PracticeUpdate Dermatology May 2019

Dr. Caroline Crabtree’s Take-Aways By Caroline K. Crabtree MD CONFERENCE COVERAGE 24

Medical dermatology challenge: complex cases from the collection of Dr. Samuel Moschella • In patients with Sweet’s syndrome who present with facial bullae, atypical pyoderma gangrenosum-like lesions, extensive oral lesions, anemia, or abnormal platelets, an associated myelo- proliferative disorder should be considered. Top cosmetic procedure complications and how to fix them • In order to minimize the risk of brow ptosis with injectable neuro- modulators, it is recommended to keep the injection point 1 cm above the orbital rim. If lid ptosis does occur, apraclonidine 0.5% eye drops (1–2 drops three times daily) can be used. Speakers recommended keeping this in the office in case the need arises. • For vascular compromise due to hyaluronic acid filler, treat with an injection of a minimum of 200 units of hyaluronidase followed by massage of the area. This should be repeated hourly until resolution of livedo. • Vision loss due to hyaluronic acid filler may be treated with retrobulbar injection of hyaluronidase typically with the aid of an ophthalmologist or retina specialist. If pursuing this option, it is important to have the cell phone number of the physician or eye hospital you anticipate contacting in the event your patient experiences this complication and to remember to bring at least 2000 units of hyaluronidase with you, as this may not be commonly stocked at an eye clinic. Even with this intervention, return of vision is not guaranteed, although the intervention may provide an opportunity for improving outcomes. • Sodium thiosulfate is on the horizon with the potential to become an option for dissolving calcium hydroxylapatite filler material (Radiesse). Cosmeceuticals and nutraceuticals: when it comes to eating for general skin health, the following recommendations may be beneficial for patients: • 2/3 carrot, raw (vitamin A, beta carotene) • 1 tomato, raw (vitamin C) • 1/4–1/2 avocado and a drizzle of olive oil (vitamin E) • 1/2 ear of corn (lutein, zeaxanthin) • 1 slice watermelon (lycopene) • 1 raw apple with the peel (phytochemicals) • 1 cup fresh or 1/2 cup dried blueberries (antioxidant blends) • Fish, chicken, yogurt, and cheese as primary sources of protein (limiting red meat) • Low glycemic diet-limiting sugar and crispy processed foods/ baked goods

• Normal water intake • Oral supplements – vitamin D, flaxseed oil 1000 mg daily to twice daily, and a multivitamin with minerals that is age-appropriate In a lecture on cosmeceuticals for patients with skin of color, a variety of topical preparations were reviewed. Use of sunscreen alone showed improvement in hyperpigmentation, a reminder to clinicians that sun protection remains a critical component in preventing post-inflammatory hyperpigmentation. Another study showed that adding the visible light-blocker iron oxide to SPF 50 and hydroquinone resulted in greater improvement in hyperpig- mentation. Although there are many new cosmeceuticals aimed at treating post-inflammatory hyperpigmentation, they have vary- ing degrees of efficacy, and hydroquinone and triple-combination therapy remain the gold standard. Methyl estradiol propanoate (MEP) is a member of a novel drug class known as the non-hormonal estrogen receptor agonists (NERA), which has been effective in treating estrogen-deficient skin characterized by dryness, itching, wrinkles, and decreased wound healing. It does this without any of the off-target effects seen with topical estradiol or selective estrogen receptor modulators. Hidradenitis suppurativa and pityriasis rubra pilaris: updates on treatments for two conditions that are difficult to manage • Jennifer Hsiao provided several tips for selecting agents to use when “stacking medications” in the treatment of hidradenitis suppurativa. ― ― In females with Hurley stage 1, she recommends oral con- traceptives and/or spironolactone. Effects of spironolactone used for hormonal modulation in hidradenitis suppurativa can take 6 to 12 months to become apparent; so, a prolonged trial is warranted. ― ― In the obese patient, metformin is a reasonable addition. ― ― Systemic antibiotics and wide local excision were recom- mended for patients with severe disease, while biologics and medication stacking were recommended for those with severe disease who are poor surgical candidates. • Squamous cell carcinoma may develop in the setting of chronic inflammation and scarring of hidradenitis suppurativa, and early diagnosis and treatment are key as these malignancies tend to be very aggressive.

PRACTICEUPDATE DERMATOLOGY