Cosmetic Surgery Forum Faculty members Drs. Roslyn Rivkah Isseroff, Rhett Drugge, M. Laurin Council and Andrea Murina discuss the latest studies, findings and the future of traditional dermatology treatments and surgery.
Roslyn Rivkah Isseroff, MD on Treating CO2 Laser Resurfacing with Timolol
Along with her collaborator Dr. Jayne Joo, Dr. Rivkah Isseroff conducted a study to determine if Timolol can treat laser burns and restore the epithelial barrier compared to the standard wound post procedure.
RI: We’ve noted that Catecholamines (epinephrine) decrease keratinocyte migration. They decrease wound healing in mouse models. We found burn wounds generate epinephrine adjacent to the wound, as early as 30 minutes after injury. Our next step was to see how blocking the receptor altered healing. Beta-adrenergic receptor (β-AR) blockade on keratinocytes promotes wound healing via downstream pathways that stimulate keratinocyte migration and re-epithelialization. But how can Timolol improve creatine on sight migration? The beta adrenergic antagonist (timolol) has been reported to improve healing of recalcitrant, chronic wounds
Through a small pilot study with an ablative CO2 laser, the control wound was treated with diluted vinegar soaks (1 part white vinegar in 4 parts water) followed by application of a topical wound hydrogel BID. The timolol site was treated with 1 drop (0.05 mL) of timolol 0.5% gel forming solution (Sandoz, Inc) to one of the two spots on each forearm prior to the application of the hydrating gel BID.
Drs. Joo and Isseroff took daily measurements of the transepidermal water loss (TEWL) as an indicator of skin barrier function and a proxy for wound healing and epithelialization. The control had high water loss and didn’t return to normal until week 4. The Timolol water loss returned to normal after the first week.
RI: Timolol restored epithelial barrier more quickly (week1) compared to standard of care. Timolol treated wound visibly healed more quickly and demonstrated decreased erythema. Topical timolol 0.5% gel forming solution may expedite healing of wounds following full CO2 ablation.
Rhett Drugge, MD on Breakthroughs in Artificial Intelligence
Artificial Intelligence (AI) is a rapidly moving field at the early beginning stages of healthcare delivery for skin cancer. Dr. Rhett Drugge encourages physicans to embrace the future because the capability of AI is very exciting.
RD: We have a terrible consequential skin cancer epidemic and a huge amount of melanoma in our youth. The screening process has been limited and we don’t have time to screen everyone. Automated coordinating systems are coming now to bare on the skin through the use of deep learning, neural-networks, and sophisticated statistical regression analysis which is reorganize the coordinate systems of the body. Not only will skin cancer be map-able, trackable but we can elucidate the changes in the changes in our skin and responses to therapies.
The future trends to look for in the AI world are a sensor that will assist us in the physical examination process. Dr. Drugge predicts a use for AI to augment total body photography for skin cancer screening as well as predict appearances up to a decade for cosmetic surgeons.
RD: We are aggregating a 20 year whole body data set and learning what people look like as they age. We can use predictors to draw from the data set to anticipate what their problems will be. We will also be able to give people what I like to call, an “expiration date,” which is their survival prediction and probability. Under the direction of AI, we can add or move volume and neuromodulators. Ultimately, AI will trend toward replication of physician thought process and extension of care.
M. Laurin Council, MD on Apps to Approve Efficiency in Your Clinical Practice
Clinical videos are becoming important in dermatology surgery, film for website or social media, patient education and resident education as well. iMovie is a free app used to edit videos taken on your smartphone or tablet. The editing options allow you to cut portions you don’t need, overlay different functions, remove sound, add music, voice over or speed/slow time.
LC: Video is becoming more important with manuscript publications. Many journals such as Journal of Dermatologic Surgery, are requesting you submit a video to a company you manuscript; particularly if it’s on a topic of reconstruction or technical aspect that might be difficult to demonstrate without one. It’s fortunate for someone with limited video experience; iMovie can make it incredibly easy to do so.
In 2012 AAD, American College of Mohs Surgery, ASDS, AMS came together to devise appropriate use criteria for Mohs micrographic surgery. They knew the utilization of Mohs surgery had dramatically increase over the past serval years. This app allows us to decide it’s important we decide when to use Mohs and or pursue other avenues if Mohs is not the right choice for the patient.
LC: Sometimes a patient will come in who wants to do Mohs and sometimes it’s difficult to tell them it isn’t the appropriate thing to do. It’s not ideal to pull out your journal and try to figure it out on your own. However, you can pull up the app, enter the type of cancer you’re dealing with and part of the body it’s on, you’re given a score. The score will then determine if Mohs is necessary.
In order to keep up with medical literature on the go, AAD Dialogues in Dermatology, JAAD, JAMA apps have podcast you can plug in anywhere to listen to.
LC: I have a bunch of kids and we are always out doing something. If I have some down time, it’s quick and easy to pick up my phone and keep up with the latest literature.
LC: I often find right before a procedure, I like to review anatomy. If I’m educating a resident, I like to show them where the danger zones are. Human Anatomy Atlas 2019 is available online and has very good head and neck diagrams of both vesicular and neurological structures.
Patient Apps Recommended by the audience: Bioplog and Photoskin
Andrea Murina, MD on New Therapeutic Options for Alopecia Areata
Alopecia Areata (AA) is immune mediated hair loss and it is profoundly impactful to patient’s life. Over 77% of patients have impairments such as anxiety, depression and suicidality. The highest impact of AA is when there is has high spread involvement like totalis or universalis in younger patients and those that are female. Historically, there have been no reliable treatments in the past for treating Alopecia Areata.
Why do JAK inhibitors work for Alopecia Areata?
AM: JAK inhibitors affect CD8 positive T cell as well as follicular epithelial cell. The interfere on gamma release signals JAK signaling and get feedback from follicular that produces aisle 15 that then, again, signals the other JAK inhibitors through CD8 positive T cell. There are multiple JAK inhibitors out now; some that are being examined for atopic dermatitis. Each JAK inhibitor may inhibit a slightly different JAK number.
A study done with Tofacitinib for Alopecia Areata showed 64% of 66 adult patients responded to treatment. The variation occurred the most in patients with universalis. There’s not a constant response rate with patients of all types. Be aware the possibility of some side effects that may need lab monitoring and counseling.
AM: These are not benign medications. One of the things they can cause is neutropenia and lymph so it’s important to check CBC. In the study, they had patients with increase liver enzymes and increase cholesterol. Infectious risks can increase. You have more upper respiratory tract infections, urinary tract infection, and more zoster. You may also see an increase with acne and weight gain in patients being treated with JAK.
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December 4-7, 2019 at the JW Marriott Nashville