Journal of Clinical and Aesthetic Dermatology

Updates on Psoriasis & Cutaneou Oncology

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S36 P r o c e e D i n G s JCAD jOUrnAl Of ClInICAl And AEsthEtIC dErMAtOlOgy september 2017 • volume 10 • number 9 • supplement medicine in general is personalized treatment, all the way to molecular targeting. the next step in the eBx evolution will be minimally invasive radiation therapy. to that end, much is needed: more prospective, long-term studies, more multidisciplinary conferences to share experiences, and the ability to incorporate treatment protocols for skin cancer into guidelines odered by national specialty societies. it would also be useful to defne an "area under the curve" (auc) for radiation therapy to better quantify treatments and compare data. ideally, there should be a method where dermatologists can perform HDr-eBx and superfcial radiation therapy independently, as dermatologists have traditionally been and continue to be skin cancer experts. Historically, too, dermatologists have typically performed radiation therapy on their patients with skin cancer. thus, dermatologists need to be better represented in these therapies and participate in conferences and development of guidelines for HDr-eBx and superfcial radiation. it may be that, in some areas, a hybrid system can emerge, bringing other disciplines to the care of skin cancer along with dermatologists. thE MAnAgEMEnt Of sCC In thE IMMUnOCOMPrOMIsEd PAtIEnt using a case study as an example, consider a 68-year-old white, female, immunosuppressed patient with multiple sccs on her legs and at signifcant risk for current or future morbidity and mortality from skin cancer. the treatment goal is to prevent morbidity from her multiple primary tumors while simultaneously decreasing her mortality risk from high-risk tumors. systemic retinoids may be appropriate for patients with multiple scc when there is a high risk for metastatic cancer with scc (risk ≥20%), when metastatic cancer is already present, when the patient is experiencing surgical fatigue, or when the patient's pharmacological regimen calls for a decrease in immunosuppressive drugs. systemic retinoids should be started at a low dose (10mg/day) and increased gradually up to 25mg/day, titrating the dose carefully to manage side edects. systemic retinoids represent a possible life-long therapy for such patients, so it is important to manage adverse events. occasional drug holidays may help patients cope with transient side edects. adverse events associated with systemic retinoids may be grouped in three broad categories: the mucocutaneous side edects include skin peeling, cheilitis, and scalp alopecia; patients may experience musculoskeletal adverse events, including hyperostosis; and fnally, systemic retinoids may cause or exacerbate hyperlipidemia, which may be managed with lipid-lowering agents. Patients should be advised that stopping treatment with systemic retinoids will increase their skin cancers. Patients on systemic retinoids should be subjected to laboratory tests at baseline, monthly for the frst three or four months of therapy, and then every three or four months thereafter once the patient is stable. these labs should include triglyceride monitoring and liver function testing. as with any therapy, systemic retinoid treatment oders risks and benefts. the advantages include possible decrease of scc and Bcc and possible reduction of the risk for metastasis and recurrence. on the other hand, systemic retinoid is a life-long therapy that may not be well tolerated by patients. systemic retinoid treatment is preventative rather than therapeutic and is associated with potentially serious side edects. in this particular case study, the 68-year-old patient could not adord the $800 a month it would cost for her to get acitretin. for such patients, ala-PDt every 6 to 8 weeks may help prevent new lesions and may be reimbursable. PDt can help reduce new scc lesions in immunocompromised patients. in a study of solid organ transplant recipients treated with cyclic PDt, scc lesions decreased 79 percent over baseline (73.3 to 81.8) in 12 months and 95 percent in 24 months (87.5% to 100%) 201 the problem with PDt over the long term is that patients may grow weary of it and want to discontinue. nevertheless, it represents a viable and important option. this year's MauiDerm convention continues to explore the new drugs, therapies, and approaches to psoriasis and skin cancers. the pathways associated with psoriasis continue to become better defned and with that, more edective and better tolerated treatments emerge. rEfErEnCEs 1. strober B, Bagel J, lebwohl M, et al. eecacy and safety of apremilast in patients with moderate plaque psoriasis with lower Bsa: week 16 results from the unveil study. J Drugs Dermatol. 2017;16(8):801–808. 2. Gottlieb aB, et al certolizumab pegol treatment for chronic plaque psoriasis: 16-week primary results from two phase iii, multicenter, randomized, placebo- controlled studies. abstract 5077. Presented at american academy of Dermatology 2017 annual Meeting; 2017 Mar 4. 3. final cimzia (certolizumab pegol) phase 3 trial meets primary eecacy endpoint in patients with moderate to severe chronic plaque psoriasis [news release]. Dermira; 2017 Jan 18. http://investor.dermira.com/phoenix.zhtml?c=253686& p=irol-newsarticle&iD=2238284 4. Warren rB, Mrowietz u, von Kiedrowski r, et al. an intensifed dosing schedule of subcutaneous methotrexate in patients with moderate to severe plaque-type psoriasis (MetoP): a 52 week, multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2017;389(10068):528–537. 5. Wu JJ, Guerin a, sundaram M, Dea K, cloutier M, Mulani P. cardiovascular event risk assessment in psoriasis patients treated with tumor necrosis factor-alpha inhibitors versus methotrexate. J Am Acad Dermatol. 2017;76(1):81–90. 6. reich K, Papp Ka2, Blauvelt a, et al. tildrakizumab versus placebo or etanercept for chronic plaque psoriasis COnClUsIOn

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