March/April 2019 - Faces of Dermatology by Advocates for Better Health

March/April 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

FACES OF DERMATOLOGY In This Issue: • Macaran Baird, MD Receives ves 2018 Shotwell Award • Ann Lowry, MD Receives Charles Bolles BollesRogers Award • Pete Dehnel Fellowship Holds Advocacy Workshop • Luminary of Twin Cities Medicine

“I TRUST DR. CRUTCHFIELD WITH MY SKIN.” C A T H E R I N E S T A N L E Y, M I S S M I N N E S O T A U S A 2 0 1 9

AES

“Look Good, Feel Great with Beautiful Skin.”

THET I C

L OF APPROVA L SEA

Photography by Olivia Crutchfield

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Recognized by Physicians and Nurses as one of the best Dermatologists in Minnesota for the past decade.

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 21, NO. 2 MARCH/APRIL 2019

IN THIS ISSUE

Dermatology in the Metro: A Bright Future By James Pathoulas, MS2

PRESIDENT’S MESSAGE

How Many Times Can the Canary be Resuscitated? By Ryan Greiner, MD

5 6 7 10

TCMS IN ACTION By Ruth Parriott, MSW, MPH, CEO TCMS ANNUAL MEETING ADVANCES IN DERMATOLOGY

•

Colleague Interview: A Conversation with Maria Hordinsky, MD

•

SPONSORED CONTENT:

Melanoma: An Update on Treatment Options By Lori Fiessinger, MD and Evidio Domingo-Musibay, MD

Page 7

Page 29 MetroDoctors

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Mohs Surgery: The Gold Standard in Skin Cancer Treatment By Sachin Bhardwaj, MD and Amanda J. Tschetter, MD

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Tanning Beds Offered as a Perk — Really? By Bruce Gregoire, MS2, University of Minnesota

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Public Health Advocacy Fellowship Update: January Workshop — “From the Clinic to the Capitol”

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Managing Pediatric Atopic Dermatitis By Sarah Asch, MD

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Cosmetic Dermatology for the Aging Face By Jing (Jenny) Liu, MD

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Dermatomyositis: Five Cutaneous Clues By David R. Pearson, MD

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Environmental Health — The Impact of Climate Change on Skin Disease By Mark D. Nissen, MD

Honoring Choices Approaches Young Adults to Talk About Advance Care Planning

29 30

2018 Shotwell Award: Macaran A. Baird, MD, MS

31 32

March/April 2019

Page 30

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

FACES OF DERMATOLOGY In This Issue:

Charles Bolles Bolles-Rogers Award— Ann C. Lowry, MD, FACS, FSCRS/ Senior Physicians Association In Memoriam/Career Opportunities LUMINARY OF TWIN CITIES MEDICINE

Noel Hauge, MD The Journal of the Twin Cities Medical Society

• Macaran Baird, MD Receives ves 2018 Shotwell Award • Ann Lowry, MD Receives Charles Bolles BollesRogers Award • Pete Dehnel Fellowship Holds Advocacy Workshop • Luminary of Twin Cities Medicine

This issue features recent advances in Dermatology highlighting treatments for skin of all colors and all stages of disease. Articles begin on page 7.

March/April 2019

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

March/April 2019

March/April Index to Advertisers

TCMS Officers

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Classified Ad .......................................................24

TCMS Executive Staff

Crutchfield Dermatology..................................... Inside Front Cover

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

Dermatology Consultants................................. 9

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Fairview Health Services .................................31

Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

HealthPartners......................................................... Outside Back Cover

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

TCMS 2019 Annual Meeting ......................... 6

Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com

University of Minnesota Health ........................ Inside Back Cover

Annie Krapek, Program Manager, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

Uptown Dermatology & Skin Spa ..............24

Amber Kerrigan, Project Coordinator, Physician Advocacy Network (612) 362-3706; akerrigan@metrodoctors.com

NEED HELP? Feeling overwhelmed and turning to alcohol and/or drugs for relief?

Physicians Serving Physicians is an independent, physician-centric organization that was established in 1981 by a group of physicians in recovery to help other physicians and their families struggling with chemical dependency. The core of PSP’s mission is to provide active help and service to physicians (including residents), medical students and their family members affected by alcohol and drug addiction.

Physicians Serving Physicians can help! For confidential assistance: • Call: (612) 362-3747; email: psp@metrodoctors.com • Jeffrey Morgan, MD, Interim Medical Director, (612) 267-8912 • Psp-mn.com

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Dermatology in the Metro: A Bright Future

In medical school, the introductory lecturer for each organ system makes the same claim: “This organ system is the most important. It supports all others and you couldn’t live without it.” As a second-year medical student, I always enjoy hearing passionate professors defend their field of study at the beginning of the semester. This year, however, Dermatology did not provide a customary reason for why we should pay attention. Instead our course director led us through how a vast number of dermatologic and systemic diseases present on exam in, what seemed at the time, infinite variations. Human skin, hair, and nails both maintain and are a window to our internal physiology and pathology. Dermatologic findings can also tell stories of lived experiences — good and bad. For example: individuals who present with only left-sided solar damage are more likely to be semi-truck drivers; humorous stories from tattoo removal clinics could be compiled into a best-selling book; and scars can be either constant reminders or sources of empowerment. Patients with dermatologic disease face unique and challenging social realties. Take, for example, the impact of vitiligo on a patient who identifies as African American. Prior to JAK inhibitors, skin bleaching was the standard of care for vitiligo — causing understandable discord in patients of color. Adolescent acne, considered by some to be a requisite of puberty, has devastating psychological consequences in vulnerable sub-groups including Lesbian, Gay, Bisexual, and Transgender (LGBT) youth. The social consequences of dermatologic disease are an important consideration in treatment and have lessened with the development of new treatment options, which are discussed throughout this issue of MetroDoctors. A clear theme by all the authors in this issue is a passion for treating disorders of the skin and a desire to seek and embrace disruptive technology and therapies to advance patient care and safety.

By James Pathoulas, MS2 Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

This issue contains articles forecasting the future practice of Dermatology, innovative research, exciting new biologic therapies, treating skin of color, cytogenetic and treatment advances in melanoma, dermatologic surgery, breakthroughs in dermatomyositis, considerations for aging and pediatric skin, banning tanning beds, and the impact of a changing climate on disorders of skin. This interplay of environment and genetics underlies much of dermatologic disease and drew the attention of our Luminary, Dr. Noel Hauge, to an accomplished career based on improving patient care and groundbreaking research. Our issue also features an interview with Dr. Maria Hordinsky, Professor and Chair of Dermatology at the University of Minnesota. I had the opportunity to record a fun and broad-ranging interview with Dr. Hordinsky, who is a world expert in hair and scalp disorders. To see our YouTube interview: open your camera app, point it at the QR box in our article, click on the link that appears on the top of your screen, and enjoy! By the end of this issue, you, too, may be convinced that our skin, hair, and nails make up the most important system. At the very least, you will find a succinct summary of advances in dermatologic therapies, clinical pearls, and a better understanding of the body’s largest organ. March/April 2019

President’s Message

How Many Times Can the Canary be Resuscitated? RYAN GREINER, MD

Once is enough… The canary (physician) in the coal mine (healthcare system) has become the “go to” analogy to describe the ubiquitous crisis of physician burnout. However, it seems the cleverness of this analogy has diluted the seriousness of its meaning. Imagine if coal miners, having discovered their deceased or dying yellow companion, convened a committee to formulate a recommendation for how leadership should respond. Is it serious enough to evacuate? Should we send another canary down to confirm? Perhaps we should just let things air out a bit so that we can go back to work. Meanwhile, the effort to resuscitate their winged friend continues. There actually was a special cage for reviving a canary; essentially a little canary oxygen chamber. Then back down they go, into the coal mine to serve another day. The mental health of physicians is the most important issue facing the healthcare system today. We’ve colored the discussions by using terms like burnout, mindfulness, and work-life balance, but the true descriptors are suicide, depression, alcoholism, substance abuse, and patient harm. We all know the statistics. Burnout is systemic among physicians. Each year, 300-400 physicians die by suicide. This is more than what is seen with military professionals and about double the general population. These high rates among physicians have been reported since 1858 and yet, despite having 150 years to tackle this crisis, the root causes of these deaths have yet to be addressed. Dr. Pamela Wible, a family medicine physician in Eugene, OR writes and speaks prolifically about physician mental health and is the founder of the ideal medical care movement. She has investigated 757 physician suicides over the last five years and has discovered the following themes, to name a few: family members of doctors who have killed themselves are also at high risk of suicide; patient deaths hurt doctors; “happy” doctors also die by suicide; malpractice suits can be devastating; academic distress kills medical students’ dreams; assembly-line medicine hurts doctors; bullying, hazing, and sleep deprivation increase suicide risk; blaming doctors increases suicide risk; doctors who need help don’t seek it because they fear mental health care won’t remain confidential; and some doctors develop on-the-job post-traumatic stress disorder. There was no mention of EMRs or lack of time for yoga, meditation, and mindfulness. Unless we commit to far reaching change, the healthcare system continuum, starting with medical school and ending in clinical practice, will continue to be an unsafe work and training environment that drives the development of mental health disorders and death by suicide. Where is the modern-day Abraham Flexner for our medical education system? Who is going to drive the call to action for addressing the root causes of physician mental health disorders? This is a crisis ripe for a physician intervention, but we must be willing to talk about our own struggles with mental health issues and substance abuse. We must demand something different from our medical schools, residency programs, and employers. Perhaps if we committed to tackling physician suicide rather than physician burnout, the urgency for change may manifest differently. Your Twin Cities Medical Society (TCMS) is committed to physician well-being and believes in the Minnesota Medical Association’s mission to make Minnesota the best state in which to practice medicine. TCMS has made the initial investment in this work by providing management services to Physicians Serving Physicians (PSP). PSP offers a monthly confidential peer support group that brings together physicians who are struggling with substance abuse disorders and provides support, consultation and referral sources. There is no cost. PSP is supported by grants and donations from hospitals, health systems, medical staff gifts and individual donations. If you or someone you know needs help, please contact PSP at (612) 362-3747, for confidential, reliable information and support. Or visit their website www.psp-mn.com for more information. 4

March/April 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

TCMS Sets its Legislative Focus

The 2019 Board of Directors braved the cold in the last days of January to share thoughts about how physicians can make a difference during the current state legislative session. The directors agreed that the Twin Cities Medical Society will continue its strong tradition of physician advocacy in advance care planning and tobacco use prevention and control. Priorities include a renewal of the state appropriation that expanded Honoring Choices beyond its roots in the metropolitan area to more than 15 additional communities across the state and supports new partnerships with American Indian and African American health leaders to develop culturally appropriate resources to promote advance care planning conversations in those communities. With a greater understanding of the benefits of patient-centered decision making during illness and at the end of life, the advance care planning appropriation has already gained the support of legislative leaders on both sides of the aisle. Physician voices will be equally important in the tobacco control movement’s triple legislative initiative: to include electronic smoking devices in the state smoke-free law, to fully fund a state Quitline to help those battling nicotine addiction, and to raise the legal age for purchasing tobacco to 21. While these common sense measures are popular with the public, it is imperative that the debate focus on the health benefits in order to make it through an often grueling legislative process. The Board also discussed their interests in measures to reduce deaths from gun violence and opioid addiction, promoting health equity through MetroDoctors

affordable housing and contraceptive care, environmental justice and healthy food access, and ensuring that stable funding for Medical Assistance and MinnesotaCare is continued despite the scheduled end of the provider tax. There is no doubt that TCMS members have a broad range of concerns for the health of their patients and our community at large. Follow Twin Cities Medical Society on Facebook and Twitter @ TCMSMN to stay abreast of the TCMS legislative priorities and join our Physician Advocacy Network (www.panmn. org) to add your expertise to important public debates. The directors also welcomed the new slate of officers who will lead the Society through the next year. You are cordially invited to chat with all of the Board Directors at the annual meeting on May 6, which will offer both socializing with peers and inspiration for physician leadership. (See invitation on page 6).

2019 Executive Committee. Clockwise from top left: Sarah Traxler, MD – President-Elect; Ryan Greiner, MD – President; Tom Kottke, MD – Past-President; Andrea Hillerud, MD – Secretary; Rupa Polam Austria, MD – Treasurer; and Matt Hunt, MD – At-Large.

The Journal of the Twin Cities Medical Society

Inspiring a New Generation of Physician Advocates

What an amazing story: educated as a transplant surgical nurse, moving into health policy with the Attorney General’s office and the MN Nurses Association, followed by election to state office and legislative leadership, culminating in attaining a major party’s endorsement for governor! TCMS’s medical student advocacy fellows were mesmerized by former Rep. Erin Murphy’s descriptions

of her path from medical professional to statewide thought leader in health care and public health policy. Her message was a clarion call-to-action for those with medical acumen willing to dive into messy public debates in order to forge a better life for their fellow citizens. Rep. Murphy’s passion and resolve made it clear she has much more to contribute, and no doubt made a lasting impression on medical students eager to fully leverage their medical education. (See article on page 20). March/April 2019

Save the Date! Monday May 6, 6:00-8:00PM Surly Brewing Company, 520 Malcolm Ave SE, Minneapolis, MN 55414 Plan now to join us for an evening to celebrate all that TCMS accomplishes! Hear speakers share how they have bene��ed from our work and from the visionaries who are planning our future, while enjoying the uni�ue se�ng, hors d’oeuvres and refreshments oﬀered by Surly.

Watch for details, as there will be limited capacity.

Advances in Dermatology

Colleague Interview: A Conversation with Maria Hordinsky, MD

r. Maria Hordinsky is Professor and Chair of Dermatology at the University of Minnesota Medical School. She serves as President of the American (North, South, Central) Hair Research Society and is on the Board of Directors of the Cicatricial Alopecia Research Foundation. Dr. Hordinsky is recognized as an international expert in hair diseases including alopecia areata and the cicatricial alopecias such as frontal fibrosing alopecia and lichen plano pilaris. She also has a special interest in neurodermatology and furthering our understanding of skin pain, burning and itch with colleagues in Neurology.

Questions and answers edited for clarity and brevity only. Open your phone camera and follow the auto-generated link to see the recorded interview.

Where do you see the practice of Dermatology going in 2019 and onward — both academic and private? It’s changing. I think academic Dermatology will stay as it is for those interested in research, seeing patients, and teaching. Residents in our field are entering large multispecialty clinics or practices with several dermatologists. The practice of Dermatology varies across the country. For example, in the Twin Cities we are unique in having several practices with many dermatologists whereas for example, practices in Southern California tend to be smaller. Additionally, residents finishing in 2019 will be facing the acquisition of practices by venture capitalists. For example, my daughter is a dermatologist in Reno, Nevada and it’s my understanding that most practices there are owned by one company based out of a different state. There are many options for new graduates in 2019. However, we can’t forget that there are still physicians going into private practice. MetroDoctors

The Journal of the Twin Cities Medical Society

Why did you pick academic medicine? I got a grant after residency. It was an NIH grant like a T32 grant, which funded fellowships for research. I was offered one and discovered that research was actually quite fun and liked that you were actually paid to do interesting work in the lab or translational research. That grant was followed by others including another NIH grant and that is how I got started — that was the bug.

Can you speak about the rapid growth of the Dermatology faculty here at the University? Our department has transformed in the last couple of years, which goes along with the transformation that is occurring in our specialty. We have been very focused on the development of the medical dermatology combined residency, and concurrently having an outstanding categorical dermatology program. The combined medicine/dermatology residency was started over a decade ago. Trainees finish as very well-trained medical dermatologists and internists. Dermatologic surgery continues to be a major part of our program. More recently, new technologies have been introduced including the use of lasers to treat many different types of dermatologic conditions. Lasers themselves have been around for a while but the way in which they and newer technologies are now being applied to different dermatologic (Continued on page 8)

March/April 2019

Advances in Dermatology Colleague Interview (Continued from page 7)

diseases by junior faculty who are exploring new directions and applications is very exciting. We also now have a very strong Pediatric Dermatology division and these faculty, too, are very engaged in clinical research and the use of new technologies to treat challenging skin conditions affecting children. Lastly, the Dermatopathology division has grown significantly in the past few years. These talented faculty are focused on providing quality interpretations of skin biopsies.

Surgery has always been a part of Dermatology, but the scope varies by location. What is the line between Dermatology and Plastic Surgery and how do you observe it here? Here at the University there is a wonderful relationship between Plastic Surgery and Dermatology. Part of that comes from the development of the cosmetic center by one of our new faculty Dr. Ronda Farah. She integrated Plastic Surgery into the newly established combined cosmetic center. There is a synergy between the two specialties.

The research volume of your department is significant, and you have hired new faculty to expand it. How, as Department Chair, do you provide an environment for them to flourish? That has come from leadership overall. One of our unique challenges at the University of Minnesota is that we are in the middle of the country, which can make recruitment difficult. We go through highs and lows in the research arena as a result. Meaning we have periods of strong NIH funding, then we slip a bit — which has been the case for decades. I thought when I came into this position years ago that I would break that trend. It is still a challenge and a goal of mine to stabilize our rankings. However, behind this is an energized and motivated faculty. They are looking at new technology, new developments, and new treatments for patients. It’s different than having a laboratory with mice models. Both types of research are important and unique.

What are some trends in alopecia? The biggest trends are looking at growth factors for alopecia. Which ones really work and what is the right combination? That is where we are headed in 2019. In terms of new drugs and treatments, you are going to see new anti-androgens be tested in phase three trials as well as the results of clinical trials using Janus kinase (JAK) inhibitors both topically and orally, particularly for alopecia areata. Another key treatment is photobiomodulation, which is a type of light treatment. Expect more trials and information on this approach as well in 2019. 8

March/April 2019

Can you share more about photobiomodulation? Light treatment is fascinating for the treatment of hair disease. For example, who would have thought that low level laser light — the kind that you have in a laser pointer — can grow hair? The FDA has now cleared several devices for this purpose. We now have patients coming into clinic asking which device is best to use as the majority can be purchased by the consumer. As we really don’t know, we got engaged in a clinical trial a few years ago looking at the laser comb device. We got a sense that it did improve outcomes for some and our data was okay, but it was not startling. We are now looking at several devices in an IRB-approved investigator initiated study. Of note, there has always been a connection between light and hair. For example, when some people get laser hair removal they can get paradoxical hair regrowth, and others who have porphyria cutanea tarda with light exposure can also experience hair growth.

What have you noticed dermatologists in other countries doing that American dermatologists are not? The American Hair Research Society has grown to include counterparts in Central and South America. When you talk to dermatologists in other parts of the world it becomes apparent that we are a little more regulated so it’s more difficult to be as bold and innovative. However, the use of platelet rich plasma (PRP) is a therapy many dermatologists in the United States are using to treat alopecia but this same therapy has not been allowed in Brazil.

Can you talk about the recent use of JAK/STAT inhibitors for a wide variety of hair and skin disorders? Sure, there are a number of JAK pathway inhibitors. These are being manufactured by a number of companies for several skin conditions including atopic dermatitis, eczema, and sarcoidosis. Contrasted with steroids where we are essentially targeting a large number of pathways, JAK inhibitors are more specific. However, they still aren’t specific and targeted enough so research continues. For example, in alopecia areata around 70% of patients are responding to JAK inhibitors but there are 30% who don’t respond. We also need to ask the question with these immune modulators: is one going to have to use these treatments life-long? From an immunologic perspective, we are still looking at the long-term safety of using oral JAK inhibitors to treat immune mediated skin diseases. The results of current research will be tracked for the next several decades, but for now many patients are very thrilled with their results.

MetroDoctors

The Journal of the Twin Cities Medical Society

What are some research and treatment trends in neurodermatology? We are fortunate to have colleagues in Neurology who are partnering with us in the area of neurodermatology. The patient we are talking about is someone who has pain or itch that canâ&#x20AC;&#x2122;t be characterized. They will say that their skin is burning but on exam it is fine. However, to them, it is burning. We took this group of patients and asked what could be going on with the nerves in the skin. Many think of such patients as having psychiatric conditions. We partnered with Neurology to look at a biological cause by examining inflammatory markers, nerves, and neuropeptides like calcitonin gene related peptide, and substance P.

What has been the biggest change in the practice of dermatology since you first started? One of the biggest changes was the development of biologics and targeted therapies. For example, when you think back, patients with erythrodermic psoriasis or severe eczema could have been hospitalized for two to three weeks and treated with topical steroids

and wraps and be maintained in the hospital for a long period of time. That era has definitely passed and, with the development of treatments that target specific Cytokines, the treatment of severe psoriasis, and atopic dermatitis has revolutionized management of these at times difficult to treat diseases.

About 60% of physicians under 35 are female, a stark contrast to what was a male dominated field 20 years ago. Why do you think we see this trend and what are the implications? Great question. It probably goes back to the pipeline of who is being groomed and who is being brought through the competitive application process. We see this, too, in our Dermatology program where this year we have four categorical spots and two medicine/dermatology spots. When you go through the process of screening, which is not biased to gender, the number of qualified females is higher than the number of qualified males. I think more women today are more confident and driven to succeed in health care than in other STEM careers, such as computer science and engineering.

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651.209.1600 March/April 2019

Sponsored Content

The Dermatology Challenge: When to Refer, How to Partner, Why it Matters Contributed by Karla Rosenman, MD and Darin Epstein, MD

Pick up practically any magazine in the grocery store check-out line and you’ll see dermatology headlines: “Say ‘goodbye’ to rough winter skin” “Mole or melanoma?” “Three tips for managing eczema” Unfortunately, dermatology appointments are harder to come by. In fact, in several metropolitan areas, it’s common for a new patient to wait more than 30 days to get an appointment with a dermatologist. The visible nature of most skin conditions lead to high patient demand for dermatology services. However, only 1-2% of physicians in the United States are dermatologists, so demand will likely always be greater than availability. Additionally, with only 472 dermatology physician training positions available in the United States each year, compared to over 30,000 total physician training positions, the percentage of dermatologists is unlikely to increase in the foreseeable future. How, then, does the medical community make the most of its limited access to dermatologists? To start, clinicians should recognize the limitations of skin cancer screenings. Cancer screenings are beneficial when the type of cancer being screened for has the potential to cause death and the screening intervention has been shown to reduce the chance of death from that cancer. However, the most common types of skin cancer, basal cell carcinoma and squamous cell carcinoma, rarely cause death or significant morbidity. These cancers account for less than 0.1% of skin cancer deaths. While melanoma can be deadly, 10

March/April 2019

Karla Rosenman, MD

Darin Epstein, MD

the US Preventative Task Force’s 2016 review of the medical literature on skin cancer screenings found that the “Evidence is inadequate to reliably conclude that early detection of skin cancer through visual skin examination by a clinician reduces morbidity or mortality.” Additionally, potential harm from skin cancer screenings exists, including unnecessary biopsies, over-diagnosis and overtreatment. So what should clinicians do when their patients ask about skin cancer? Share ways to reduce their risk of skin cancer. Encourage patients to use sun-protective clothing and sunscreen — and avoid tanning beds. This is especially important for patients 6 months old to 24 years old who have fair skin types. However, patients with changing, bleeding, or ‘ugly duckling’ skin lesions do benefit from rapid access to care. To ensure these patients have access to care when they need it, health systems could

consider partnerships between dermatology and primary care physicians. At HealthPartners, dermatologists support primary care clinicians in diagnosing and treating a multitude of skin conditions, and performing skin biopsies. Its dermatologists teach family medicine residents skin biopsy techniques and provide skin biopsy courses at CME conferences to ensure primary care clinicians know how to perform this important first step in diagnosing skin cancer. Additionally, for urgent referrals from primary care clinicians, there are specific appointment slots built into HealthPartners dermatologists’ schedules. But people who have multiple atypical moles, a history of melanoma, or people who have medical conditions that increase the risk of skin cancer, like a renal transplant, should be seen by dermatologists. Beyond skin cancer, clinicians should refer patients with chronic inflammatory conditions like psoriasis, atopic dermatitis,

MetroDoctors

The Journal of the Twin Cities Medical Society

and hidradenitis suppurativa to dermatology. There are many newer medications available to help these patients manage these chronic skin issues. Psoriasis

According to the National Psoriasis Foundation, more than 8 million people in the United States have psoriasis. Historically, treatment was limited to topical medications, phototherapy, and systemic oral medications, like methotrexate, that have significant side effects, such as liver toxicity. However, multiple biologic medications targeting key immune pathways have recently been approved for psoriasis: tumor necrosis factor alpha inhibitors (etanercept, adalimumab, infliximab), interleukin 12/23 inhibitor (ustekinumab), IL-17 inhibitors (secukinumab, ixekizumab, brodalumab), and IL-23 inhibitors (tildrakizumab, guselkumab). These biologic medications have achieved impressive results. In clinical trials, treatment with the IL-17 and IL-23 inhibitors achieved at least 75% improvement in Psoriasis Area and Severity Index score among 80-90% of patients. These effective treatments prompted the National Psoriasis Foundation to establish the “Treat to Target” goal of 1% body surface area or less within three months of starting a new treatment. Dermatitis

Atopic dermatitis — or eczema — is also benefiting from biologic medications, which is encouraging considering it’s the most burdensome skin condition, according to the Global Burden of Disease study. In the US alone, nearly 32 million people have it. The first biologic medicine for atopic dermatitis, dupilumab, was approved by the FDA in March 2017. It is a fully human monoclonal IgG4 antibody that inhibits the cytokines IL-4 and IL-13, which are central to the pathogenesis of atopic dermatitis. Trials showed that 60% of patients with moderate-to-severe atopic dermatitis achieved a 75% or greater reduction in their Eczema Area and Severity Index following weekly or biweekly dupilumab injections. Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a less MetroDoctors

common chronic inflammatory skin disease, but burdensome nonetheless. It’s also responsive to a biologic medication called adalimumab. Patients with HS experience painful, draining lesions in the apocrine gland-bearing regions of the axilla, chest, buttocks, and groin. It effects an estimated 1 to 4% of the population. But with adalimumab treatment, patients experience improvement in their fistulas, inflammatory nodules, and skin pain as early as 2 weeks. As in all areas of medicine, the best outcomes happen when clinicians collaborate. While biologic medications significantly benefit dermatology patients, they are also associated with risks. Patients treated with dupilumab are at increased risk for inflammatory conjunctivitis which may require an ophthalmologist’s expertise. Many of the biologic medications for psoriasis are associated with increased risk of infection, including reactivating tuberculosis. If a patient becomes ill or shows signs of infection, it’s important the patient stop taking the medication and seek care. Perhaps the strongest reason for collaboration between dermatologists and other clinicians is that many conditions, like psoriasis and HS, are more than skin deep. Both psoriasis and HS are associated with a significant increase in cardiovascular disease risk. According to an American Journal of Medicine study, severe psoriasis confers an additional 6.2% risk of a major adverse cardiac event over 10 years compared with the general population. A JAMA Dermatology study found that the risk of cardiovascular death was 58% higher in patients with HS than in patients with severe psoriasis. Dermatologists closely partnering with Primary Care will ensure this heightened cardiovascular risk is factored into patients’ overall care. Improving Access Through Technology, Education

Because most dermatology conditions are visible on the skin, they lend themselves to digital forms of care. HealthPartners Dermatology partnered with Virtuwell, its online diagnosis and treatment service, to build treatment plans for more than 30 common skin conditions. A Virtuwell visit provides patients with a virtual exam

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from the comfort of home and a dermatology-approved treatment plan in about 30 minutes. For patients who prefer in-person visits, HealthPartners Dermatology has partnered with Primary Care to make it easier for patients to receive acne care in Primary Care. Shared treatment protocols built into the electronic medical record enable primary care clinicians to prescribe the same treatment that a dermatologist would. To address the need for additional dermatologists, the HealthPartners and Park Nicollet Dermatology departments partnered with the HealthPartners Institute to establish a dermatology residency physician training program. The HealthPartners Institute Park Nicollet Dermatology Residency was accredited by the Accreditation Council for Graduate Medical Education in 2018. The three-year training program will accept two physicians each year starting July 2019. It’s one of the few dermatology residency training programs in the nation embedded in an integrated healthcare system. By working together we, as a medical community, can continue to provide evidence-based care and achieve the best outcomes for our patients while making the most of our limited healthcare resources. Karla Rosenman, MD, is a dermatologist and dermatopathologist at the Park Nicollet Clinic in St. Louis Park and Vice-Chair of Dermatology across the HealthPartners Enterprise. She has been with Park Nicollet since 2009. She is an Epic-certified Physician Builder who is passionate about harnessing the power of the electronic medical record for the good of patients and clinicians. Darin Epstein, MD, is a dermatologist at the Park Nicollet Clinic in St. Louis Park and Chair of Dermatology across the HealthPartners system. He has been with Park Nicollet since 2005 and has led the expansion of Dermatology from under 10 clinicians to over 50 clinicians at 11 locations, with subspecialty care that includes Contact Dermatitis, Pediatric Dermatology, Cosmetic Dermatology, and Mohs/Dermatologic Surgery.

March/April 2019

Advances in Dermatology

New Drugs in Dermatological Medicine

A discussion of the growing importance of new biologics and Janus kinase(JAK) inhibitors as treatment for specific skin diseases, and trends in research and drug development. Biologics and Janus kinase (JAK) inhibitors are two drug innovations changing the way many dermatologists manage and care for patients with recalcitrant disease whom were previously left without other treatment options. The treatment algorithm for psoriasis has been completely changed since the introduction of the anti-tumor necrosis alpha (TNF) agents almost 20 years ago and continues to evolve with the newer IL-23 inhibitors stekinumab and guselkumab, and the IL-17 inhibitors secukinumab and ixekizumab. Dupilumab, the first biologic drug for atopic dermatitis, is a new medication approved to treat atopic dermatitis. JAK inhibitors, a new class of disease modifying anti-rheumatic drug, are currently being explored for treatment of alopecia areata and other dermatologic conditions. Treating Psoriasis and Atopic Dermatitis

Biologics have revolutionized the treatment of psoriasis and there are multiple classes of biologic drugs available to treat psoriasis patients. Several biologics that target psoriasis, including the IL-17 inhibitors secukinumab, ixekizumab, and guselkumab, have been FDA approved within the last five years. While dupilumab is the only biologic medication available to

By Phillip Keith, MD and Kathryn Barlow, MD

March/April 2019

Phillip Keith, MD

Kathryn Barlow, MD

treat atopic dermatitis, the JAK inhibitor fofacitinib has been used to treat alopecia areata, vitiligo, atopic dermatitis, and psoriasis. It’s important to note that patients with atopic dermatitis have an impaired skin barrier that leads to an overactive Th2–driven immune response.1 Dupilumab is an injectable human monoclonal IgG antibody FDA-approved for the treatment of atopic dermatitis in March 2017. Duilumab is an IL-4 receptor alpha-antagonist. By binding to the IL-4 receptor, it in turn inhibits the signaling of both IL-4 and Il-13. Both IL-4 and IL-13 activate and encourage the survival of Th2 cells, and their levels have been correlated with atopic dermatitis disease severity. The reduction of IL-4 and IL-13 helps decrease inflammatory mediators and helps upregulate the production of epidermal barrier proteins. This results in clinical and symptomatic improvements for the patient.2 Many of the placebo-controlled clinical studies demonstrated marked improvement in skin involvement as well as

a significant reduction in pruritus at 16 weeks. When combined with a regimen of topical corticosteroids, the results are even better. In fact, many of our own patients have commented in clinic that this medication has been no less than “life changing.” Treating Alopecia Areata with JAK Inhibitors

Alopecia areata is a common autoimmune disease that causes hair loss in people of all backgrounds and ages, yet the severity of this condition is highly variable. Alopecia areata can have a serious impact on a patient’s well-being, and is associated with anxiety, depression, psychosocial distress, as well as other autoimmune diseases.3 There are four JAK proteins: JAK1, JAK2, JAK3, and tyrosine kinsease 2(TYK2). These drugs work by blocking the JAK STAT signaling pathway that activates inflammatory gene expression and cytokine production that contributes to alopecia areata.4, 5 Tofacitnib (a JAK 1/3 inhibitor), FDA approved to treat rheumatoid arthritis,

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and ruxolitinib (a JAK1/2 inhibitor), FDA-approved to treat myelofibrosis and polycythemia vera, have been used to treat recalcitrant alopecia areata. One study found oral tofacitinib therapy was associated with hair regrowth in approximately 64% of patients after a three-month period. The same study found that 32% of patients achieved greater than 50% improvement in their Severity of Alopecia Tool (SALT) score.6 Another study also reported regrowth with 58% achieving greater than 50% improvement in their SALT score for a four to 18-month duration.7 Oral ruxolitinib was associated with 75% of patients reaching a SALT score greater than 50%.8 Topical tofacitinib and ruxolitinib can be effective10 and theoretically are less likely to have systemic side effects.9 JAK inhibitors can be used to treat severe and recalcitrant alopecia areata in patients who do not respond to conventional therapies such as topical or intralesional steroids, minoxidil, or topical immunotherapy. JAK inhibitor therapy may need to be continuous since alopecia frequently recurs with drug discontinuation.3 These medications are associated with increased risk of urinary tract infections, varicella zoster reactivation, cytopenias, and mild increases in cholesterol but do not appear to increase the risk of malignancy. Obtaining a complete blood count, creatinine, hepatic functional panel, hepatitis B, hepatitis C, and tuberculosis screening is recommended prior to starting treatment.10 Cautions when Using Biologics and JAK Inhibitors

Biologic medications can have rare but serious side effects and, in some cases, have been associated with increased risks of infections, demyelinating neurologic conditions, and malignancy. It’s important to note that most biologic drugs require baseline and annual tuberculosis screening in addition to other specific laboratory tests to ensure patient safety. The associated adverse side effects of systemic JAK inhibitors include infections, drug eruptions, hematological abnormalities, and hyperlipidemia. On the other hand, topical JAK inhibitors have a low MetroDoctors

incidence of side effects which can be taken into consideration when prescribing treatment. Specifically, the most common side effects of dupilumab are injection site reactions, upper respiratory tract infections and conjunctivitis. The conjunctivitis, which in actual practice seems to be the most common side effect, is perplexing. At this time it’s unknown if this is related to the dupilumab specifically or is part of the impaired barrier and inflammation that comes along with atopic dermatitis. The use of artificial tears is recommended prophylactically, and loprednol ophthalmic drops or ointment does help to treat this if it occurs. So far, there have been no reports of increased risk of malignancy, but long-term data are lacking. Like many biologics, there is a risk of immunogenicity, or antibody formation, to the dupilumab, but in the clinical studies this seemed very low, about 6% overall, with only 2% that were persistent and drug-neutralizing. There is no recommended screening or ongoing monitoring required with dupilumab; however, any patient with a known parasitic or helminth infection should not use dupilumab until they are clear of the infection. The use of dupilumab in pediatric patients (those less than 18 years old, and pregnant or lactating women) has not been well studied. Live vaccines are not recommended while on dupilumab; however, the response to non-live vaccines did not seem to be altered or affected by dupilumab and are recommended as needed. Another challenge for these types of drugs may be financial. Although insurances do cover the costs of therapy, for some with high deductible plans it may be prohibitive. For example, dupilumab costs approximately $3,000 a month while systemic tofacitinib costs approximately $4,300 a month. One month’s supply of topical tofacitinib, however, costs approximately $330. The Place of Biologics and JAK Inhibitors within Dermatology Treatment

is a target for new psoriasis medications. Another biologic to treat atopic dermatitis that targets IL-4, IL-17, and IL-31 is also in development. Systemic and topical JAK inhibitors are also being considered for a broader span of dermatologic conditions, including vitiligo, atopic dermatitis and psoriasis. Stay tuned as more research is published, and exciting new applications of these innovative medications are introduced. Phillip Keith, MD and Kathryn Barlow, MD are board certified dermatologists practicing with Dermatology Consultants. Dr. Barlow received her medical degree from the Chicago Medical School and completed her Dermatology residency at Loyola University. Dr. Keith received his medical degree from the Medical College of Wisconsin and completed his Dermatology residency at Mayo Clinic Rochester. References: 1. Rahman S, et al. The pathology and immunology of atopic dermatitis. Inflamm Allergy Drug Targets 2011 Dec;10(6):486-96. 2. Gooderham, MJ et al. Dupilumab: A review of its use in the treatment of atopic dermatitis. J Am Acad Dermatol 2018;78:S28-36. 3. Strazzula et al. Alopecia areata disease characteristics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatology 2018; 78:1-14. 4. De Medeiros AKA, Speeckaert R, Desmet E, Van Gele M, De Schepper S, Lambert J, JAK3 as an emeriging target for topical treatment of inflammatory skin diseases. PloS One, 2016; 11: e0164080. 5. Schwartz DM, Bonelli M, Gadina M, O’Shea JJ. Type I/II cytokines, Jaks, and new strategies for treating autoimmune diseases. Nat Rev Rheumatol. 2016; 12(1): 25-36. 6. Kennedy Crispin M, Ko JM, Craiglow BG, et al. Safety and efficacy of the JAK inhibitor tofacitinib citrate in patients with alopecia areata. JCI Insgiht. 2016;1 (15):e89776. 7. Liu LY, Craiglow BG, Dai F, King BA. Tofacitinib for the treatment of severe alopecia areata and variants: at study of 90 patients. J Am Acad Dermatol. 2017; 76:22-28. 8. Mackay-Wiggan J, Jabbari A, Nguyen N, et al. Oral ruxolitinib induces hair regrowth in patients with moderate-to-severe-alopecia areata. JCI Insight. 2016;1(15):e89790. 9. Bayart C, et al. Topical Janus kinase inhibitors for the treatment of pediatric alopecia areata. J am Acad Dermatol 2017;77;167-170. 10. Damsky W, King B. JAK inhibitors in dermatology: The promise of a new drug class. J Am Acad Dermatol 2017;76:736-744.

There are several promising new treatments on the horizon. IL-23, for example,

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March/April 2019

Advances in Dermatology

Treating Skin of Color

ost skin diseases occur in people of all nationalities, regardless of their skin color. Particular problems encountered in the skin are more common in people with different hues of skin, and sometimes a disorder seems more prominent because of its unique presentation in skin of color. Melanocytes, located in the epidermis, determine skin color and make up only 2-3% of all skin cells; all people inherently have the same number of melanocytes. The variation in skin color we see across all people is determined by the type and amount of the pigment melanin produced by the melanocytes. Differences in skin color are probably a reflection of the skin’s ability to protect against ultraviolet radiation. Hence, groups of people living closer to the equator produce more protective melanin in the skin, and groups of people living further away from the equator produce less melanin — resulting in lighter skin color. Traditionally, in medical education in the US, inflammatory lesions have been described as red, pink, salmon, or fawn-colored. This indeed is true in Caucasian skin and in many of the medical textbooks this skin color represented the majority of patients depicted. However, in tan, brown, or dark-brown skin, inflammation can appear grey, copper, or violaceous in color. Additionally, certain conditions will have a slightly different presentation in pigmented skin (e.g., pityriasis rosea). Post-inflammatory Hyperpigmentation and Hypopigmentation Melanocytes can either stop producing color or produce excessive color in inflammatory By Charles E. Crutchfield, III, MD

March/April 2019

conditions. It is very common for a child of color to have a very light area of post-inflammatory hypopigmentation in the area of diaper dermatitis; however, with the appropriate treatment, the color almost always returns to normal within a few weeks. In older patients, inflammation can lead to post-inflammatory hyper-pigmentation. This is most commonly seen in areas where acne blemishes heal, leaving a dark spot behind. These too will fade with time; however, it can be quite persistent and require medical intervention. Vitiligo Vitiligo is a skin condition that occurs in all people but it is most noticeable in patients with tan, brown, or dark-brown skin, and presents as white patches on the skin. Because these areas lack natural photo-protection, vitiliginous patients must wear sunscreens to prevent ultraviolet radiation exposure and subsequent cancer later in life. In the majority of cases, vitiligo is probably the result of an auto-immune or inflammatory attack on melanocytes. In these cases, topical anti-inflammatories and phototherapy, most notably narrow-band ultraviolet B, can be very effective treatments. Pityriasis Alba Pityriasis alba is a condition where light round patches occur on the cheeks in teen patients of color. It is a result of a very mild irritant or xerotic eczema leading to post-inflammatory hypopigmentation. The loss of color in this condition is usually only temporary and can resolve spontaneously or more rapidly with medical intervention. Dermatosis Papulosa Nigra These small dark facial papules occur commonly in patients of color. Patients may refer to them as ‘flesh moles,’ or ‘Morgan Freeman

spots.’ Indications for treatment can be pain, itching, irritation, or for cosmetic reasons. Acne When treating persons of color, post-inflammatory hyperpigmentation and active acne need to be differentiated as part of patient education. A program that addresses active inflammatory acne and residual hyperpigmentation should be explained and implemented. When treating acne in skin of color a good initial approach is to use a topical retinoid. This is a fundamental treatment for acne and will also reduce post-inflammatory macules that result from earlier, resolving acne. A good addition to topical retinoid treatments is a topical preparation containing azelaic acid. This, too, addresses acne and dark spots. If there is a significant amount of inflammation, including pustules, an oral antibiotic should be considered. Oral retinoids can be employed in cases of severe, nodulocystic acne with or without scarring. Dry or ‘Ashy’ Skin Dry skin is a problem seen in all patients, but when one has tan, brown, or dark-brown skin, dry skin tends to turn silvery white. This phenomenon is often referred to as having ‘ashy’ skin. The most important

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Keloids A keloid occurs when too much collagen is produced at the site of skin injury and repair. The scar can become thick and hard. When the collagen presses on nearby sensory nerves, the keloidal scar can also produce tenderness, pain, and extreme itching. The difference between a hypertrophic scar and a keloid is that keloids can spread and invade normal surrounding skin. For unknown reasons, certain areas are more susceptible to forming keloids such as the upper chest, posterior shoulders, and ear lobes. Also, persons of color, especially African-Americans, have an increased incidence of keloid formation. Again, the reason is unclear. The most effective treatments for keloids involve a six month, regular and intensive treatment program. Acne Keloidalis Nuchae This condition presents as small, itchy bumps at the nape of the neck. This is most commonly seen in African-American patients, but to a lesser degree, it can affect all patients. It is most commonly seen in men but can also be seen in women. Without treatment, the bumps can coalesce into large painful, unsightly plaques. The condition can be managed quite well if treatment begins when the situation is first noticed.

Acne Keloidalis Nuchae

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Pseudofolliculitis Barbae Also known as ‘razor bumps,’ this condition is called ‘pseudo’ folliculitis because hair can come out of the follicular opening and penetrate nearby skin, causing it to look like inflammation or folliculitis of that pore. However, because it is just nearby the actual follicle, it is ‘pseudo’ folliculitis. This is most often seen in persons with curly hair or hair that grows in an oblique angle to the skin. Sometimes, if curly hair is cut extremely close, it never even exits the skin surface but instead penetrates the sidewall of the follicle (known as transfollicular penetration), or it comes out of the follicle and pokes the skin (known as extrafollicular penetration). The results are the same: the keratin (hair) invades the skin, producing a brisk inflammatory reaction that causes itching and the formation of pustules. When pseudofolliculitis is mild to moderate, many topical palliative treatments can be implemented. In severe cases, the best treatment is to remove the offending agent via laser hair removal. Pseudofolliculitis barbae has been a vexing problem throughout history and can even interfere with occupations that require a clean-shaven face such as military officers, peace officers, and firefighters. Thankfully, this condition can be addressed by implementing appropriate treatments and techniques. Tinea Capitis Tinea capitis, also known as ringworm, is endemic in children of color. Any child, under the age of 15, with a scaling, itching scalp should be thoroughly investigated for tinea capitis. One of the clues to this is enlarged posterior cervical lymph nodes. Successful treatment depends on eight weeks of continuous antifungal therapy. It is also recommended that all objects that touch the hair, such as combs, barrettes, rubber bands, and pillowcases, be replaced or treated to prevent re-infection. All members of the household should use an anti-fungal shampoo throughout the treatment period. Melanonychia Striata This is a condition where brown to black longitudinal bands occur in many, if not all, the fingernails and toenails. Melanonychia striata is a common, benign condition that is often seen in multiple family members.

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Melanonychia Striata

component of any skin care program is a gentle, non-detergent cleanser, and an ultra-moisturizing lotion should be applied immediately after patting the skin dry after a bath or shower. This seals in the moisture achieved from the shower and the appropriate moisturizing lotion can provide continuous moisture and protection throughout the day. Often, two or three days of this program can completely reverse dry or ‘ashy’ skin.

However, if one band should occur spontaneously without a family history, this should be evaluated for an underlying mole or melanocytic malignancy. Voigt or Futcher Lines These are lines seen most commonly on the upper arms and sometimes thighs and are normal variations. The condition is named after a physician and anatomist who first described these near the turn of the century. They are harmless and only reassurance need be given. Melasma Melasma is a common and challenging problem for many patients. It presents as hyperpigmented patches that occur on the cheeks, upper lip, forehead and sometimes dorsal forearms. It’s a result of hormones, genetics and sun exposure. Commonly the hormones can include the initiation of oral contraceptives and or pregnancy and childbirth. Melasma can be considered as a very rapid uneven suntan occurring in the areas described. Melasma is exacerbated by sun exposure and, discovered recently, heat exposure. So, inform patients that meticulous sun protection and heat avoidance are necessary for best results. Patients with Melasma must be informed that treatment is a constant, life-long battle with imperfect results. Charles E. Crutchfield, III, MD, is a Clinical Professor of Dermatology at the University of Minnesota Medical School and Medical Director of Crutchfield Dermatology, in Eagan. For additional information on skin of color treatments, visit www.CrutchfieldDermatology. com/treatments/ethnicskin.

March/April 2019

Sponsored Content

Melanoma: An Update on Treatment Options Contributed by Lori Fiessinger, MD and Evidio Domingo-Musibay, MD

The American Cancer Society projects 96,480 new cases of invasive melanoma and 7,230 deaths related to melanoma in 2019.1 The incidence of melanoma has steadily increased for many years and continues to rise.1 Despite the increase, the mortality rate has stayed relatively stable.2 Latestage melanoma treatment options, including targeted therapies against activating mutations, immunotherapy treatments, and intralesional therapies, are contributing to improvements in survival. In this article, we will review these treatment options and their implications for future melanoma treatments and survival. Targeted Therapies: BRAF and MEK Inhibitors Found in approximately 50% of cutaneous melanomas, the BRAF V600E mutation leads to activation of downstream signaling via the MAPK pathway, which in turn results in cell proliferation. BRAF and MEK inhibitors have emerged as important targeted therapies for melanoma. In 2011, the BRAF inhibitor, vemurafenib was approved for metastatic melanoma with the BRAF V600E-activating mutation. Prior to vemurafenibâ&#x20AC;&#x2122;s development, treatment options for metastatic melanoma were limited. The only Food and Drug Administration (FDA)-approved agent for melanoma was the chemotherapeutic agent dacarbazine. In a phase 3 clinical trial, the objective response rate for vemurafenib was 48% compared to 5% for dacarbazine.3 Median progression-free survival increased with vemurafenib, reaching 5.3 months compared to 1.6 months with dacarbazine. Common adverse events 16

March/April 2019

of BRAF inhibitors, when added to BRAF inhibitors, the combination provides more potent and sustained inhibition of the MAPK pathway. In a randomized, double blind, placebo-controlled multicenter trial, combination vemurafenib (BRAF inhibitor) and cobimetinib (MEK inhibitor) led to increased median overall survival of 22.3 months compared to 17.4 months with vemurafenib plus placeLori Fiessinger, MD Evidio Domingo-Musibay, MD bo.5 Combination treatment regimens show comparable and manageable associated with vemurafenib monotherapy in side-effect profiles to that of BRAF inhibiclinical trials include arthralgia, rash, fatigue, tor monotherapy, but notably, combination alopecia, keratoacanthoma or squamous cell treatment results in lower incidence of treatcarcinoma, photosensitivity, nausea, and ment emergent cutaneous squamous cell diarrhea. carcinoma, keratoacanthoma, or Bowenâ&#x20AC;&#x2122;s The second-generation BRAF inhibdisease. The current FDA-approved BRAF itor dabrafenib was approved in 2013 for inhibitor/MEK inhibitor combinations intreatment of both V600E/K-mutated melclude vemurafenib/cobimetinib, dabrafenib/ anomas. A phase 3 clinical trial comparing tramatenib, and encorafenib/binimetinib.6 dabrafenib to dacarbazine showed similar No prospective studies have directly comimprovements in progression-free survivpared these treatment combinations. In adal with dabrafenib (5.1 vs. 2.7 months).4 dition to their approved use in metastatic Side effects of dabrafenib are very similar melanoma, BRAF/MEK inhibitor combito vemurafenib.4 nations were recently approved as adjuvant While BRAF inhibitors have high initreatment for BRAF-mutated stage III meltial objective-response rates, patients develanoma after a study showed decreased risk op treatment resistance within about 6-8 of recurrence with treatment.7 months. The most common mechanism for Immunotherapy: treatment resistance is paradoxical activation Checkpoint Inhibitors of the MAPK pathway with other RAF proAdvances in tumor immunology over the teins, leading to increased activation of the past decade have identified key negative downstream proteins and upregulated cell regulatory proteins on cytotoxic T-lymphogrowth. cytes that impair their ability to kill cancer These findings led researchers to evalcells. The major clinically exploited proteins uate the downstream protein, MEK, as a are the checkpoint molecules, cytotoxic T possible target. While MEK inhibitor monolymphocyteâ&#x20AC;&#x201C;associated antigen 4 (CTLA-4) therapy produced outcomes inferior to that MetroDoctors

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and programmed death-1 (PD-1) pathways. CTLA-4 and PD-1signaling in cytotoxic T-cells leads to downregulation of T-cell activation. Antibody drugs that block signaling through these checkpoint molecules prevent T-cell downregulation, leading to significant antitumor responses. Ipilimumab, a fully human monoclonal antibody that blocks CTLA-4, was approved by the FDA for use in metastatic melanoma in 2011. The first published study on use of ipilimumab for melanoma compared three treatment arms: ipilimumab plus glycoprotein 100 (gp100) peptide vaccination, ipilimumab alone, or gp100 vaccine alone. Median overall survival in the study was 10.0 months among patients receiving ipilimumab plus gp100, 10.1 months in those receiving ipilimumab alone, and 6.4 months with gp100 vaccination alone.8 In long-term studies, survival curves plateaued after three years, with 21% of patients living with durable, long-term responses.9 The majority of adverse events seen were autoimmune in nature, with about 50% of patients developing severe or life-threatening (grade 3 and 4) adverse events. Following the initial success of ipilimumab, two checkpoint inhibitors targeting the PD-1 pathway, nivolumab and pembrolizumab, were approved by the FDA in 2014. Much like ipilimumab, PD-1 inhibitors work by disrupting a signal that normally leads to T-cell deactivation. Studies comparing ipilimumab to nivolumab found that nivolumab showed higher median progression-free survival and significantly fewer grade 3 or 4 adverse events.10 Because CTLA-4 and PD-1 are distinct pathways leading to downregulation of tumor immunity, combination therapy has shown increased response rates and improved survival. In a study comparing dual checkpoint inhibition versus monotherapy for metastatic melanoma, overall survival rate at 3 years was 58% in the nivolumab-ipilimumab combination group, 52% in the nivolumab alone group, and 34% in the ipilimumab alone group.11 Grade 3 or 4 adverse events were highest in the combination group (59%) compared to nivolumab alone (21%) and ipilimumab alone (28%). Combination therapy offers modest improvement in overall survival, so the additional risk of adverse events must be considered carefully when choosing appropriate therapy for patients. MetroDoctors

Immune checkpoint inhibitors have also been approved for adjuvant treatment of resected stage III and IV melanoma after several studies demonstrated improved recurrence-free survival.12,13 Intratumoral Therapies In late 2015, the oncolytic virus talimogene laherparepvec (T-VEC, Imlygic) was approved for use in advanced, unresectable cutaneous melanoma. T-VEC is a herpes simplex type I virus modified to include the cytokine, granulocyte-macrophage colony-stimulating factor (GM-CSF). Injected into tumors, T-VEC selectively replicates within and lyses melanoma tumor cells while releasing the immunostimulatory cytokine GM-CSF to enhance anti-tumor immune responses.14 In an open-label phase 3 clinical trial treating patients with unresectable stage IIIB to IV melanoma, T-VEC resulted in a higher durable response rate (16.3%) than did GMCSF alone (2.1%).15 Overall response rate was also higher in the T-VEC arm (26.4% versus 5.7%), and there was a 4.4-month median overall survival benefit for T-VEC over GM-CSF alone. Given promising results, a recent phase 2 clinical trial evaluated T-VEC in combination with the checkpoint inhibitor ipilimumab.16 The combination therapy resulted in a higher objective response rate (39%) compared to that with ipilimumab alone (18%). Interestingly, tumor response was seen outside of lesions injected with the oncolytic virus, with visceral lesions decreasing in 52% of patients that received combination treatment as opposed to 23% of patients that received ipilimumab alone.16 University of Minnesota Health Melanoma Treatment Program In 2019, the University of Minnesota Health melanoma care team revamped its program to provide an integrated, multidisciplinary approach to management of high-risk skin cancers, including preventive care, local and systemic treatments, and post-treatment surveillance. Through regular tumor board meetings, we review high-risk skin cancer and malignant melanoma in order to provide highly individualized care to our patients. Our multidisciplinary clinic for patients with melanoma or who are at high risk of developing melanoma draws on specialists in Dermatology, Medical Oncology, and

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Surgical Oncology. Because of the high number of cutaneous adverse effects associated with melanoma treatments, integrated dermatology and medical oncology collaboration is more important than ever. With recent studies showing a role for Mohs microscopic surgery in preventing recurrence of early stage melanoma, we also offer this approach for select stage 0 and stage 1 melanomas. Through our partnership with the Masonic Cancer Center, University of Minnesota, we offer access to clinical trials for patients with advanced stages of melanoma. We are currently enrolling participants in two promising immunotherapy trials. In a phase 2 study sponsored by Iovance Biotherapeutics, melanoma tumors are harvested from patients to isolate tumor infiltrating lymphocytes. These melanoma associated lymphocytes are later expanded and activated in the laboratory and then re-infused into the patient (NCT02360579). In another phase 1/2 study sponsored by Nektar Therapeutics, patients receive combination intratumoral and systemic immunotherapy to activate and expand cytotoxic T-cells and natural killer cells to induce anti-tumor immune responses (NCT03435640). Lori Fiessinger, MD, is a University of Minnesota Health staff dermatologist. Dr. Fiessinger attended the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. She completed her dermatology residency training at the University of Minnesota prior to joining the department as staff. She has a subspecialty clinic with the Masonic Cancer Clinic that is dedicated to seeing patients at high risk for melanoma or with history of melanoma. Evidio Domingo-Musibay, MD is a University of Minnesota Health Melanoma specialist and Assistant Professor in the Division of Hematology, Oncology and Transplantation. He received his medical degree from the University of Minnesota Medical School and completed internal medicine residency training and Hematology/Oncology Fellowship at Mayo Clinic in Rochester, MN. He is principal investigator of industry-sponsored and investigator initiated clinical trials and works with basic research and industrial partners to identify promising treatments for clinical testing. References available upon request.

March/April 2019

Advances in Dermatology

Mohs Surgery: The Gold Standard in Skin Cancer Treatment

kin cancer, the most common form of cancer in the United States, is a growing epidemic, and can affect anyone, regardless of skin color. Approximately 9,500 people in the US are diagnosed with skin cancer every day. By current estimates, one in five Americans will develop skin cancer in their lifetime. While basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the two most common types of skin cancer, are estimated to affect more than 3 million Americans a year, they are highly curable if detected early and treated properly. Mohs surgery has the highest cure rate of any type of skin cancer treatment; 97-99% for primary tumors, and 94-95% for recurrent tumors. History of Mohs Surgery

Developed in the 1930s, the Mohs micrographic surgical procedure has been refined and perfected for more than half a century. Mohs micrographic surgery (MMS) is named after its originator, Frederic E. Mohs, MD (1910-2002). As a medical student, Dr. Mohs conducted cancer research. He used the microscopic techniques he learned during this time to map out cancer around nerves, blood vessels, muscle and bone. He treated his first patient on June 30, 1936. Initially, Dr. Mohs removed tumors with a chemosurgical technique which entailed the application of zinc chloride paste to the tumor for 24 hours before tissue was removed. Thin layers of tissue were excised, frozen and then pathologically examined. The surgery included a special technique for color-coding excised specimens, and created a mapping process By Sachin Bhardwaj, MD and Amanda J. Tschetter, MD

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to accurately identify the location of remaining cancerous cells. Most uniquely, the process involved horizontal sectioning of tissue to allow for microscopic examination of 100% of the surgical margin. However, the process was time consuming, often requiring the surgery to extend over a number of days. Sachin Bhardwaj, MD Amanda J. Tschetter, MD As the process evolved, surgeons omitted the chemical treatment • grows rapidly. and refined the technique so surgery could • exists in an area of scarring or previous be completed in one day. The rapid proradiation. cessing of today’s procedure generally • occurs in an immunocompromised permits for immediate, same-day reconpatient (solid organ transplant, HIV, struction of the wound with the confihematologic malignancy, pharmacodence of clear margins. The color-coded logic immunosuppression). mapping, the thorough microscopic exam• occurs in a patient with a genetic synination of excised tissue, and the fact that drome at high risk for skin cancer. the same physician acts as both surgeon Advantages of Mohs Surgery and pathologist remain central to MMS. Common treatment procedures such as Indications for Mohs Surgery curettage and electrodesiccation, cryosurMMS is primarily used to treat BCC and gery, and radiation therapy often prove less SCC, but can be used to treat nearly any effective because they destroy the tissue type of skin cancer, including certain types and leave no specimen for pathological of melanoma. examination. Standard surgical excision MMS is indicated when the cancer: relies on an estimation of tumor margins • is in a difficult area, where it is imby the human eye, and the pathologic portant to preserve healthy tissue to processing allows for less than 1% of the maximize function and cosmesis (eyesurgical margin to be evaluated. lids, nose, ears, lips, fingers, toes and Mohs surgery is unique and so efgenitals). fective because of the way the tissue is • has an aggressive histologic subtype. processed and microscopically examined, • is recurrent. evaluating 100% of the surgical margin. • is large: >1cm on the head, neck, The pathologic interpretation is done on hands, feet or genitals or >2cm elsesite by the Mohs surgeon, who is specially where on the body. trained in the interpretation of these slides • cannot be clearly defined with the and is best able to clinically correlate the naked eye. MetroDoctors

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microscopic findings with the patient’s surgical site. Advantages include: • ensuring complete cancer removal prior to reconstruction. • cure rates exceed 99% for primary cancers, and 94% for recurrent cancers. • minimizing the amount of healthy tissue lost. • maximizing the functional and cosmetic outcome. • repairing the defect on the same day the cancer is removed, in most cases. • cost-effective; less expensive than standard excision. • curing skin cancer when other methods have failed. • other skin cancer treatment methods blindly estimate the amount of tissue to treat, which can result in the unnecessary removal of healthy skin tissue or tumor recurrence if any cancer is missed. Fellowship Training for the Mohs Micrographic Surgeon

While many dermatologists perform Mohs surgery, only members of the American College of Mohs Surgery (ACMS) have undergone rigorous fellowship training that includes extensive training in Mohs surgery, pathology and reconstructive surgery. The ACMS is the oldest professional organization of physicians who have attained extensive training and experience in MMS. The organization was founded by Dr. Frederic Mohs in 1967. One of the major goals of the Mohs College is to ensure the highest quality of training in MMS, which thereby ensures the highest quality of care for patients undergoing this procedure. After completing a residency in Dermatology, a dermatologist can apply to participate in fellowship training at an ACGME-accredited training program. The fellows engage in training that builds upon their experiences with oncology, pathology and surgery acquired during residency. Each fellow is paired with a senior fellowship-trained Mohs micrographic surgeon to receive direct training and mentoring throughout the program. Fellowship training follows a structured curriculum MetroDoctors

including graded responsibility, operative and non-operative education, and exposure to long-term results and complications. To complete the fellowship program, each fellow must: • participate in a minimum of 500 Mohs surgery cases. • learn to accurately interpret slides of tissue samples that have been removed during Mohs surgery. • perform a wide breadth of reconstructions, ranging from simple closures to complex, multi-step repairs. • learn how to set up and direct a frozen section laboratory. Because fellows-in-training undergo training over 1-2 years, they gain a breadth of exposure that includes rare tumor pathology, difficult tumor locations, and complex wound reconstruction. Physicians who have completed a Mohs College-approved fellowship will, by virtue of their rigorous training, possess the skills and expertise necessary to perform Mohs micrographic surgery at all levels of complexity. Cost-Effectiveness of Mohs Surgery

When assessing the cost-effectiveness of Mohs surgery there are several factors to consider. Because of the procedure’s high success rate, most patients require only a single surgery. While other methods might initially appear less expensive, additional surgeries and pathology readings can be required after non-Mohs procedures to treat the cancer that was not completely removed or has grown back. Each of these additional surgeries and pathology readings will require separate fees, while a single Mohs surgery procedure includes all of these services bundled into one fee. Moreover, Mohs surgery is overwhelmingly performed in an office setting, thereby avoiding additional hospital, surgery center, anesthesiology and pathology fees. Human costs must also be considered. Because MMS minimizes the amount of healthy tissue removed, the aesthetic outcome of the surgery is optimized with the smallest scar possible. Patients also find it reassuring to know that their cancer has been treated with a single procedure that gives them the highest possible chance of complete cure.

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Various studies have been conducted to calculate and compare Mohs surgery costs with those of traditional surgical methods. Studies show that Mohs surgery is less expensive than standard excision, radiation therapy or excision in an ambulatory surgery center. Because the process of Mohs surgery minimizes the risk of recurrence, it reduces, and frequently eliminates, the costs of larger, more serious surgeries for recurrent skin cancers.

Sachin S. Bhardwaj, MD is a Fellowship trained Mohs surgeon and board-certified dermatologist at Dermatology Specialists, where he has over 12 years of experience. His interests include Mohs micrographic surgery and facial reconstruction, dermatologic surgery, and cutaneous oncology. He can be reached at sbhardwaj@dermspecpa. com. Dermatology Specialists’ surgical coordinator can be reached at (952) 285-2203 for referrals or questions. Amanda J. Tschetter, MD is a Fellowship trained Mohs surgeon and board-certified dermatologist at Dermatology Specialists. Her interests include Mohs micrographic surgery, dermatologic oncology, surgical dermatology, scarring and scar revisions, cosmetic surgical excisions, laser medicine, and the dermatologic care of the immunosuppressed and solid organ transplant recipients. She can be reached at atschetter@ dermspecpa.com. Dermatology Specialists’ surgical coordinator can be reached at (952) 285-2203 for referrals or questions. References: • Rogers, HW, et al. Incidence estimate of nonmelanoma skin cancer (keratinocyte carcinomas) in the U.S. population, 2012. JAMA Dermatol, 151 (10) (2015), pp. 1081-1086. • Eisemann, N, et al. Non-melanoma skin cancer incidence and impact of skin cancer screening on incidence. J Invest Dermatol, 134 (1) (2014), pp. 43-50. • J.L. Buker, R.A. Amonette, Micrographic surgery, Clin Dermatol, 10 (3) (1992), pp. 309-315. • Tolkachjov SN, et al. Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist. Mayo Clin Proc. 2017 Aug;92(8):1261-1271. • Connolly SM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery. J Am Acad Dermatol 2012;67(4):531-550. • http://www.mohscollege.org. • Ravitskiy L1, Brodland DG, Zitelli JA. Cost analysis: Mohs micrographic surgery. Dermatol Surg. 2012 Apr;38(4):585-94.

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Advances in Dermatology

Tanning Beds Offered as a Perk — Really?

n the weeks prior to starting medical school at the University of Minnesota I helped my sister move out of her apartment near the University. In the lobby I noticed that her apartment offered a tanning bed as an amenity to the tenants. To my surprise a simple search for apartments offering tanning beds demonstrated that nearly all were located within the vicinity of the University. This suggested that apartment buildings exploit university students’ naiveté about the dangers of tanning beds. The literature is clear that the ionizing radiation of tanning beds damages DNA and that the oncogenic effect By Bruce Gregoire, MS2 University of Minnesota

is compounded with each use. In 2014, the Minnesota legislature banned the use of tanning beds by minors in recognition of their association with an increased risk of skin malignancies. As a Dr. Pete Dehnel Public Health Advocacy Fellow, I am working towards increasing the distance between young people in Minneapolis and tanning beds. With the help of Dr. Rebecca Thoman and the Twin Cities Medical Society, we are working to make the city more aware of these tanning beds. We have already met with members of the Department of Health, who were surprised to learn that apartment buildings are providing tanning beds. The process going forward will require getting a sense of all the tanning beds

that are currently in apartment complexes. Once the scale is known, we will work with city councils to propose ordinances that prohibit any multi-unit housing facility from offering tanning beds as a common use amenity. We believe that prohibiting tanning beds is a common-sense solution to prevent young people from being exposed to ionizing radiation and will take us closer to a future where Minnesota has fewer preventable skin malignancies. The Minneapolis City Council agrees and is positioned to remove tanning beds from apartment buildings within its borders. All physicians interested in helping are encouraged to contact Bruce Gregoire at grego238@umn.edu.

Public Health Advocacy Fellowship Update: January Workshop — “From the Clinic to the Capitol”

ur eleven 2018-19 Dr. Pete Dehnel Public Health Advocacy Fellowship medical students have been hard at work on their advocacy projects, ranging from writing official policy briefs, to working with the Minneapolis City Council to pass a policy, to creating resources for public school nurses, and more. From the beginning of the Fellowship, many of our fellows expressed an interest in learning more about Minnesota’s legislative process, so in early January we gathered together with policy and lobbying experts to learn how laws are passed and how our fellows, as current medical students and future physicians, can use their expertise and passion to support legislative action. We were joined by Twin Cities Medical Society CEO, Ruth Parriott, who prior to 20

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joining TCMS oversaw lobbying efforts in 19 states for the American Cancer Society’s Cancer Action Network. Ruth gave the fellows an in-depth look at the extensive advocacy efforts and grassroots support required to successfully pass a law. Eric Dick,

a lobbyist with the Minnesota Medical Association, facilitated an engaging question and answer time pulling back the curtain on what being a lobbyist entails and giving the fellows pointers on how to engage with legislators. We ended our workshop with a moving discussion led by nurse, lobbyist, and elected official, Erin Murphy, who shared her journey from being a practicing provider to a politician. Erin’s honesty and humor, along with her pragmatic tips, left both our staff and fellows feeling informed and motivated. The 2018-19 cohort will complete their fellowship in May with a celebration and poster presentation at the Mill City Museum. Watch for more information on this event and plan to join us in congratulating each on their inspiring work and accomplishments.

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Managing Pediatric Atopic Dermatitis

topic dermatitis (AD) is a common chronic inflammatory condition. Up to 10% of adults have it, but the prevalence of AD among children is about 18%.1-4 Treating pediatric atopic dermatitis can be life-changing for children and their families, but it requires physicians to address all parts of AD simultaneously. This article provides specific highyield clinical pearls that physicians can incorporate easily into practice. Soak and Seal: Repairing the Skin Barrier

Barrier repair is the cornerstone of AD management and prevention. In many cases, mild AD or simple xerosis — which is dry skin, without inflammation — may improve markedly just by reducing exposure to irritating soaps. Thus, less frequent bathing is sometimes sufficient to control the disease, when used in combination with moisturizing. However, for moderate AD or acute flares, the soak and seal method is recommended by pediatric dermatologists. “Soak” means spending 10-15 minutes in a bathtub of comfortable temperature water with no soap or other cleansers. The keratinocytes, cells that are critical to repairing AD damage, migrate best in slightly moist environments so daily bathing is recommended to hydrate the skin. After soaking, it’s important to seal the moisture in by applying a layer of emollient, such as a cream (which typically come in jars) or ointment (greasy, clear) moisturizers. However, lotions (which typically come in pumps) can sting when applied

By Sarah Asch, MD

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to inflamed skin and are not always thick enough to seal moisture into the skin in dry weather. Prescribing Steroids to Treat Inflammation

When the dermatitis is active, parents should help their kids apply a topical steroid ointment to rough and itchy skin twice daily until smooth. It was previously thought that topical steroids should be applied prior to moisturizers, but a recent trial showed that order of application did not change efficacy.5 If families have specific preferences for cream versus ointments, you can tailor accordingly — after all, a medication or moisturizer won’t work if it’s sitting in a drawer. One common pitfall, though, is that physicians prescribe insufficient quantities. Most electronic medical records default to very small quantities for topical medications. A very useful table was published in the journal Pediatrics showing that a 1-pound (454 g) jar is needed to treat an adult/teen body surface area twice daily for one week. In children and infants, these quantities are less, approximately 250g for a child and approximately 100g for an

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infant.6 These topical steroids are thought to be absorbed within 30 minutes. Any parents concerned about young children mouthing steroid-covered skin may use mittens or socks to cover the treated area for a short amount of time. Families may also express concern over possible thinning of skin, which is a side effect of topical steroids. Physicians should reassure them about the long history of topical steroids as safe and effective medications. To ensure compliance, schedule a follow up visit 4-6 weeks from the initial acute flare. This allows the flare to calm, and is often enough time for a smaller recurrence, which test a family’s ability to manage the condition on their own. The brief follow-up visits can be extremely reassuring to families and help limit visits to urgent care and emergency rooms. They also allow the physician to monitor for side effects of the topical medications and counsel on appropriate intermittent use. This ensures families are confident in managing the condition moving forward. Wet Wraps, or Wet Dressings

Treatment sometimes requires wrapping the dermatitis with a damp cloth. This helps the medications and emollients absorb into the skin.7, 8 At a minimum, these damp wraps should be applied for at least 30 minutes. Pajamas can be an excellent tool for wrapping a child’s affected areas. Using one set of damp pajamas, a parent can cover the affected areas. Then, layer the moist pajama with a warm, dry pair to improve overall comfort and warmth. These can both be warmed for 10 minutes in the dryer while the patient “soaks.” Similar to pajamas, two sets of socks can be (Continued on page 22)

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Advances in Dermatology Managing Pediatric Atopic Dermatitis (Continued from page 21)

used for hands, wrists or ankles. Physicians should reassure families that wearing the damp clothes will not lead to a respiratory illness in the winter. Pruritus, the Itch that Rashes

Scratching and rubbing damage the skin barrier. Fortunately, repairing the barrier dramatically improves the itch, which is often the most difficult symptom to treat. Parents should keep their child’s nails trimmed short, cover their hands at night with socks or gloves, and dress them in long sleeves or pants while focusing on skin directed therapy. If itch is disturbing sleep, physicians can prescribe sedating antihistamines for bedtime to decrease overnight scratching. While antihistamines do not treat the itch, they are useful in assisting in less disturbed sleep for a week or two while skin heals. For daytime, non-sedating antihistamines can be utilized for children with allergic rhinitis or other triggers, but do not work for AD itch, as the itch is not directly histamine driven.8 Bleach Baths

Bleach baths are now widely recommended for pediatric AD treatment.10 A common recipe is approximately ¼-⅓ cup of regular household bleach to a standard bathtub filled to drainage holes, which is about 40 gallons of water. Regular household bleach recently increased in concentration from 6% to 8.25% so many older recipes recommended ½ cup. This level of diluted bleach is safe for brief contact with eyes and mouths, and can be likened to a chlorinated swimming pool. However, to reduce any risk of harm, remind parents to never apply bleach directly to the child’s skin because it can cause a chemical burn.9 Treating Infection and Other Triggers

Infection can be a trigger for flares of AD. But prescribing oral antibiotics for every flare is not consistent with pediatric principles of antibiotic stewardship or the American Board of Internal Medicine or American Academy of Dermatology “Choosing Wisely” campaigns.11 22

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If a flare occurs, the patient should start skin directed therapy that includes wet wraps. But, if there are still small open areas after 48 hours or if the patient is not improving, they may require treatment with oral antibiotics. Cephalexin is a frequently utilized antibiotic as it has adequate coverage of gram positive bacteria, specifically Methicillin-sensitive Staphylococcus aureus (MSSA) and Streptococcus. Even in patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA), MSSA is still often the culprit with AD flares, so cultures should be taken at initiation of skin directed therapy. These cultures can help guide appropriate oral antibiotic therapy. Other common triggers include change of seasons, new more humid or dry environment, stress, airborne allergens, fragrances, and skin infections. Of note, AD is rarely directly related to food allergy. An expert panel sponsored by the National Institute of Allergy and Infectious Diseases, one of the National Institutes of Health, recommends testing only for milk, egg, peanut, wheat and soy allergy in children under 5 years of age with moderate to severe AD, only if the child has persistent AD in spite of optimized management and topical therapy; or if the patient has a reliable history of an immediate reaction after ingestion of a specific food. The panel specifically recommended against avoiding potential allergenic foods as a means of controlling AD.12 If certain foods appear to exacerbate a child’s dermatitis, refer them to an allergist for appropriate testing. Education

There is not a single cause and there is not a known cure for this chronic disease. It is important to educate caregivers and patients on this point. In addition, treatments may need to be adjusted over time and so follow-up visits over time are helpful. There continues to be promising advances in AD therapy, like crisaborale, which is a new non-steroid topical, and dupilumab, which is a new biologic. However, such medications are typically not required to manage mild to moderate AD in children. The approaches listed in

this article, “soak and seal,” bleach baths and wet wraps are simple, affordable and effective tools that all physicians can confidently share with their patients. Dr. Sarah Asch is a Pediatric Dermatologist who is triple board certified in Pediatrics, Dermatology and Pediatric Dermatology. She is accepting new patients at HealthPartners and Park Nicollet Medical Groups, where she practices full-time Pediatric Dermatology. References: 1. Wolter S, Price HN. Atopic Dermatitis. Pediatr Clin North Am. 2014 Apr;61(2):241–60. 2. Kvenshagen, B., Jacobsen, M. & Halvorsen, R. Atopic dermatitis in premature and term children. Arch. Dis. Child. 94, 202–205 (2009). 3. Margolis, J. S., Abuabara, K., Bilker, W., Hoffstad, O. & Margolis, D. J. Persistence of mild to moderate atopic dermatitis. JAMA Dermatol. 150, 593–600 (2014). 4. Silverberg, J. I. & Hanifin, J. M. Adult eczema prevalence and associations with asthma and other health and demographic factors: A US population–based study. J. Allergy Clin. Immunol. 132, 1132–1138 (2013). 5. Ng SY, Begum S, Chong SY. Pediatr Dermatol. Does Order of Application of Emollient and Topical Corticosteroids Make a Difference in the Severity of Atopic Eczema in Children? 2016 Mar-Apr;33(2):160-4. 6. Eichenfield LF, Boguniewicz M, Simpson EL, Russell JJ, Block JK, Feldman SR, et al. Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers. Pediatrics. 2015 Sep;136(3):554-65. 7. Dabade TS, Davis DMR, Wetter DA, Hand JL, McEvoy MT, Pittelkow MR, et al. Wet dressing therapy in conjunction with topical corticosteroids is effective for rapid control of severe pediatric atopic dermatitis: Experience with 218 patients over 30 years at Mayo Clinic. J Am Acad Dermatol. 2012 Jul;67(1):100–6. 8. Sidbury R, Davis DM, Cohen DE, Cordoro KM, Berger TG, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327–49. 9. Lang C, Cox M. Pediatric cutaneous bleach burns. Child Abuse Negl. 2013 Jul;37(7):485–8. 10. Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218–33. 11. Coldiron, B. M. & Fischoff, R. M. American Academy of Dermatology Choosing Wisely List: Helping dermatologists and their patients make smart decisions about their care and treatment. J. Am. Acad. Dermatol. 69, 1002 (2013). 12. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel. J Allergy Clin Immunol. 126(6):S1–58.

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Cosmetic Dermatology for the Aging Face

osmetic dermatology has become extremely popular over the years and is considered to be the treatment choice for facial rejuvenation. Over 14.2 million of these procedures were performed in 2015, with the top three being Botulinum toxin injection, soft tissue fillers, and chemical fillers respectively. Chemical peels, microdermabrasion, lasers and intense light-based technologies help with skin resurfacings and photojuvenation. The low-risk nature of these procedures, along with high patient satisfaction and easy accessibility, has been a common reason for a visit to a dermatology office. Many factors contribute to aging. Besides genetics, environmental exposures including sun, diet and smoking play a major role. The triangle of youth, or inverted triangle, exemplifies youthful features of high cheek bones, full cheeks, defined jawline, and minimal wrinkles. This triangle is often reversed with aging caused by drooping of skin in the mid face, volume loss over the cheeks, and sagging jawline and sometimes fullness around the chin and neck. Our skin also changes with age. Sun spots, discoloration, rough texture, and wrinkles often become more prominent between the eyebrows, forehead, and around the eyes. Therefore, the goal of cosmetic dermatology is to help reverse some of these signs of aging. Botulinum toxin injections are used to soften the wrinkles on the face; fillers are used to replace the volume loss around the cheeks and soften the deep furrows around the lower mouth; and chemical

By Jing (Jenny) Liu, MD MetroDoctors

peels, microdermabrasion, and lasers are used to smooth the texture of the skin and eliminate sun spots and discoloration. Botulinum Toxin

Botulinum toxin injections are the most frequently performed procedure used to treat facial wrinkles or rhytids. Deep wrinkles on the face are created by skin thinning from aging and the repetitive facial movements over time. Botulinum toxin reduces these rhytides by working as a potent neurotoxin that causes temporary muscle paralysis. It has been around for many years and is used extensively for medical treatment of certain neurologic diseases and dermatologic conditions, such as excessive sweating. Cosmetically, botulinum toxin is injected in very small quantities into certain areas of the eyebrow muscles, forehead muscles, and around the eyes to treat frown lines, forehead wrinkles, and crows feet respectively. Because this procedure is relatively quick and easy with very few side effects, it has become the most performed aesthetic procedure in the dermatology office. Repeat injections are recommended usually every four months for sustained facial improvement. Soft Tissue Filler

Soft tissue filler injections are another commonly performed procedure in the office. As we age, volume is lost from our upper face, which often leads to hollowing of the cheeks. Gravity over time also leads to sagging of the skin and deepening of lines around the nose and mouth (marionette lines). Soft tissue fillers will temporarily restore volume to the face where injected to help improve facial lines and contour defects due to aging. There are

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various materials approved by the FDA with hyaluronic acid being one of the most commonly injected agents. These agents are designed for specific areas of the face, lasting between six months to over one year before they are slowly degraded by our bodyâ&#x20AC;&#x2122;s natural enzymes. Skin Resurfacing Treatments

Skin resurfacing treatments include chemical peels, microdermabrasion, and laser ablation. Chemical peels and microdermabrasions are mechanical resurfacing procedures as they physically remove a superficial layer of the skin. Chemical peels have been utilized throughout history and involve applying certain acids to purposely (Continued on page 24)

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Advances in Dermatology Cosmetic Dermatology for the Aging Face (Continued from page 23)

create a chemical burn of the skin, and in the case of microdermabrasion, it involves using a special type of sandpaper to physically remove layers of skin. Lasers

Lasers have gained popularity over the years. Lasers use heat to target specific tissue in the skin to create the desired outcome. These lasers can be categorized into ablative vs. non-ablative and fractionated vs. non-fractionated. Ablative lasers, which involve removing the top layer of the skin, is a more aggressive treatment with longer recovery and higher risk of side effects. However, it also results in a more dramatic improvement. Fractionated lasers create a myriad of microscopic injury zones in the skin simultaneously. These areas are just big enough to generate wound healing and stimulate collagen production in the

skin. Since the majority of the skin is still intact, the recovery period is less but improvements are also modest. For the more severe facial wrinkles, discoloration and texture change, ablative laser works best. Since the late 2000s, ablative fractionated lasers have hit the market. These lasers are able to produce the same clinical results as the traditional counterparts but without being as invasive with story recovery time. Deoxycholic Acid

Submental fullness, or double chin, can also be the result of weight gain and the sagging of skin over time. Regardless of diet and exercise, this area responds poorly to normal interventions. Deoxycholic acid (KybellaÂŽ) injection is the first FDA approved chemical treatment for submental fullness. This treatment involves a series of monthly injections that over time will

permanently remove the undesired double chin. Deoxycholic acid is a natural derivative of our digestive enzymes. When injected into the submental area, it generates an inflammatory response which, over time, leads to removal of fat. Usually a series of three injections are performed. Compared to conventional liposuction, this treatment offers similar improvement without the risk of anesthesia and surgery. Many cosmetic procedures now exist for facial rejuvenation. Often, a combination of procedures is performed for optimal improvement. To find out which procedures would benefit your patients, please refer them to a board-certified dermatologist to ensure the best result and minimize complications. Dr. Jing (Jenny) Liu is the Chief of Dermatology at Hennepin Health. She is a graduate of the University of Minnesota Department of Dermatology residency program. She specializes in general dermatology for adults and children, cosmetic dermatology cutaneous surgery, and also has a special interest in dermatologic diseases in patients with skin of color. During her free time, she enjoys going on walks with her husband, 9-month-old baby girl, and Bichon FrisĂŠ. She also loves to listen to audiobooks while whipping up Asian cuisine for dinner.

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The Journal of the Twin Cities Medical Society

Dermatomyositis: Five Cutaneous Clues

ermatomyositis is a rare, multisystem autoimmune disorder that most often affects the skin, muscles, and lungs, but symptoms can manifest in virtually any organ. Its severity ranges broadly from mild, skin-limited disease to full-body rashes, weakness, lung disease, and death. In some cases, it may herald underlying malignancy (breast, lung, gastrointestinal, and genitourinary are most common), and detection of symptoms can lead to discovery of cancer. The reported prevalence of dermatomyositis is only about 1 in 10,000 but women are affected 2-3 times more often than men, particularly Caucasians over the age of 45 years.1 However, this likely underestimates the true prevalence because it is notoriously challenging to diagnose. No single laboratory test can definitively confirm its presence; instead, clinicians must assemble the composite of symptoms, physical examination findings, laboratory tests, and pathology to make the diagnosis. In the following article, we will discuss a few key symptoms and five skin findings that may be observed in dermatomyositis. Fatigue One of the most common concerns of patients with dermatomyositis is profound fatigue. This is a nonspecific symptom that can be a difficult to evaluate out of context, but checking for significant changes in activity levels from a few years prior can be helpful. Obtaining further corroborating evidence from a spouse, family members, or friends, if they also attend the visit, can make this assessment easier. Fatigue with weight loss, especially in older patients with dermatomyositis, requires close evaluation for underlying malignancy. By David R. Pearson, MD MetroDoctors

Rash Skin manifestations, the ‘dermato-’ of dermatomyositis, may be particularly challenging to interpret. Rashes are red to reddish-purple in color, often with flaking or scaling, and are typically itchy. They may demonstrate poikiloderma — mottled areas of light, dark, pink-to-red, atrophic skin. Common areas of involvement are the hands, eyelids, upper trunk, and scalp, though other regions may be involved. Rashes can be subtle and localized. Mimickers include psoriasis, eczema, and cutaneous lupus erythematosus, but there are important distinctions that can assist with proper diagnosis. Weakness The ‘-myositis’ of dermatomyositis refers to inflammation in the muscles, and typically manifests as weakness or muscle pain distinct from generalized feelings of fatigue. Myositis classically involves large, proximal muscle groups such as the hip flexors, thighs, and shoulders. Patients may have difficulty standing up from a chair, climbing stairs, or combing their hair. It is important to note that despite the name of the disease, approximately one-third of patients are clinically amyopathic and do not have symptomatic muscle involvement.

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Dyspnea Shortness of breath, particularly with exertion, can be a clue to pulmonary involvement. Dermatomyositis may manifest with interstitial lung disease, which represents scarring and fibrosis of the lung parenchyma. While serious pulmonary involvement is uncommon, a few variants demonstrate rapidly progressive disease that can be fatal (most notably those with anti-melanoma differentiation antigen-5 [MDA-5] autoantibodies). Early recognition and diagnosis are critical because interstitial lung disease may be reversible with appropriate treatment. In addition to these key symptoms, below are five skin signs that may indicate referral to a specialist is necessary. 1. Gottron’s sign and Gottron’s papules Rash on the backs of the hands is one of the most characteristic features of dermatomyositis and is described as a pathognomonic feature in the original Bohan and Peter classification.2 It is most prominent overlying joints (Gottron’s sign) and may develop into raised, flat-topped papules (Gottron’s papules) over time, particularly at the metacarpophalangeal joints. It is hypothesized that the predilection for the skin over joints is due to stretch-induced inflammatory signaling.3 The eruption may be exacerbated by sunlight, extend beyond the joints, and precede other cutaneous and systemic findings. A rare variant manifests with pink or red papules on the palmar aspects of finger joints (inverse Gottron’s papules). Key items on the differential include psoriasis, eczema, and multicentric reticulohistiocytosis, a rare disease associated with disfiguring arthritis. Gottron’s papules (Continued on page 26)

March/April 2019

Advances in Dermatology Dermatomyositis: Five Cutaneous Clues (Continued from page 25

should be differentiated from cutaneous lupus erythematosus, which characteristically spares the knuckles. Unfortunately, Gottron’s papules can be resistant to treatment even when the disease is otherwise well-controlled. Punched out, deep, painful ulcers over the knuckles are uncommon but particularly important to recognize since they are associated with rapidly progressive interstitial lung disease. These patients can quickly deteriorate and despite treatment, there is high risk of mortality. Outside of the specific serologic finding (anti-MDA-5 autoantibodies), this easily observed physical finding is one of the best predictors for this phenotype.4 Prompt, aggressive treatment by a multidisciplinary team of physicians is indicated. 2. Heliotrope rash Red-to-violet discoloration of the eyelids (evocative of the light purple of the flowering Heliotropium spp.), often with associated swelling and subtle scaling, is the other characteristic skin finding described in the original Bohan and Peter classification.2 Many patients find this sign distressing because the edema can be difficult to conceal. It nearly always has a symmetric predilection for the upper eyelids. Usually this eruption is asymptomatic, though there may be mild itching or irritation. The heliotrope rash is often amenable to treatment with low-potency topical corticosteroids or alternatives but can be recalcitrant in some patients. Intrinsic eczema and contact dermatitis (both irritant and allergic) are the most common mimickers. The presence of swelling, the rash’s coloration, and the clinical history are important clues to the correct diagnosis. 3. Mechanic’s hands Scaling and hyperkeratosis along the lateral sides of the digits, particularly on the thumbs and pointer fingers, classically characterizes mechanic’s hands. Scaling may extend to the distal digit or onto the palmar surface and may manifest as papules or fissures in the same distribution. Mechanic’s hands may be misdiagnosed as hand eczema, but typically do not itch and are 26

March/April 2019

not associated with vesicles. Furthermore, like Gottron’s papules, they tend to be resistant to topical corticosteroids. Diagnosis is important because mechanic’s hands are a risk factor for the development of interstitial lung disease. They are present in the overlapping condition, anti-synthetase syndrome, which is typified by pulmonary fibrosis.

mycophenolate mofetil are the mainstays of treatment. Often, skin disease responds incompletely to these medications and is known to profoundly affect patient quality of life.6 It is clear that additional therapeutic options are needed for this disease. With improved recognition of dermatomyositis, we can work toward developing better treatment options for our patients.

4. Cuticular overgrowth (Samitz sign) Thickened, rough, irregular cuticles are a subtle finding that can be important in distinguishing dermatomyositis from hand eczema or psoriasis. Cuticular overgrowth is morphologically similar to post-traumatic cuticular dystrophy, such as might be observed after aggressive manicures, but its pathogenesis in dermatomyositis has not been definitively elucidated. This finding is not specific to dermatomyositis, and may be observed in systemic sclerosis (scleroderma) and, less commonly, in lupus erythematosus.

David R. Pearson, MD, is an Assistant Professor of Dermatology at the University of Minnesota. He graduated from Gustavus Adolphus College and received his medical degree from Washington University in St. Louis. Dr. Pearson completed a Dermatology residency and served as chief resident at the University of Colorado, then completed his rheumatologic dermatology fellowship at the University of Pennsylvania. Dr. Pearson is particularly interested in the cutaneous manifestations of autoimmune connective tissue diseases including dermatomyositis, lupus erythematosus, systemic sclerosis, and morphea, and sees patients at the Clinics and Surgery Center in Minneapolis. He can be reached at pearsond@umn.edu or (612) 625-8625.

5. Nailfold capillary changes In addition to cuticular overgrowth, redness and hemorrhage on the proximal nailfolds may be observed in patients with dermatomyositis. Examination with a magnifying glass or dermatoscope demonstrates widely spaced, dilated and tortuous capillaries as well as empty areas of capillary dropout. Nailfold capillary changes are correlated with disease activity, and may be particularly useful in distinguishing autoimmune connective tissue diseases like dermatomyositis, systemic sclerosis, and lupus erythematosus from more common inflammatory conditions like hand eczema and psoriasis.5 Nailfold capillary changes may be asymmetric, but are commonly observed on multiple digits of both hands. After diagnosis, patients with dermatomyositis require a thorough workup to exclude underlying malignancy and assess systemic manifestations like myositis and interstitial lung disease. Treatment of these patients can be challenging. There are no targeted therapies for dermatomyositis and systemic corticosteroids are the only FDA-approved medication. Off-label use of systemic immunomodulatory and immunosuppressive medications like hydroxychloroquine, methotrexate, and

References 1. Bendewald MJ, Wetter DA, Li X, Davis MD. Incidence of dermatomyositis and clinically amyopathic dermatomyositis: a population-based study in Olmsted County, Minnesota. Arch Dermatol. 2010; 146: 26-30. doi: 10.1001/archdermatol.2009.328. 2. Bohan A, Peter JB. Polymyositis and dermatomyositis. N Engl J Med. 1975; 292: 344-347, 403-407. 3. Kim JS, Bashir MM, Werth VP. Gottron’s papules exhibit dermal accumulation of CD44 variant 7 (CD44v7) and its binding partner osteopontin: a unique molecular signature. J Invest Dermatol. 2012; 132: 1825-1832. doi: 10.1038/jid.2012.54. 4. Xu Y, Yang CS, Li YJ, et al. Predictive factors of rapidly progressive-interstitial lung disease in patients with clinically amyopathic dermatomyositis. Clin Rheumatol. 2016; 35: 113-116. doi: 10.1007/ s10067-015-3139-z. 5. Bertolazzi C, Cutolo M, Smith V, Gutierrez M. State of the art on nailfold capillaroscopy in dermatomyositis and polymyositis. Semin Arthritis Rheum. 2017; 47: 432-444. doi: 10.1016/j.semarthrit.2017.06.001. 6. Robinson ES, Feng R, Okawa J, Werth VP. Improvement in the cutaneous disease activity of patients with dermatomyositis is associated with a better quality of life. Br J Dermatol. 2015; 172: 169-174. doi: 10.1111/bjd.13167.

MetroDoctors

The Journal of the Twin Cities Medical Society

Environmental Health — The Impact of Climate Change on Skin Disease

ccording to recently released authoritative reports, the US National Climate Assessment 4 and the Lancet’s Countdown on Health and Climate Change, increases in carbon dioxide emissions are occurring at a more rapid rate than previously thought. Investigators predict that the increased levels will have major implications for human health and will be severe by 2030. Climate changes that will result in worsening morbidity and mortality include extreme heat exposure, air pollution, population displacement, extreme weather events and vector-borne and water-borne diseases. In addition to the well-recognized consequences of cardio-pulmonary exacerbations and fatal infectious diseases, climate change can create challenging skin conditions as well: • Flooding washes toxins and waste into surface waters that can increase the risks of a variety of inflammatory skin diseases and traumatic skin injuries. The CDC reported methicillin-resistant Staphylococcus aureus wound infections, tinea corporis, folliculitis, miliaria and arthropod bites among survivors after Hurricane Katrina. • Temperature and humidity affect the prevalence of atopic dermatitis, especially in children. • Climatic factors may play an important role in the onset of chronic leg ulcers.

•

Some evidence suggests that higher temperatures may increase the risk of skin cancers such as squamous and basal cell carcinoma. Lyme disease, tularemia, Rocky Mountain spotted fever, dengue fever, malaria, Zika, West Nile virus and leishmaniasis are appearing in habitats not seen before. Many of these infections are associated with ulcerations, vesicles, bullae, rashes, and erythema migrans. Warming temperatures increase the risk of contracting hand, foot and mouth disease. Displaced people living in camps are at increased risk of skin infections, eczema, acne and hair-related diseases.

There has been a steady increase in the number of medical and health professional associations actively responding

to climate change. Over 500,000 physicians have already joined the US Medical Society Consortium on Health and Climate. The International Society of Dermatology has established a Committee on Climate Change to “improve understanding of what climate change is and how it may affect health, disease patterns and specifically the incidence of dermatologic diseases.” Mark D. Nissen, MD is a member of the TCMS Environmental Health Taskforce. References: • The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come, Lancet 2018; 392:2479-514. • Andersen, Louise and Davis, Mark, A wakeup call to dermatologists-climate change affects the skin, International Journal of Dermatology 2017, 56, e192-e206. • Hui, Young and Maibach, Howard, Global warming and its dermatologic impact, Expert Rev. Dermatol. 6(5), 521-523 (2011). • More references upon request.

Search for Twin Cities Medical Society on Facebook and follow us on Twitter @TCMSMN

By Mark D. Nissen, MD

MetroDoctors

The Journal of the Twin Cities Medical Society

March/April 2019

Honoring Choices Approaches Young Adults to Talk About Advance Care Planning

an millennials talk about death? Will they? Stereotypes for this generation include denial, self-centeredness and avoidance,1 but the findings of a study by Nathan Gerard, PhD of California State University Long Beach1 indicate otherwise. There is very little written about this topic; Gerard’s 2017 report appears to be the only recent attempt to explore millennials’ attitudes towards talking about dying with loved ones. According to Gerard’s research, today’s young people are more diverse, more technologically-savvy, more suspicious of institutions, and more stressed than any generation before them. In addition, the generation as a whole is less healthy than their predecessors. So how do these traits affect their willingness to consider and discuss dying? While the sample was small (n=84), the results were clear: contrary to the expectations, this group was willing to have the conversation. The study raises questions for further exploration — how can we bridge the openness to conversations with mistrust of institutions? How can physicians encourage their young adult patients to have these discussions? What do these questions mean for Minnesota? Opportunity! Honoring Choices has worked with medical and nursing students for several years, orienting them to the importance of Advance Care Planning and how it will impact their future practice. But in 2018, we began working with undergraduate students at

By Karen Peterson, Honoring Choices Executive Director

March/April 2019

Table 1: Having the Conversation Item

Scale

Have you had a conversation about end-of-life care options with a family member?

Yes

54%

46%

Slightly or not at all difficult Would a discussion about death or planning around death be difficult to Moderately difficult have in your family? Very or extremely difficult

55%

25%

20%

Slightly or not at all disrespectful Would a discussion about death or planning around death be considered Moderately disrespectful disrespectful in your family? Very or extremely disrespectful

81%

13%

Unwilling or very unwilling

10%

Neutral

33%

Willing or very willing

57%

55%

36%

How willing would you be to have a conversation about end-of-life care options with a family member?

Less Compared to your parents or caregivers, are you more or less willing to About the same have a conversation about end-of-life care options? More

a liberal arts college to explore how they respond to the idea of talking with their peers and families about end-of-life topics. Small groups of students are introduced to Advance Care Planning and then tasked with introducing the topic to peers, using a variety of approaches. Following interactions, the effectiveness of the strategy is evaluated and analyzed. In addition, the students are researching what new tools and resources are available, specifically focusing on technological options (social media, apps, etc.) From this initial work, we hope to develop best practices to help millennials and “Gen Zers” (those born

since 1996) understand what Advance Care Planning is and why they should begin. As Honoring Choices explores working with this age group in Minnesota we hope to find answers and develop a model to engage both the individuals and their health care providers in the conversation. Findings will be reported in a future issue of MetroDoctors. 1.

Gerard, Nathan (2017). Can millennials talk about death? Young adults’ perception of end-of-life care. The Journal of Health Administration Education, Winter, 23-48.

MetroDoctors

The Journal of the Twin Cities Medical Society

2018 Shotwell Award Recipient Macaran A. Baird, MD, MS Education: B.A. Degree: Macalester College, St. Paul, MN M.S. Degree: Environmental Health, University of Minnesota M.D. Degree: University of Minnesota Medical School Residency: Family Medicine, University of Minnesota M.S. Degree: Family Practice and Community Health, University of Minnesota Scholar: Harvard Macy Institute Program for Leaders in Healthcare Education, Harvard Medical School, Boston, MA Board Certified: American Board of Family Practice Macaran Baird, MD, MS started his career in Wabasha, MN, practicing for five years in this rural community. In 1985, his academic career was launched — first serving as an Assistant Professor at the University of Oklahoma, followed by an appointment as Professor and Chair of the State University of New York Medical School, Syracuse, Department of Family Medicine. In 1996, Dr. Baird returned to Minnesota as Associate Medical Director for HealthPartners, then moved to Mayo as Medical Director of the Mayo Health Plan and Professor of Family Medicine. He returned to his alma mater as Professor and Head, Department of Family Medicine and Community Health, at the University of Minnesota Medical School, a position he held from July 2002 until his retirement in December 2017. Dr. Baird has received awards from the American Academy of Family Physicians, the Society of Teachers of Family Medicine, the Minnesota Academy of Family Physicians and the Minnesota Medical Association. During Dr. Baird’s tenure at the University of Minnesota,

the Family Medicine program grew in the number of resident positions, residency programs and in research grants, and is today recognized as one of the top three primary care programs in the country receiving NIH funding. This success was achieved through his ferMacaran Baird, MD (L) was presented vent personality — bring- with the 2018 Shotwell Award by TCMS ing people together for Foundation Chair, Chris Johnson, MD. a common cause; his community health perspective — identifying and executing on opportunities for physicians to play a role in community health; and his ability to passionately engage medical students, residents and faculty in public health and social issues. He also participated on a team that developed the Patient Centered Assessment Method©, a tool to assess social determinants of health and help identify barriers to patient care. In November 2017, Dr. Baird was called into another leadership role — to serve as the Interim Chief Executive Officer of University of Minnesota physicians. During this 12-month assignment he was one of the key leaders who helped create new institutional partnerships and strengthened key relationships within and beyond the university group practice. He is now retired and living in Lake City, Minnesota with his wife, Kris.

April 16 is a day to focus on Advance Care Planning. Do you talk with your patients about their future healthcare preferences? Honoring Choices can help: visit our website HonoringChoices.org and search ‘NHDD’ for resources and ideas.

MetroDoctors

The Journal of the Twin Cities Medical Society

March/April 2019

Charles Bolles Bolles-Rogers Award— Ann C. Lowry, MD, FACS, FSCRS Clinic: Colon and Rectal Surgery Associates, Ltd. Medical School: Tufts University School of Medicine, Boston, MA Residency: New England Medical School, Boston, MA Chief Surgical Residency: New England Medical Center, Boston, MA Colon and Rectal Surgery Fellowship: University of Minnesota, MN Board Certification: American Board of Surgery; American Board of Colon and Rectal Surgery Collaborative, humble, passionate, a skilled surgeon, mentor, educator, and visionary with excellent communication skills — all are words used to describe Ann C. Lowry, MD, the 2018 recipient of the Charles Bolles Bolles-Rogers Award. Dr. Lowry has long been a pillar of leadership and surgical excellence within the local, national, and even global medical communities. In 1987 she became a partner of Colon and Rectal Surgery Associates and was named Chief Executive Officer and President in 2008. In addition to her commitments within her private practice, Dr. Lowry also holds leadership roles at the University of Minnesota, Minnesota Endoscopy Center, and Fairview Health System. Instrumental in training a generation of new colorectal surgeons, she was named Director of the Colon and Rectal Surgery Residency and Fellowship program in 1997. Shortly thereafter, she attained the rank of Full Clinical Professor in 2002. Nationally, her accomplishments did not go unnoticed and Dr.

Lowry was elected as the first female physician president of the American Society of Colon and Rectal Surgeons in 2005. Dr. Lowry is widely recognized for her research on fecal incontinence, pelvic floor pathophysiology and rectal prolapse, and developed the Fecal Chris Johnson, MD, Chair, Twin Cities Incontinence Quali- Medical Society Foundation, presented the award to Ann Lowry, MD. ty of Life Scale. This work has heightened the awareness and elevated the importance of these issues while helping to establish a standard of care for these disorders, significantly improving the quality of life of patients throughout the world. She has published numerous peer-reviewed articles, book chapters and abstracts and has been an honored Visiting Professor all over the world. An accomplished colon and rectal surgeon, researcher, educator and physician leader, Dr. Lowry is highly recognized and respected by her colleagues and friends. The Twin Cities Medical Society Foundation is honored to award the Charles Bolles Bolles-Rogers Award to Ann Lowry, MD.

Senior Physicians Association Holds Winter Meeting Forty physicians and a few guests gathered on January 15, 2019, for an engaging and enlightening presentation by Jakub Tolar, MD, PhD, Dean, University of Minnesota Medical School and Vice President for Clinical Affairs. Dr. Tolar’s presentation on the Current State of the Medical School and Vision for the Future, was enthusiastically received and appreciated. Join your colleagues (in all stages of their medical career — “senior” is not a requirement) for the next gathering tentatively scheduled for May 21, 2019. Watch your email for updates. Jakub Tolar, MD, PhD

March/April 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

In Memoriam WILLIAM NUESSLE, MD passed away on November 21, 2018. Early in his career, Dr. Nuessle was the Medical Director of IDS insurance company, followed by a private practice in Internal Medicine in downtown Minneapolis. He was a Clinical Associate Professor at the University of Minnesota. Dr. Nuessle joined the medical society in 1956. GEORGE E. REISDORF, MD passed away on January 11, 2019. Dr. Reisdorf was an orthopedic/hand surgeon at Park Nicollet Clinic and Methodist Hospital. He performed his last surgery in 2002 in Africa with the African Medical Mission. Dr. Reisdorf joined the medical society in 1970.

CAREER OPPORTUNITIES

GREGORY SPRAFKA, MD passed way on December 20, 2018. He was a family physician in St. Paul for more than 40 years. He joined the medical society in 1950. JAMES STANDEFER, MD passed away on December 28, 2018. Dr. Standefer was an ophthalmologist and founder of Associated Eye in Stillwater, MN. He attained the rank of Clinical Professor of Ophthalmology at the University of Minnesota. After retirement he volunteered in more than 31 countries performing ophthalmic procedures and training. Dr. Standefer joined the medical society in 1971.

OMAR TVETEN, MD passed away on November 9, 2018. Dr. Tveten was a family physician with clinics in St. Paul at Rice Street, Payne Avenue and the Como Park Clinic. Dr. Tveten joined the medical society in 1960. FRANK UBEL, MD passed away on January 9, 2019. Dr. Ubel had a private Internal Medicine practice in St. Paul, which was followed by 22 years with 3M where he also served as Medical Director. He was a past president of the American Academy of Occupational Medicine. Dr. Ubel joined the medical society in 1959.

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MetroDoctors

The Journal of the Twin Cities Medical Society

March/April 2019

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

NOEL HAUGE, MD

In these days of corporate medicine and mind boggling technological clinical advancements, it’s more than refreshing to learn about a current physician who has embraced those modern advancements, yet who additionally possesses the characteristics and beliefs of a more subjective nature which have stood the test of time. Let’s see how that combination has worked with our newest Luminary. Dr. Noel Hauge grew up in south Minneapolis and stayed close to home while obtaining his bachelor’s degree from Augsburg College in 1970 and his M.D. from our U of M Medical School in 1974. His fascination with the study of genetics and the role it plays in medicine led him into a pediatric residency at the U of M Hospitals. There he learned the basics of caring for children and their parents while still indulging his appreciation for the esotericism of chromosomal abnormalities. While assigned to the neonatal ICU, there were occasions to confer with Dr. Bob Gorlin (Luminary, 2017) while delving into the mysterious world of syndromes and inborn errors of metabolism. Many of the engaging cases on which they consulted had dermatologic manifestations — which then brings us to the next chapter of Dr. Hauge’s career. Upon completion of his formal pediatrics education, Noel was then accepted into the dermatology residency — also at his alma mater — under the direction of a valued mentor, Dr. Robert Goltz. During those formative years, there was didactic travel to London and enlightening opportunities in the University clinic service while collaborating with and learning from another of his mentors, Dr. John Kersey (Luminary, 2015). There he explored such intricacies as bone marrow transplantation and graft v. host reactions. The ground work being established, it was then time for the good Dr. Hauge to use those cultivated talents in his established professional career . . . and use them he did! He joined Dr. Harold Ravitz, a valued “father-like” mentor, at Dermatology Consultants in downtown St. Paul after stints on the faculty of the University and staffing the dermatology clinic at Minneapolis Children’s Hospital. As his private practice grew, he found the time and energy to share his considerable fount of knowledge with other physicians via teaching family practice 32

March/April 2019

residents and with a variety of physician CME presentations. His early patient mix at Dermatology Consultants was primarily pediatric, though through the years that’s been modified to include all age ranges and a wonderful variety of skin conditions. During the eighties, he spent months in Madison, Wisconsin learning Mohs surgery from Dr. Fredrick Mohs himself. Dr. Hauge remains today as one of the most respected and accomplished practitioners of that highly intricate combination of surgical and pathological skills. Noel states he has seen the practice of Dermatology gradually change its routine from “being a workhorse” in an office setting to an often sub-specialized pursuit utilizing evidence-based treatment modalities — among them being immunologic medications, modern laser applications, Mohs surgery and a variety of necessary and scientifically accepted surgical and non-surgical cosmetic activities. His gently comforting and unhurried manner proves successful in caring for the most routine of eczema or acne cases to the most serious malignant melanoma. He enjoys and collaborates easily with oncologists, plastic surgeons and other medical specialists. Dr. Hauge “deeply respects and loves” his practice partners, is “excited about the future of Dermatology,” and states the most self-satisfying and gratifying portions of his long and fruitful career are “just any time you can be of help to others.” His wife and grown children — who have similar successful productivities and proclivities for being of service to humanity — are rightly proud of our Luminary . . . and so are we. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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