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Onychomycosis is a fungal infection of the toenails or fingernails that can involve any component of the nail unit, including the matrix, bed, and plate. It is a common disorder that may be a reservoir for infection resulting in significant medical problems. Moreover, onychomycosis can have a substantial influence on one’s quality of life. An understanding of the disorder and updated management is important for all health care professionals. Aside from reducing quality of life, sequelae of the disease may include pain and disfigurement, possibly leading to more serious physical and occupational limitations. Dermatologists, Podiatrists, and other clinicians who treat onychomycosis are now entering a new era when considering treatment options—topical modalities are proving more effective than those of the past. The once sought after concept of viable, effective, well-tolerated, and still easy-to-use monotherapy alternatives to oral therapy treatments for onychomycosis is now within reach given recent study data. In addition, these therapies may also find a role in combination and maintenance therapy; in order to treat the entire disease the practitioner needs to optimize these topical agents as sustained therapy after initial clearance to reduce recurrence or re-infection given the nature of the disease.

As the understanding of the immune system pathways, cytokine balances, and cellular interactions continues to expand, so must the potential applications of therapies that can impact the process of diseases instead of just controlling their symptoms. In the case of Polypodium leucotomos extract, which is derived from a tropical fern of the Polypodiaceae family, the future potential of applications in dermatology and beyond will be better understood as its incorporation into daily routines gives rise to the development of new regimens. Clinicians may position this agent as an option for daily maintenance, accept its use in combinations, or use it as a template for further development of oral supplementation that may evolve into a true immunomodulator. The antioxidant activity of P. leucotomos extract is primarily driven by caffeic acid and ferulic acid, resulting in the control of cutaneous responses to ultraviolet-induced erythema, in the interception of inflammatory mechanisms, and the promotion of other cytotoxic responses. Histologically, the impact of P. leucotomos extract induces an effect on the overall reduction of angiogenesis, photocarcinogenesis, and solar elastosis, while on the cellular level there are improvements in cell membrane integrity and elastin expression. Future applications for P. leucotomos extract could include the potential for photoprotective effects, and subsequent research efforts should focus on determining the optimal dosage regimen, duration of action, and utility of combinations with sunscreens, among other outcomes. Recently published data have also demonstrated how the antioxidant effects of oral P. leucotomos extract can delay tumor development in mice models, suggesting there might be a protective role that could be described with further clinical research. In addition, it is important to recognize the distinction between photoprotection and chemoprevention, in that there has yet to be any in vivo or controlled clinical trial data in human subjects that show a role for P. leucotomos extract in the prevention of carcinogenesis.

New therapies, recent pathophysiological findings, and updated guidelines combined to create compelling presentations at the Skin Disease Education Foundation's 41st Annual Hawaii Dermatology Seminar™. This educational supplement summarizes the highlights of clinical sessions presented during this CME/CE conference. A growing understanding of the biology of psoriasis has facilitated the development of increasingly efficacious medications. Skin clearance used to be regarded as an impractical goal for psoriasis therapy. Now, some clinical trials of newer medications report more than half of participants attaining Psoriasis Area and Severity Index (PASI) scores of 90. Two leading investigators review the latest findings about the treatment of this condition. Recent evidence demonstrates that psoriasis and psoriatic arthritis share multiple pathological underpinnings. A T helper type 17 (Th17) lymphocyte-based pathogenesis, genes, and microbiome changes have been identified in both conditions. Many therapeutics used in psoriasis care are efficacious in psoriatic arthritis. An expert in psoriatic arthritis updates readers about this condition. Cutaneous fungal infections, including onychomycosis, pose diagnostic and treatment challenges. New topical therapies and an investigational oral agent offer expanded options for management. The American Academy of Dermatology has issued new guidelines for the treatment of acne. Appropriate antibiotic use is a prominent theme. The US Food and Drug Administration has issued a communication about the risk of unintentional injection of soft tissue fillers into facial blood vessels-including blindness. The lead author of a recent review about this topic discusses how to prevent this serious outcome. The volume of new information about pathophysiology, diagnosis, therapy, and safety challenges our ability to keep current while enabling us to improve patient care. We hope that the highlights of this seminar offer you information that can be applied to your busy practices.

pThe limitations of photoprotection modalities have been the inability to arrest the progression of photodamage. Chemoprevention strategies involving a sunscreen has been incomplete because of the need to induce sustained repair of mutations and slow carcinogenesis. Photolyases, or photoreactivation enzymes, serve the role of repairing mutations and damage to DNA induced by ultraviolet (UV) radiation and therefore influence the initiation phases of carcinogenesis. As these enzymes are absent in humans, exogenous forms have been manufactured and are now utilized in topical agents to supplement and augment the innate repair mechanisms that are mostly inefficient./ppemJ Drugs Dermatol. 2017;16(5 Suppl):61-66./em/p.

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Topical therapy of acne vulgaris (acne) is very common, however cutaneous tolerability can influence patient adherence, and concerns about skin irritation have lead to a number of comparative split-face studies. Advances in formulation technology have provided new fixed combinations with lower concentrations of potentially irritating ingredients without compromising efficacy. These developments now afford the opportunity to formulate fixed combinations with higher concentrations of active ingredients that may provide the greater efficacy needed in more severe disease with good tolerability.br /Here, we compare the tolerability of two such developments, clindamycin-BP 3.75% gel and adapalene 0.3%-BP 2.5% gel, in healthy volunteers with no apparent facial redness or dryness over 21-days, using a split-face methodology.br /Clindamycin-BP 3.75% gel was more tolerable than adapalene 0.3%-BP 2.5% gel over the duration of the two studies, with statistically significant differences in cumulative change from baseline starting as early as day 4 (stinging), day 5 (erythema, dryness, and scaling), day 6 (burning), and day 8 (itching); and in composite irritation index (stinging, erythema, dryness, scaling, burning, and itching) from day 4. Transepidermal water loss was less with clindamycin-BP 3.75% gel (statistically significant from day 8). Adverse events were twice as common with adapalene 0.3%-BP 2.5% gel.br /These data suggest that clindamycin-BP 3.75% gel is likely to be better tolerated than adapalene 0.3%-BP 2.5% gel in moderate-to-severe acne.br /br /emJ Drugs Dermatol./em2016;15(6):721-726.

Background Acne fulminans (AF) is a severe variant of inflammatory acne. It typically manifests as an explosive worsening and ulceration of skin lesions, and can be associated with systemic symptoms. However, there is a paucity of evidence-based information and no clear guidelines concerning the classification and treatment of AF. Objective To better define the spectrum of AF and its variants, devise optimal therapeutic approaches, and identify areas of future research. Methods A panel of physicians with expertise in severe acne vulgaris was convened after a comprehensive literature review of severe acne variants. Priority topics were reviewed and presented by each panelist at a 5-hour conference. Following review of the audiotape and scribed notes from the conference, surveys were utilized to address points of controversy and to clarify consensus recommendations. Results Appropriate clinical case presentations and consensus survey questions were utilized to create final recommendations based on both the literature and the expert consensus. Limitations Limited evidenced-based data and prospective studies in the literature concerning the treatment of AF is available. Conclusion These guidelines better characterize AF and provide health care practitioners approaches to the classification, treatment, and prevention of AF and its variants.

There is no general agreement as to what constitutes cure or treatment success in onychomycosis. Regulatory guidelines differ in the United States and Europe, and outcomes reported in clinical trials do not consistently report secondary endpoints.br/We reviewed definitions of onychomycosis cure to develop a less stringent and more practical approach to assess improvement and treatment success.br/Complete cure (totally clear nail and mycologic cure) remains an important regulatory standard. Mycologic cure (negative fungal culture and negative potassium hydroxide) is the only consistently reported outcome in clinical trials, however the potential for discrepancies between microscopy and culture can be problematic. We propose a more practical approach to assessing improvement in infected nails that relies on both physician and patient input in a similar fashion to other skin diseases.br/Treatment success should be based on both physician and patient assessment of improvement in the affected toenails and negative fungal culture.br /br /emJ Drugs Dermatol./em2016;15(5):626-632.

Recurrence (relapse or re-infection) in onychomycosis is common, occurring in 10% to 53% of patients. However, data on prevalence is limited as few clinical studies follow patients beyond 12 months. It has been suggested that recurrence after continuous terbinafine treatment may be less common than with intermittent or continuous itraconazole therapy, probably due to the fungicidal activity of terbinafine, although these differences tended not to be significant. Relapse rates also increase with time, peaking at month 36. Although a number of factors have been suggested to play a role in recurrence, only the co-existence of diabetes has been shown to have a significant impact. Data with topical therapy is sparse; a small study showed amorolfine prophylaxis may delay recurrence. High concentrations of efinaconazole have been reported in the nail two weeks' post-treatment suggesting twice monthly prophylaxis with topical treatments may be a realistic option, and may be an important consideration in diabetic patients with onychomycosis. Data suggest that prophylaxis may need to be continued for up to three years for optimal effect. Treating tinea pedis and any immediate family members is also critical. Other preventative strategies include avoiding communal areas where infection can spread (such as swimming pools), and decontaminating footwear.

The incidence of Condyloma acuminata and other HPV-related dermatoses is increasing, with as many as one million new cases of infections diagnosed yearly. Therapeutic options that were once limited to in-office procedures or topical podophyllin toxins are now directed toward modifying the immune responses against the viral burden and minimizing recurrence potential. For years, compliance with follow-up and topical management has been limited due to issues with convenience, toxicities, and costs. There are now several pharmacological agents in the dermatology marketplace that can be incorporated into treatment regimens, either as monotherapy or in combination with in-office destruction modalities. One of the newer agents, Sinecatechins 15 % ointment (Veregen®), promotes localized antioxidative effects in conjunction with other proinflammatory actions. As the elucidations of the immune mechanisms that create viral diseases as well as other dermatoses continues to expand, so will the potential applications of this class of therapies. Several studies have supported its use in the treatment of external genital warts as well as other diseases. This article focuses on the pathogenesis and epidemiology of external genital warts and other manifestations of HPV, as well as on the history, mechanisms of action, and therapeutic applications of Sinecatechins 15 % ointment.

not available. Disclosures: Study sponsored by Dermavant.Copyright 2018 SKIN

not available. Disclosures: Study supported by BioPharmX, Inc. Copyright SKIN 2018

One fascinating element of medical dermatology is the diversity of available therapeutic agents, and dermatologists are well versed in applying the mechanism of action of a drug to modify a disease process. Oral antibiotics are the ideal example of pharmacologic agents that are effective against inflammatory processes and have obvious roles in infectious diseases.

Many classes and preparations of immunomodulators are available to the clinician, serving as stimulatory or inhibitory influences on a variety of disease states. To maximize their efficacy, it is important for the clinician to take a step back from the usual routine of treating symptoms and consider the immune processes that took place to create inflammation, tumors, or responses to infections. From there, after considering the short-term and long-term consequences of the treatment, one can match the immune profile of the disease to the treatment. Most importantly, immunomodulators provide the opportunity to do what is best for the patient at that time, as well as for control of the future of the disease, whether it is acute or chronic.

Background: Cosmetic compatibility in the treatment of acne is an important issue significantly impacting quality of life, but often overlooked, as dermatologists commonly recommended avoidance of cosmetic foundations when treating adult female patients. Fixed combinations of clindamycin/benzoyl peroxide are widely used in the treatment of acne, but little is known about the impact of their concomitant use with facial foundation. Objective: To assess the compatibility of clindamycin phosphate 1. 2%/benzoyl peroxide 3. 75% gel with foundation makeup for up to six hours after application. Methods: Twenty-nine female subjects applied makeup to their face after randomly applying clindamycin phosphate 1. 2%/benzoyl peroxide 3. 75% gel to one side of the face. Investigator and subject self- assessment included facial skin attributes, facial tolerability, and cosmetic compatibility post-application and at Hour 6; as well as cutaneous tolerability. Results: No statistical difference was noted between the treated and untreated side of the face in terms of coverage, blotchiness, appearance, skin tone, or visual smoothness. Tolerability was excellent, with no erythema, edema, dryness, and peeling post-makeup application. For both the treated and untreated side, there was a slight lack of improvement in cosmetic appearance six hours post-makeup application. Conclusion: Clindamycin/benzoyl peroxide 3. 75% gel was shown to have excellent cosmetic compatibility with facial foundation.

Successful treatment of onychomycosis is both a clinical and therapeutic challenge. Effective patient education and reassurance are critical. This post hoc analysis aims to provide some guidance to physicians based on initial disease severity and influencing factors.A post hoc analysis of two multicenter, randomized, double-blind, vehicle-controlled studies evaluating the efficacy and safety of efinaconazole topical solution, 10% in mild to moderate onychomycosis. Outcomes were assessed based on baseline severity (20%-29%, 30%-39%, 40%-49%, and ≥50% affected target toenail).Overall, the mean percent affected toenail following efinaconazole treatment decreased from 36.4% to 20.6% (a 43% reduction). The percent reduction in mean percent affected toenail (range, 43.6% to 59.8%) with efinaconazole was similar irrespective of baseline severity. Improvement was only seen in the very mildest patients with vehicle and not before week 36. Improvement was influenced by gender (females did better) and disease duration (long standing disease responding less well).Our onychomycosis patients treated with efinaconazole might expect a 50% improvement in their disease within a year, and this will be seen as significant by many, especially those who have suffered for many years. Many will do better, but they will need to be reminded of the slow growth of the toenail.

As the pathophysiology of acne is complex and multifactorial, the continued influx of new basic science and clinical information requires careful analysis before drawing conclusions about what truly contributes to the development and progression of this chronic disease. Our objective is to review the latest evidence and highlight a number of important perspectives on the pathophysiology of acne. An improved understanding of acne pathogenesis should lead to more rational therapy and a better understanding of the role of P acnes opens new perspectives for the development of new treatments and management. Further research may be directed at targeting receptors, adhesion molecules, cytokines, chemokines or other pro-inflammatory targets implicated in the activation of immune detection and response (i.e., toll-like receptors [TLRs], protease-activated receptors [PARs]) that appear to contribute to the pathophysiology of acne. Therapeutic options that reduce the need for topical and/or oral antibiotic therapy for acne are welcome as bacterial resistance to antibiotics is a clinically relevant concern both in the United States and globally.

Onychomycosis is an often overlooked and/or undertreated disease. This may be in part due to an under appreciation among both physicians and patients of its impact on quality of life and the potential for significant complications, from tinea corporis and cruris, to bacterial superinfection. Some health care providers are unaware of the effective low-risk treatments currently available. Changing demographic characteristics such as the relative aging of the population; the increasing prevalence of diabetes and peripheral vascular disease, and widespread iatrogenic immunosuppression; and changes in lifestyle practices such as earlier and greater participation in sports, are likely to lead to an increased prevalence of onychomycosis in both adults and children. Two topical onychomycosis treatments, efinaconazole 10% solution, and tavaborole 5% solution were recently approved by the FDA. This article reviews the state of knowledge and describes, briefly, these new treatment options.

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Polypodium leucotomos extract (PLE), derived from the tropical fern of Polypodiaceae family, has properties ranging from immunomodulatory and antioxidative to photoprotective. It is these multiple mechanisms of action, in combination with a favorable side effect profile, which makes PLE a promising adjunctive treatment for several dermatologic disorders. Studies are summarized on the use and potential applications of PLE in the treatment or management of photodermatoses, vitiligo, melasma, psoriasis, atopic dermatitis, and more recently, in minimizing infections in high-performance athletes. More data, however, with larger sample sizes are needed to confirm these benefits.

External genital warts (EGWs) are a common sexually transmitted infection caused by the human papillomavirus (HPV). Although over 100 HPV types have been identified, some of which are associated with cancer, EGWs are caused by noncancerous HPV subtypes 6 and 11. This cutaneous manifestation of HPV infection can be asymptomatic or produce warty lesions that may assume a cauliflower-like, flat, papular, or keratotic appearance. Physical symptoms may also accompany warts, such as pruritus, burning, pain, and obstruction. EGWs typically appear in anogenital areas, such as the vulva, penis, groin, perineum, perianal skin, or mucosal surfaces. EGWs are typically a transient type of infection that often spontaneously regresses without treatment, but long-term remission rates are currently unknown. Treatment is determined according to the size and number of lesions, which can cluster or develop at multiple sites. Because of the individual variability in disease, treatment should be determined on a case-by-case basis. Further investigation, such as a biopsy, may be advisable in cases of atypical lesions, lesions that are unresponsive to therapies, and immunocompromised individuals, who are essentially more susceptible to HPV infections and less responsive to treatment. Although HPV testing is available, it is not currently recommended for detection and HPV typing. Differential diagnoses may include normal skin variations, other infectious or inflammatory diseases, and cancerous growths.

The primary goal of treatment for external genital warts (EGWs) is to eradicate visible lesions and address symptoms that may accompany them, but it does not address the underlying virus. Left untreated, warts may grow, remain the same, or spontaneously regress as a result of being cleared by the immune system. However, recurrence is common with or without treatment and may occur within 3 months of ending treatment in one-quarter to two-thirds of cases. Treatment options fall into two categories: provider or patient applied. Provider-based therapies include cryotherapy, trichloroacetic and bichloroacetic acid, electrocautery, surgical excision, and CO2 laser therapy. Patient-applied therapy choices include imiquimod and podophyllotoxin. Imiquimod 3.75% is a fairly new, patient-administered topical cream approved by Health Canada in 2011. Another recently approved patient-applied choice is sinecatechins, a green tea extract with immunomodulatory effects. Self-treatment options are attractive to patients because they offer privacy, convenience, and autonomy. In contrast, provider-administered therapies may boast increased precision (especially for areas that are hard to reach) and closer monitoring, which can be augmented by patient education and counseling. Available topical and surgical therapies vary widely in terms of cost, efficacy, adverse effects, dosage/frequency, and length of treatment. No one treatment is ideally suited to all patients or constitutes a gold standard. Treatment regimens must be tailored to each patient's needs and preferences. The health care provider's skills and experience will also factor into treatment decisions. In addition, the size, number, and location of lesions and whether the infection is new or recurrent will help guide the decision process toward the best treatment for a given patient.

As the most commonly sexually transmitted disease worldwide, human papillomavirus (HPV) infections are associated with significant morbidity and mortality. HPV infections most commonly affect young adults, women under 25 in particular. The most common risk factor for HPV infection in both sexes is a high number of lifetime sexual partners, whereas leading protective factors include circumcision, consistent condom use, and abstinence. Over 100 HPV types have been identified to date and are classified according to their level of oncogenic potential. HPV types 6 and 11 are responsible for approximately 90% of genital warts; HPV types 16 and 18 are responsible for 70% of invasive cervical cancers. External genital warts (EGWs) are the most common clinical manifestation of nononcogenic HPV infection. Coinfection with multiple HPV types is possible and may combine both low- and high-risk types, even in cases of genital warts. HPV infections are DNA viruses transmitted through skin-to-skin contact, invading the basal epithelial cells via microtears and evading the host immune response. Although non-life threatening, even low-risk HPV-type infections such as EGW carry a substantial psychosocial and economic burden. Stressors include the shame and embarrassment related to diagnosis, as well as the inconvenience and discomfort of treatment and the fear of recurrence, transmission, and the possible threat of cancer. Costs relate to routine screening for cervical cancer, treatment of genital warts, and the management and follow-up of malignancies.

Rising rates of human papillomavirus (HPV) infections in recent decades, including external genital warts (EGWs), underscore the need for effective management of this common sexually transmitted disease. Although treatment is a vital aspect that aims primarily to resolve physical symptoms, health care providers must also address the psychosocial burden that typically accompanies diagnosis, treatment, remission, and recurrence. Education and counseling are integral components of care to address the cascade of negative emotional reactions that follow diagnosis, which often include anger, shame, stigma, frustration, and fear. Health care providers should offer patient information that is clear and simple, both verbally and in written form. Research to date has shown that information is most helpful when it is conveyed in a supportive tone and avoids stigmatization. Treatment decisions should consider the patient's preferences and the clinician's ability to offer certain therapies. A locally relevant algorithm and an individualized treatment approach are recommended by various treatment guidelines to improve the chances of compliance and treatment success. Given that success rates are variable, monitoring treatment is also necessary to gauge the patient's response to treatment, local reactions, and the potential need to switch treatments. Patients diagnosed with EGWs should also be screened for other sexually transmitted diseases because coinfection is common. Vaccination is becoming an increasingly important aspect of prevention strategies for HPV infections and should be considered for eligible patients.

Seborrheic dermatitis is one of those conditions that dermatologists and patients alike tend to find a routine for, and in many cases those routines are hard to break. And, unlike the new treatment paradigms for eczema, acne, and even actinic keratoses, combination therapies for addressing the disease process typically have not been a part of the approach to treating seborrheic dermatitis. However, with the advent of new therapies and vehicles as well as a better understanding of how neutrophils and free oxygen radicals impact inflammation,1 there are new options to maintain and control the disease process of seborrheic dermatitis to minimize flares. Although the needs of the scalp, face and chest are different, as are the variations in skin types, the fundamental mechanisms of the inflammatory process are often the same. If it is understood that seborrheic dermatitis is histologically classified as a papulosquamous disorder with paucineutrophilic and lymphocytic infiltrates, and if the trigger and etiologic agent most likely is Malassezia furfur, then the ideal mechanisms of action of therapies should be directed as such

Azelaic acid (AzA) gel 15% is approved by the US Food and Drug Administration (FDA) for the treatment of papulopustular rosacea (PPR). Its efficacy and safety as monotherapy have been demonstrated. Release of active drug from the gel formulation is superior to the cream. The combination of AzA gel 15% with oral doxycycline appears to expedite and augment response, especially in cases of PPR of greater severity, and AzA gel 15% maintains control of PPR over 6 months as compared to vehicle. Adjunctive skin care is recommended to augment the therapeutic outcome of PPR and reduce the potential for irritation that can occur with topical therapy.

Data is very limited on the demographics, epidemiology, grading, and management of truncal acne vulgaris. In this study completed in 5 cities across the US, 696 patients were assessed to evaluate the frequency and severity of truncal acne vulgaris. Approximately 50% of patients who presented with acne vulgaris demonstrated involvement on the chest and/or back, with more than 3% presenting with truncal acne lesions alone. Interestingly, approximately 1 out of 4 patients who presented with both facial and truncal acne involvement did not voluntarily mention the presence of truncal acne as part of their presenting complaint. In such cases, the presence of truncal acne lesions was detected by clinical examination. A grading system for truncal acne vulgaris is also presented. The majority of patients presenting with truncal acne vulgaris exhibited mild to moderate severity and more than 75% were interested in treatment for truncal acne lesions.

We report a case of an elderly female in remission from acute myelogenous leukemia that presented with a nonhealing enlarging asymptomatic nodule on her right thigh. A wide excision of the nodule and histological examination revealed myeloid sarcoma without evidence or overlap of leukemia cutis, which had been suspected from nodules that had developed early in the course of the disease. The patient subsequently underwent radiation therapy to the area with sustained clearance.

Imiquimod is an immune-response modifier that has the potential to be useful in many dermatological indications (Table 1). To date, the approved use is for condyloma acuminata; approval for use in treating basal cell carcinoma (BCC) has been filed with the FDA and is expected to be approved in the coming months. In the interim, the expansion of the horizons for this immunomodulator depends on the application of the science and immunology behind the drug to the appropriate disease states. Recent investigations have presented explanations on the possible mechanisms behind the anti-tumor activity of imiquimod, more specifically for its use in treating superficial BCC. There are studies currently underway as well as anecdotal data published for its possible use in treating squamous cell carcinoma (SCC), although this is not as widely accepted for off-label use as BCC among many dermatologists. However, many patients who may not be surgical candidates that present with tumors other than BCC have been successfully treated with imiquimod. This is a case of an elderly patient who could not undergo surgery that presented with a large keratoacanthoma and was clear of her tumor after five months using imiquimod 5% cream on a daily basis.