which he said is a very

common complaint. He described her

patches, which appeared on the

cheek and temple, as being brown

with a purplish-grey hue. She also had

a past medical history of hypertension,

for which she was prescribed diltiazem.

“What else can it be?” he asked

the audience.

It turns out that diltiazem triggered

a photodistributed lichenoid

drug eruption, he said.

“After identifying the causative

agent — diltiazem in this case — discontinuing

it and switching to a chemically

unrelated antihypertensive, she

got better,” he said.

He noted that this purplish-grey

photodistributed lichenoid drug eruption

could also be caused by therapies

such as antimalarials, thiazide diuretics,

furosemide, ethambutol and tetracycline.

“When you see dark patches on

the face that aren’t quite brown but

[are] more greyish blue or lichenoid

looking, consider photodistributed

lichenoid drug eruption,” he said.

He used other examples to give

an idea of the process he went

through to find the correct diagnosis.

One case involved a woman with

post-inflammatory hyperpigmentation

brought on by months of harsh scrubbing

of her facial area “in an effort to

even her skin tone,” said Dr. Alexis.

“She was trying to treat hyperpigmentation

but induced hyperpigmentation

from her very irritating skin-care

regimen,” he said.

A second case he noted was a patient

with lichen planus pigmentosus,

which tends to be in a photodistributed

area, he said. Characteristics include

bluish-grey pigmentation on the

face, head and neck.

He used these cases as a lesson

to the audience to be thorough in

their investigation of the causes of a

patient’s symptoms.

“When thinking about the common

things we see in patients of

colour, it is easy to get into a little bit of

a rut. Not every brown patch on the

face is melasma, and not every white

patch is vitiligo,” he said.



The three basic methods for sun protection

Dr. Sunil Kalia

Dr. Sunil Kalia

The three basic forms of sun protection are

seeking shade, wearing protective clothing

and using sunscreen, but it is not always

that simple, according to Dr. Sunil Kalia.

In his presentation at Skin Spectrum Summit in

Vancouver, Dr. Kalia went over the finer details of

each form of protection.

Since the ozone layer protects from UVC, UVB

and UVA are the most worrying because they can

cause skin cancer, he said.

“UVB can cause direct DNA damage, and UVA

can cause indirect DNA damage,” said Dr. Kalia.

Moreover, unlike infrared light, UV light is not

warm, so it cannot be felt. UVB peaks around the

noon hours, so much of the key messaging for skin

protection centres around avoiding sun exposure

between 10 a.m. and 3 p.m., he said.

According to Dr. Kalia, simply avoiding the sun

during these times is the most effective way to protect

against damage. But if that is not possible, wearing

protective clothing and sunglasses and using

sunscreen are the next best options, in that order.

“Clothing gives good protection, but what is the

protection factor of something like a thin white T-

shirt? It’s equivalent to an SPF of about five,” he said.

Although that is not adequate, the T-shirt cannot

be wiped off and does not have to be reapplied, he

said. For clothing, he recommends darker shades,

heavier fabrics and tighter weaves. The type of fabric

matters too.

“Polyester, wool, then cotton,” he said. “For a pair

of jeans, the protection factor on that is 200 SPF,

which is amazing, but, of course, it is hard to wear

that thick pair of jeans when it is really hot.”

Although it is more expensive, UV protection factor

clothing also exists. This brought him to the subject

of sunscreens.

“When you see the sunscreen bottle, what are

you looking for?” he asked.

Most people look for SPF, but that is not the only

factor to consider, he said. UVA protection is also another

important factor to consider.

Although many sunscreen bottles will tell you to

apply 15 to 30 minutes before sun exposure, Dr.

Kalia said that is not necessary. Applying just before

going out will still work.

He also said that most sunscreens recommend

that the user reapply them every two hours, but that

is just an arbitrary number. It is better to reapply

sunscreen based on perspiration, if or when it is

wiped off or after swimming, he said.

It is also not necessary to rub it in deeply, he

said. A light application is sufficient.

Finally, he recommends using two tablespoons

of sunscreen for the full body and half of one teaspoon

for the face.

“That’s quite a bit of sunscreen,” he said. “You

could be going through a whole bottle of sunscreen

in one day if you’re doing it properly.”

You are invited to

join us at the 2020

Summit and

receive a discount on

registration fees.

See back cover

TORONTO

APRIL 18, 2020


8 am to 4 pm


Sickle cell disease may

complicate ulcers in patients of colour

Dr. Brian Kunimoto

WOUND

MANAGEMENT

In his presentation at Skin Spectrum Summit in

Vancouver, Dr. Brian Kunimoto spoke about sickle

cell disease and its complicating effects on venous

leg ulcers or livedoid vasculopathy in patients of

colour.

“Clinically, in dermatology, we see patients who have extremely

painful venous ulcers,” he said.

These ulcers can lead to a drastic decrease in quality of

life. A person with venous insufficiency can develop hypoxia

around the ankles, and this can trigger a sickle cell crisis, he

said.

“Which really is a vicious circle because you get the hypoxia,

you get the ulceration and then you get the sickle cell

crisis, which causes more hypoxia, and it just goes around

and around,” he said.

Dr. Kunimoto explained the difference between sickle

cell trait and sickle cell disease.

“Sickle cell trait is when the situation is heterozygous,

and it is an autosomal recessive inheritance of a single

amino acid substitution in the beta globin protein as part of

hemoglobin,” he said.

Patients who are heterozygous

have sickle cell trait. Patients who are

homozygous have sickle cell disease,

he said.

Approximately 300,000 infants

worldwide are born with sickle cell

disease each year, he said, the majority

coming from central Africa.

“This is truly a genetic disorder

that affects people of colour,” he said.

According to Dr. Kunimoto, one

of the effects of sickle cell disease is

that cells pile up.

“They get very sticky,” he said. “Red blood cells stick together,

they stick to platelets, they stick to white cells and

they stick to the walls of the vessels.”

This causes an increase in blood viscosity, which can

trigger thrombotic events.

“Thrombosis in the vessels becomes a real problem

with plugging and potentially something known as vasculopathy,”

he said.

Because of all this, ischemic injury can occur, which can

lead to reperfusion injury and a severe stimulation of inflammation,

he said.

A patient with ischemic changes may develop livedoid

vasculopathy, which Dr. Kunimoto said is less common.

Livedoid vasculopathy looks very different, he said. The

ulcers can look irregular in shape. When they heal, they heal

with atrophie blanche, which is associated with dilated

blood vessels and pigmentation, he said.

In managing a venous leg ulcer, he said first rule out arterial

disease by doing an arterial Doppler ultrasound. Then

concentrate on local wound care, which involves periwound

protection.

“A lot of them drain a lot of

fluid, so you have to select a good

moisture balance dressing,” he

said. He also emphasized the use

of compression bandaging.

“If your patient has sickle cell

disease, make sure you consult

with a hematologist because all of

the conditions are comorbidities

that a hematologist can really help

with,” he said.

Dr. Brian Kunimoto



Risk factors for diabetic foot ulcers

and what to look for in an initial foot exam

Mariam Botros

In her presentation in Montreal at Skin Spectrum

Summit, Mariam Botros outlined some

risk factors for diabetic foot ulcers and amputation,

as well as what doctors should be

looking for in their initial diabetic foot exam.

According to Diabetes Canada, 11 million Canadians

live with diabetes and prediabetes, she said.

Foot ulcers are also costly to treat, she said, so

doctors should concentrate on trying to prevent it.

According to Botros, 85% of diabetic foot ulcers and

amputations are preventable.

“If we can’t prevent it, we want to manage it appropriately,”

she said.

Neuropathy is the “key permissive factor” for the

development of diabetic foot ulcers, she said. This is

because once patients lose the ability to sense pain

in their feet, the skin breaks down quickly.

Miriam Botros

In searching for a systematic approach to preventing

foot ulcers, she said that doctors need to

start by going back to assess the patient.

One alarming symptom to take note of would be

pain in a neuropathic foot, which means an infection

is quite advanced, she said.

Another red flag is finding exhibited inflammatory

signs, which could indicate that the infection is

progressing.

Other risk factors for ulcers and amputation are

a history of amputation or ulcers, she said. In addition,

Dr. Botros mentioned peripheral neuropathy,

foot deformity, peripheral arterial disease, diabetic

nephropathy, diabetic retinopathy, poor glycemic

control, smoking, inappropriate footwear and other

psychosocial considerations.

When doing a diabetic foot exam, she recommends

looking at a few key categories: skin and nails,

peripheral neuropathy, peripheral arterial disease,

bone deformity and footwear.

“These are the categories that we want to see

addressed in a diabetic foot exam,” she said.

Callouses increase pressure on the foot, so debriding

the callous is always a good idea, she said.

They’re not there to protect the wound, contrary to

some misconceptions, she said. Deformity can also

increase the pressure rate.

Investigating for fungal infection is also a key

part of the diabetic foot exam, she said, emphasizing

that doctors check first between the fourth and fifth

toe web space.

A vascular examination is also recommended, as

well as checking for loss of sensory perception in the

foot.

Botros also recommends that doctors make

sure their patients are wearing appropriately supportive

footwear. Whether the footwear is too large

or too small, it can cause friction, which could result

in a diabetic foot ulcer, she said.

Once the foot exam is complete, she said that

the attending doctor must categorize the risk level. If

the risk is urgent, the doctor must address patients

by either treating them themselves or referring them

to a multidisciplinary team.

Patients who have undergone lower limb amputations

have lower quality of life, high rates of depression

and loss of productivity, she noted. For this

reason, she said, preventive measures and noting

red flags early are keys to preventing amputation

and ensuring a higher quality of life.



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