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Issue 8 - 2019Making Education Easy
Welcome to the 8th issue of Dermatology Practice Review.This Review covers news and issues relevant to clinical practice in dermatology. It will bring you the latest updates, both locally and from around the globe, in relation to topics such as new and updated treatment guidelines, changes to medicines reimbursement and licensing, educational, professional body news and more. And finally, on the back cover you will find a summary of upcoming local and international educational opportunities including workshops, webinars and conferences.
We hope you enjoy this new Research Review publication and look forward to hearing your comments and feedback.
Kind Regards,
Dr Janette TenneMedical Research [email protected]
Clinical Practice
AAP guidelines for the management of infantile haemangiomasThe American Academy of Pediatrics (AAP) has developed its first guidelines for the management of infantile haemangiomas.
Infantile haemangiomas may occur in up to five percent of infants. The guidelines define potentially higher risk infantile haemangiomas, which should prompt concern, and point out the importance of increased vigilance, consideration of active treatment, and specialist consultation when appropriate. The most rapid and significant growth occurs between 1 and 3 months of age; in most cases, growth is completed by 5 months of age. Early intervention and/or referral is recommended for infants with potentially problematic infantile haemangiomas, ideally by 1 month of age. Propranolol should be used first-line when systemic treatment is indicated, at a dose of 2 to 3 mg/kg/day. Treatment is usually continued for at least six months, and is maintained until 12 months or longer. Select, small, thin, superficial infantile haemangiomas may be treated with topical timolol. For treatment of residual skin changes after involution, surgery and/or laser treatment are recommended. A summary of key action statements from the guidelines are listed below.
• Infantile haemangiomas should be classified as high risk if there is evidence of: life-threatening complications; functional impairment or ulceration; structural anomalies (e.g., PHACE syndrome or LUMBAR syndrome); or permanent disfigurement.
• After identifying an infantile haemangioma as high risk, haemangioma specialist evaluation should occur promptly.
• Imaging should not be performed unless the diagnosis is uncertain, there are at least five cutaneous infantile haemangiomas, or associated anatomic abnormalities are suspected.
• Ultrasound is recommended when the diagnosis of infantile haemangiomas is uncertain.
• MRI should be performed if there is concern about associated structural abnormalities.
• Oral propranolol is the first-line agent of choice if systemic treatment is required.
• Propranolol should be administered at a dose of 2 and 3 mg/kg per day unless there are comorbidities or adverse effects (e.g., sleep disturbance) requiring a lower dose.
• Advise caregivers that propranolol is given with or after feeding and that doses be held at times of reduced oral intake or vomiting.
• Advise caregivers about and monitor patients for potential adverse effects of propranolol, including sleep disturbances, bronchial irritation, and clinically symptomatic bradycardia and hypotension.
• Oral prednisolone or prednisone may be prescribed if there are contraindications or an inadequate response to propranolol.
• Intralesional injection of triamcinolone and/or betamethasone is recommended for focal, bulky infantile haemangiomas during proliferation or in certain critical anatomic locations.
• Topical timolol maleate may be prescribed for thin and/or superficial infantile haemangiomas.
• Surgery and laser therapy may be treatment options for selected infantile haemangiomas.
• Caregivers should be educated about the condition, including the expected natural history, and its potential for causing complications or disfigurement.
Pediatrics. 2019 Jan;143(1). pii: e20183475.
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In this issue: > AAP guidelines for infantile haemangiomas
> German guidelines for cutaneous BCC
> Efficacy and safety of antiscabietic agents
> Management of severe atopic dermatitis
> Atopic dermatitis and suicidality
> US guidelines for psoriatic arthritis
> Oral isotretinoin for acne
> Australasian guidelines: infant feeding for allergy prevention
> Surgery or intralesional MTX for keratoacanthoma
> PBS listings
> PBAC recommendations
> TGA – extended indications
> Billing multiple MBS items
> Policy drivers in atopic eczema
> OTC hair loss treatments
> WHO 4th edition of Classification of Skin Tumours
> Medical Board of Australia sexual boundaries guidelines
> Epidermolysis Bullosa survey
> Workshops, conferences and CPD
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MBS = Medical Benefits SchedulePBAC = Pharmaceutical Benefits Advisory CommitteePBS = Pharmaceutical Benefits SchemeTGA = Therapeutic Goods Administration
Abbreviations used in this issue:
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German guidelines for cutaneous basal cell carcinoma – part 1: epidemiology, genetics and diagnosisThe German Cancer Society and the German Society of Dermatology have published the following recommendations, based on strong consensus, on the diagnosis of basal cell carcinomas (BCCs):
Examination of a patient without additional tools is suitable for making a suspected clinical diagnosis of BCC. Following a diagnosis of BCC, a total-body skin examination should be performed. In patients younger than 20 years with several BCCs, a diagnostic workup should be undertaken to rule out a genetic syndrome.
Dermoscopy may improve the reliability of a clinical diagnosis of BCC, while confocal laser microscopy and optical coherence tomography may be useful in both the diagnosis of BCC and in assessing the effect of topical therapies for BCC.
If there is suspicion of osseous infiltration, CT and/or contrast-enhanced MRI should be used to determine the extent of intraosseous tumour spread. Likewise, if orbital invasion is suspected, use CT of the orbit to assess bone destruction, and contrast-enhanced MRI of the orbit to assess intraorbital tumour spread. If metastasis is suspected, cross-sectional imaging studies should be performed, and the primary histology should be re-evaluated. If basal cell carcinoma syndrome is suspected, imaging studies to rule out further malignancies and to detect associated abnormalities should be performed; MRI is preferred in order to prevent radiation-induced neoplasms.
The diagnosis of BCC should be confirmed by histology. Exceptions include multiple superficial tumours or basal cell carcinoma syndrome. Assess subclinical spread histologically; this applies to the sclerosing subtype in particular, which is characterised by fibrosis. Microscopically controlled surgery has the highest accuracy for histological detection of subclinical spread.
During tissue processing, consider tumour inhomogeneity. If necessary, serial sections should be examined. The histopathological diagnosis is performed on routine haematoxylin and eosin–stained sections.
The dermatopathology report should include diagnosis, tumour thickness, the excision margins, and histological subtype, in particular if there is evidence of infiltrative growth and/or fibrosing/sclerosing or perineural growth.
J Dtsch Dermatol Ges. 2019;17(1):94-103.
Efficacy and safety of antiscabietic agentsA meta-analysis of 52 randomised controlled trials with 9917 patients evaluated 13 antiscabietic agents to compare their efficacy and safety.
Permethrin showed significantly higher cure rates than sulfur, malathion, lindane, crotamiton, and benzoyl benzoate. Addition of oral ivermectin to topical permethrin had a non-significantly higher cure rate than permethrin alone. The permethrin plus oral ivermectin combination, topical ivermectin, and synergized pyrethrins ranked the best in terms of cure, persistent itching, and adverse events, respectively.
There were small numbers of trials and patients in some comparisons, and high risk of bias in some trials. There was no one treatment that ranked highest in all aspects. Clinicians should consider an easy-to-use treatment with balance between efficacy and safety.
J Am Acad Dermatol. 2019 Jan 14. pii: S0190-9622(19)30071-4.
Strategies for successful management of severe atopic dermatitisGuidelines have been developed for the management of severe atopic dermatitis; the recommendations have been published in The Journal of Allergy and Clinical Immunology: In Practice.
Among patients with atopic dermatitis, between 10% and 18% have severe disease.However, patients with severe atopic dermatitis have a poor quality of life and may have a number of atopic and nonatopic comorbidities. Treatment of this patient group has often involved inappropriate use of systemic corticosteroids and unapproved immunosuppressants. Recent evidence has described the systemic nature of atopic dermatitis, which has important therapeutic implications. Management of severe atopic dermatitis requires correct diagnosis, evaluation of disease severity, effect on patient’s and caregiver’s quality of life, education regarding the chronic relapsing nature of the disease as well as treatment options. Biologics offer a novel, targeted therapeutic approach for this systemic disease.
J Allergy Clin Immunol Pract. 2019;7(1):1-16.
Association between atopic dermatitis and suicidalityPatients with atopic dermatitis are at significantly greater risk of suicidal ideation and suicide attempts, according to a systematic review and meta-analysis published in The Journal of the American Medical Association. The study found that patients with atopic dermatitis are 44% more likely to exhibit suicidal ideation and 36% more likely to attempt suicide compared with patients without the condition. The analysis identified 15 studies with a total of 4,770,767 participants. Of those, over 300,000 had atopic dermatitis and over 4.4 million people did not. Due to these findings, the authors concluded that it is important for dermatology providers to be aware of and monitor for the increased risk of suicidality, and make referrals to mental health professionals when necessary.
JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.
ACR/National Psoriasis Foundation guidelines for the treatment of psoriatic arthritisThe American College of Rheumatology (ACR) and US National Psoriasis Foundation have developed guidelines for the treatment of psoriatic arthritis (PsA). The recommendations discuss management of active PsA in treatment-naive patients and those who have active PsA despite treatment. The guideline addresses use of oral small molecules, TNF inhibitors, IL-12/23 inhibitors, IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). Recommendations include use of a treat-to-target strategy for adult patients with active PsA and starting treatment with a TNF inhibitor over oral small molecules, an IL-17 inhibitor biologic, and an IL-12/23 inhibitor biologic.
Arthritis Care Res (Hoboken). 2019 Jan;71(1):2-29.
Oral isotretinoin for acneThis Cochrane review assessed the efficacy and safety of oral isotretinoin for acne. The review included 31 randomised controlled trials (RCTs) involving 3836 participants (12–55 years) with mild to severe acne. There were twice as many male participants as females. Pharmaceutical companies funded 12 trials, of which 9 had high risk of bias. The main comparison (oral isotretinoin versus oral antibiotics plus topical treatments) included only 3 RCTs with 400 patients assessed immediately after only 20 to 24 weeks of treatment. These three trials showed no difference in reducing inflammatory lesions during therapy (RR = 1.01) but demonstrated increased efficacy with isotretinoin when assessed by physician’s global evaluation (RR = 1.15). There were consistent dose-dependent decreases in acne severity with isotretinoin, and daily regimens were superior to intermittent therapy. However, the evidence for these findings was considered of low quality. Only one serious adverse event (Stevens-Johnson syndrome) was reported in the isotretinoin group, which leaves uncertainty of the risk of serious adverse effects; however, isotretinoin may result in more minor adverse effects.
While isotretinoin is currently considered a highly effective first-line medication for acne unresponsive to other therapies, the findings of this review do not fully support nor challenge this recommendation, owing to low-quality evidence.
Cochrane Database Syst Rev. 2018 Nov 24;11:CD009435
The Australasian Society of Clinical Immunology and Allergy infant feeding for allergy prevention guidelinesNew guidelines released by the Australasian Society of Clinical Immunology and Allergy (ASCIA) advise that infants should be introduced to peanut and egg by 12 months but not before four months. In a departure from earlier advice, the guidelines no longer recommend hydrolysed (partially and extensively) formula for the prevention of allergic disease. The guidelines recommend babies start eating a variety of solid foods by around six months, but not before 4 months; this is not a strict window of introduction but rather a recommendation not to delay the introduction of solid foods beyond 12 months.
Med J Aust 2019; 210 (2): 89-93.
NEW
PBS Information: Authority required. Refer to PBS Schedule for full authority information
Click here to review full Product Information before prescribing. Further information available on request from Sun Pharma.
References: 1. Approved Product Information 2. PBS. Schedule of Pharmaceutical Benefi ts - Effective 1 February 2019. Department of Health, Canberra. www.pbs.org.au.
Sun Pharma ANZ Pty Ltd ABN 17 110 871 826, Macquarie Park NSW 2113. Ph: 1800 726 229. Fax: +61 2 8008 1639. Med Info and to report Adverse Events: [email protected] or 1800 726 229. ILUMYA™ is a trade mark of Sun Pharma ANZ Pty Ltd. IL2019/02RR2. Date of preparation: February 2019.
First IL-23 inhibitor with 12-weekly dosing* and results that last†
*First IL-23 inhibitor approved with 12 weekly dosing after initial doses at weeks 0 and 41
†Of 100mg responders at week 28, 94% and 78% maintained PASI 75 or 90 respectively out to week 521
NOW PBS LISTED1 February 2019for severe chronic plaque psoriasis2
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Policy drivers in atopic eczemaAtopic Eczema patient organization leaders from eight countries, including the Eczema Association of Australasia, participated in a Patient Leader Dialogue Workshop on atopic eczema in September 2018 in Paris, France. The group published ‘Policy Drivers in Atopic Eczema: Patient Leader Dialogue Report’ which defines key policy drivers needed to establish eczema as a healthcare priority for governments and decision-makers.
Download the report here.
Over-the-counter hair loss treatmentsUsing sales data from an online retailer, this US study provides an overview of popular over-the-counter hair loss products and reviews the available evidence regarding their use. Common active ingredients included minoxidil, nutrients (i.e., vitamins, minerals, proteins), and plant-based botanicals. 23.8% of products were FDA-approved treatments for androgenetic alopecia. The evidence for many FDA non-approved treatments was limited to small studies and could not be generalized. While some over-the-counter hair loss treatments may be efficacious, more rigorous study is required.
J Drugs Dermatol. 2018;17(12):1317-1321.
World Health Organization releases 4th edition of Classification of Skin TumoursThe World Health Organization (WHO) has published the 4th edition of Classification of Skin Tumours. This edition discusses the significant changes to the classification of melanoma, based on the latest evidence. It also offers information on pathology, genealogy, prognosis and protection for each of the tumour types.
Find out more here.
Medical Board of Australia sexual boundaries guidelinesThe Medical Board of Australia’s updated ‘Guidelines: Sexual boundaries in the doctor-patient relationship’ came into effect in December 2018. Important changes include an obligation for patient consent if medical students or anyone else is to be present during an examination and advise that an unwarranted physical examination may constitute sexual assault.
Download the guidelines here.
Epidermolysis Bullosa surveyThe Clinical Network of Epidermolysis Bullosa Health professionals (EB-Clinet) in along with DEBRA International are conducting a survey to understand the priority areas for revision of new best Clinical Practice Guidelines. The Australasian College of Dermatologists is asking all College members to contribute.
Click here to complete the survey.
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Management of keratoacanthoma with surgery or intralesional methotrexateThis study reports the experience of a single institution in managing keratoacanthomas with intralesional methotrexate or surgical excision. Data on 157 tumours from 136 patients were collected over 6 months.
Of 157 tumours (54 patients), 73 were treated with methotrexate with an 88% cure rate (clinical resolution with no recurrence within 6 weeks). Nonresolving tumours were excised with no recurrences or complications and were of the same size or smaller after methotrexate. Of the 73 tumours treated with methotrexate, 29 were multiple keratoacanthomas; all 29 resolved. There were 84 tumours treated with surgical excision, with no complications and no recurrences (100% cure).
The authors concluded that intralesional methotrexate may be considered as the initial treatment for solitary or multiple keratoacanthomas in cases not amenable to surgery.
Dermatol Surg. 2019 Jan 2. doi: 10.1097/DSS.0000000000001739.
Regulatory News
Two biologics for chronic plaque psoriasis PBS listedGuselkumab (Tremfya®) and tildrakizumab (Ilumya®) were listed on the PBS from February 1 for the treatment of severe chronic plaque psoriasis.
Read more here.
PBAC recommendationsThe PBAC made the following recommendations at its November 2018 meeting:
• The Section 100 (Efficient Funding of Chemotherapy) Authority Required listing of brentuximab vedotin for the treatment of refractory or relapsed CD30 positive cutaneous T-cell lymphomas.
• The Authority Required (STREAMLINED) listing of encorafenib in combination with binimetinib, for the treatment of BRAF V600 mutation positive unresectable Stage III or Stage IV metastatic melanoma.
• The listing of the new strength (5mg capsule) of isotretinoin for the treatment of severe cystic acne.
• The Authority Required listing of tofacitinib on a cost minimisation basis with the least costly biological disease modifying antirheumatic drug for psoriatic arthritis.
Read more here.
TGA – extended indicationsTofacitinib (Xeljanz®) is now also indicated in combination with conventional synthetic DMARDs for the treatment of active psoriatic arthritis in adult patients who have had an inadequate response to a prior DMARD therapy.
Find out more here.
Education guide - billing multiple MBS items and writing PBS and RPBS prescriptionsThe Department of Human Services have released a new education guide on how to bill multiple Medicare Benefits Schedule items, including interpreting common MBS phrases. The Department have also put out a guide on Pharmaceutical Benefits Scheme (PBS) and Repatriation Schedule of Pharmaceutical Benefits (RPBS) prescriptions for all eligible prescribers.
News in brief
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