Hawaii Dermatology Seminar – Day two

Joe Fowler MD addressing the meeting attendees at the 34th Hawaii Dermatology Seminar. The Hawaii Derm Seminar is the original and premier Hawaii dermatology meeting. This year has seen a 10 % growth in attendees, many of whom are the younger set. All are welcome to enjoy participating in these extraordinarily beautiful surroundings where they will receive the real facts without commercial bias.

Skin Barrier and its effect on eczema. Joe Fowler MD.

Skin barrier is not simply an esoteric matter.Barrier dysfunction in a normal individual is not such a big deal. But in those who have functional problems, it is one of the most important components to control. Barrier dysfunction can induce epidermal injury and associated inflammation, and is related to age, UV, stress, low humidity, skin disease, and genetic factors. Dysfuntion is normally followed by barrier repair.

Exogenous causes of barrier dysfuntion include both irritant exposures and allergic contactants. Irritant exposures include friction, harsh or excessive cleansing, hydrocarbon solvents., acids and alkalis, and photodamage. Allergic contactants include industrial and skin care products, medications, gloves, cosmeceuticals among others. These all damage the stratum corneum, which has a biosensor function. Natural moisturizing factor (NMF), coined by British scientists, is very hygroscopic, is produced within the corneocytes, and is a “soup” of amino acids. Profillagrin is the major component of NMF which breaks down to fillagrinand amino acids. Considerable literature on this subject now exists. NMF production is blocked or reduced with UVB exposure.

So why isn’t Vaseline good enough to prevent barrier problems? Peter Elias MD PhD showed in normal subjects that after damaging the skin barrier, natural ‘healing’ occurs over course about 8 hours (50% improvement), but addition of (non-physiologic) petrolatum tends to slow this process. Add a gemish of ceramide and other physiologic mixtures, you get much better recovery over time. So physiologic barriers are important, and non-physiologic agents such as vaseline may not be as good as we thought.

Many barrier creams have been touted as being useful without much evidence. Newer agents such as Tetrix Cream, and Neo-Salus Foam, (no generic names available) both enhance skin barrier to allergens and irritants. They both have good data on barrier function, in patch testing studies and on hand eczema.

IvyBlock lotion blocks poison ivy. It’s quite effective, and well established to block and protect against urushiol in poison ivy, oak, and sumac. Available OTC.

Regular moisturizers can be helpful in situations of mild xerosis or tansient stratum corneumdamage. Not so good for subjects with prolonged inflammation, poor inherent repair such as atopy. A balanced mixture of ceramides1,3,6 may be important. The delayed release of components may prolong therapeutic effect. Three brands CeraVe, Mumyx, and Epiceram.

Guy Webster MD Acne from an Expert – Drugs, Diet, and More

Antibiotic resistance …. why care? Because acne is becomingharder to treat. Resistant strains are becomingmore common, including MRSA and Vanco resistant enterococcus. Safety of longterm antibiotics is likely. Concerns over association with breast cancer is likely coincidental; statistical correlations aren’t always valid.

Which antibiotics are most effective?Combining antibiotics and benzoyl peroxide (BPO) is synergistic; erythromycin or clindamycin alone can be made three times more effective when used in combination with BPO. And clindamycin with BPO is currently quite effective in comparison to other antibiotic regimes.

Isotretinoin and its complications…. apart from the usual dry lips, dry skin, dry eyes, high triglycerides, and acne flare, there are several much less common, but more significant issues. Elevated CK, AST and ALT enzymes, decreased night vision, depression, acne fulminans have all been reported. The question that arises in young athletes with acne is, should they stop or slow down their workout routine to prevent high muscle enzyme levels. Individual assessment needed, but Dr Webster recommends slowing up the workouts ….

Vincent Deleo MD discusses Vitamin-D, Sunscreens and You!

A review of the traditional messages concerning sunlight protection vs new advice that we give to patients. A need to recognize that we should advise reasonable precautions with which the public can live.

And then came Michael HolickMD NEJM 357, 2007, stating his views on vitamin D status and sunlight.

UVB is still the major cause of premature skin aging, although we recongnize that UVA, which penetrates much deeper, is clearly also relevant.

Do sunscreens work? Yes, if you use them correctly, and most people don’t. Do they prevent skin cancer?No adequate data to assure us that sunscreens protect us against BCC or melanoma. But they do prevent AKs and SCCs. Do they prevent photoaging? Yes probably, but very difficult to do these studies because they need to be long term studies.

25-OH Vitamin D .. what is normal? Key message here is that most of us are deficient! Deficient (1-10 ng/ml), Insufficient (10-20 ng.ml), Hypovitaminosis (20-30 ng/ml), Adequate >31 ng/ml.

Normal Vitamin-D levels are found in only 43% white individuals, 7.8% African Americans, and 20% Hispanics. Fully 50% of blacks are deficient in Vit D for normal health. What are the problems with low Vit D? Decreased bone density, hip fractures, falls, especially in the elderly. There is a 26 % increase risk of deathfrom any cause. Other diseases that may be associated with low Vitamin-D levels are breast cancer, colon cancer, type I and II diabetes, heart disease, MS, lower survival in melanoma and non-Hodgkins lymphoma.

Vitamin D-3 taken as a supplement is sufficient to bring serum levels up to normal levels. Recent recommendation are that all adults need 1000 – 2000 international units per day, and that children receive 400 iu per day.

Are we winning the war against excessive sun light? Only 34% of children who are from 12-18 years actually use sun block (which is no big surprise since they all think they are going to live forever …)

Tanning devices are regulated as Class I medical devices, like tongue depressors, which is rediculous and this has always been more than half the problem. Noonewas taking this seriously …. But now the FDA is taking action against tanning salons, their regulation, and what they can claim in terms of ‘tanning being healthy’. The cost of doing business is going to increase, and the public are going to hear more about the dangers of tanning. But these tanning salons are not going away any time soon …..

AAD recommendations include sunscreen use with SPF 30 or greater, protect your children, use Vit-D supplements, avoid tanning beds, check your skin at least annually.

Future regulations regarding suncreens …. SPF will be known as Sunburn Protection Factor, rather than Sun Protection Factor … SPF ratings will be rated as Low (2-15), Medium (15-30), High (30-50), Highest >50. Stability and longevity will be referred to as water resistant (40 mins), or very water resistant (80 mins).

UVA rating… in vivo and in vitro testing is coming. Of these two measures, the manufacturers may use the lower of the two scores. The product label will have from one star to four stars based on these in vivo and in vitro measures.

Grenz-Rays are back!

According to Joe Fowler MD, Grenz rays are safe, effective, and ecomomical. Grenz rays are “soft” X-rays with a half-value layer of < 1 mm. There is no detectable radiation at 3-4 feet, and essentially no radiation precautions are required. They should be used in localized areas (6-12 inches circumference) and are very useful on localized chronic eczmatous areas such as the hands, scalp, and genitalia. I am personally delighted to hear Dr Fowler say this, since I saw several patients with severe hand eczema ‘cured’ with this therapy back in 1980-85 at St John’s Hospital in London …..