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Lessons abound for dermatologists when animal health and human health intersect
NEW YORK – We share more than affection with our dogs and cats. We also share diseases – about which our four-legged furry friends can teach us plenty.
That was the conclusion of speakers at a session on “cases at the intersection of human and veterinary dermatology,” presented at the summer meeting of the American Academy of Dermatology.
“Human health is intimately connected to animal health,” said Jennifer Gardner, MD, of the division of dermatology, University of Washington, Seattle, and a collaborating member of the school’s Center for One Health Research. The One Health framework looks at factors involved in the human, environmental, and animal sectors from the molecular level to the individual level and even to the planetary level.
Dr. Gardner challenged her audience to think beyond their individual areas of expertise. “How does the work you’re doing with a patient or test tube connect up the line and make an impact to levels higher up?” she asked.
The One Health framework also challenges practitioners to look horizontally, at how work done in the human world connects to what’s going on in the veterinary world – that is, how treatments for dermatologic conditions in dogs may one day affect how dermatologists treat the same or similar disorders in humans.
Learning from the mighty mite
For example, the study of mites that live on the skin of animals could eventually shed light on how dermatologists treat mite-related conditions in humans.
Dirk M. Elston, MD, professor and chair of the department of dermatology at the Medical University of South Carolina, Charleston, noted that Demodex mites occur in humans and in pets.
In such cases, “sulfur tends to be my most reliable” treatment, he said, noting that it releases a rotten egg smell. “You’re basically gassing the organism.” Dr. Elston said he frequently gets calls from fellow dermatologists whose antimite efforts have failed with ivermectin and permethrin and does not hesitate to give his advice. “I’m like a broken record,” he said. “Sulfur, sulfur, sulfur, sulfur.”
The Demodex mite affects dogs to varying degrees, depending on where they live, said Kathryn Rook, VMD, of the department of dermatology at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. In North America, demodicosis occurs in 0.38%-0.58% of dogs, and in 25% of dogs in Mexico, she said.
Amitraz, the only Food and Drug Administration–approved treatment for canine demodicosis, is available only as a dip. But it has fallen from favor as a result of sometimes serious side effects, which can include sedation, bradycardia, ataxia, vomiting, diarrhea, and hyperglycemia.
Daily administration of oral ivermectin – often for months – also carries a risk of side effects, including dilated pupils, ataxia, sedation, stupor, coma, hypersalivation, vomiting, diarrhea, blindness, tremors, seizures, and respiratory depression.
But the discovery of isoxazoline has “revolutionized” the treatment of demodicosis and other parasitic infestations in dogs, Dr. Rook said, citing quicker resolution of disease and improved quality of life for both the patient and its owner.
Isoxazoline, which Dr. Rook said carries little risk for side effects, is licensed in the United States only as a flea and tick preventive.
Atopic dermatitis
Atopic dermatitis (AD) tends to be similar in people and dogs, according to Charles W. Bradley, DVM, of the University of Pennsylvania School of Veterinary Medicine, Philadelphia. About 10%-30% of children and up to 10% of adults have the disorder, the prevalence of which has more than doubled in recent years, he said.
In dogs, the prevalence is 10%-20%, making it “an extraordinarily common disorder,” he said. Lesions tend to be located on the feet, face, pinnae, ventrum, and axilla/inguinum. Additional sites vary by breed, with Dalmatians tending to get AD on the lips, French Bulldogs on the eyelids, German Shepherds on the elbows, Shar-Peis on the thorax, and Boxers on the ears.
In humans, Staphylococcus aureus is the chief microorganism of concern, said Elizabeth Grice, PhD, of the department of dermatology at the University of Pennsylvania, Philadelphia, who copresented the topic with Dr. Bradley.
“My true love is anything to do with the skin microbiome,” she said. “The more severe the disease, the lower the skin microbiome diversity.”
Though most studies of AD use mice as animal models, dogs would be better, according to Dr. Grice and Dr. Bradley.
That’s because canine AD occurs spontaneously and exhibits immunologic and clinical features similar to those of human AD. They include prevalence, environmental triggers, immunologic profiles, genetic predispositions, lesion distribution, and frequent colonization by Staphylococcus species. In addition, dogs and their owners tend to share the same environment.
A rash of itches
Among dermatology patients – man or beast – itch can outweigh rash as a key focus of concern, according to Brian Kim, MD, of the division of dermatology at Washington University in St. Louis, and codirector for the University’s Center for the Study of Itch. “The problem is my patients don’t complain about their rash; they complain about their itch,” he said. “But we don’t understand the basic question of itch.” In fact, the FDA has not approved any drugs for the treatment of chronic itch, he said.
For dogs, advances have been made with Janus kinase (JAK) inhibitors, which “may function as immunomodulators,” Dr. Kim said. And JAK-1 selective inhibition “may be more effective than broad JAK blockade for itch.”
‘The perfect culture plate’
Lessons can be learned from studying canine AD, which “is immunophysiologically homologous to human AD,” said Daniel O. Morris, DVM, MPH, professor of dermatology, at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. “The main difference: My patients are covered in dense hair coats.” Because of that, systemic treatment is necessary, he said.
Canine AD primarily affects areas where hair is sparse or where the surface microclimate is moist, he said. A dog’s ear canal, which can be 10 times longer than a human’s, harbors plenty of moisture and heat, he said. “It’s the perfect culture plate.”
But, he added, the owners of his patients tend to resist using topical therapies “that could be potentially smeared on the babies and grandma’s diabetic foot ulcer.” So he has long relied on systemic treatments, initially steroids and cyclosporine. But they can have major side effects, and cyclosporine can take 60-90 days before it exerts maximum effect.
A faster-acting compound called oclacitinib has shown promise based on its high affinity for inhibiting JAK-1 enzyme-mediated activation of cytokine expression, including interleukin (IL)-31, he said. “Clinical trials demonstrate an antipruritic efficacy equivalent to both prednisolone and cyclosporine,” he noted. Contraindications include a history of neoplasia, the presence of severe infection, and age under 1 year.
Monoclonal antibody targets IL-31
The latest promising arrival is lokivetmab, a monoclonal antibody that targets canine IL-31, according to Dr. Morris. It acts rapidly (within 1 day for many dogs) and prevents binding of IL-31 to its neuronal receptor for at least a month, thereby interrupting neurotransmission of itch.
But side effects can be serious and common. Equal efficacy with a reduced side effect is the holy grail, he said.
Some doctors are not waiting. “People are throwing these two products at anything that itches,” he said. Unfortunately, they tend to “work miserably” for causes other than AD, he added.
Dr. Gardner, Dr. Elston, Dr. Rook, Dr. Bradley, and Dr. Morris reported no financial conflicts. Dr. Grice’s disclosures include having served as a speaker for GlaxoSmithKline and for L’Oreal France, and having received grants/research funding from Janssen Research & Development. Dr. Kim has served as a consultant to biotechnology and pharmaceutical companies.
NEW YORK – We share more than affection with our dogs and cats. We also share diseases – about which our four-legged furry friends can teach us plenty.
That was the conclusion of speakers at a session on “cases at the intersection of human and veterinary dermatology,” presented at the summer meeting of the American Academy of Dermatology.
“Human health is intimately connected to animal health,” said Jennifer Gardner, MD, of the division of dermatology, University of Washington, Seattle, and a collaborating member of the school’s Center for One Health Research. The One Health framework looks at factors involved in the human, environmental, and animal sectors from the molecular level to the individual level and even to the planetary level.
Dr. Gardner challenged her audience to think beyond their individual areas of expertise. “How does the work you’re doing with a patient or test tube connect up the line and make an impact to levels higher up?” she asked.
The One Health framework also challenges practitioners to look horizontally, at how work done in the human world connects to what’s going on in the veterinary world – that is, how treatments for dermatologic conditions in dogs may one day affect how dermatologists treat the same or similar disorders in humans.
Learning from the mighty mite
For example, the study of mites that live on the skin of animals could eventually shed light on how dermatologists treat mite-related conditions in humans.
Dirk M. Elston, MD, professor and chair of the department of dermatology at the Medical University of South Carolina, Charleston, noted that Demodex mites occur in humans and in pets.
In such cases, “sulfur tends to be my most reliable” treatment, he said, noting that it releases a rotten egg smell. “You’re basically gassing the organism.” Dr. Elston said he frequently gets calls from fellow dermatologists whose antimite efforts have failed with ivermectin and permethrin and does not hesitate to give his advice. “I’m like a broken record,” he said. “Sulfur, sulfur, sulfur, sulfur.”
The Demodex mite affects dogs to varying degrees, depending on where they live, said Kathryn Rook, VMD, of the department of dermatology at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. In North America, demodicosis occurs in 0.38%-0.58% of dogs, and in 25% of dogs in Mexico, she said.
Amitraz, the only Food and Drug Administration–approved treatment for canine demodicosis, is available only as a dip. But it has fallen from favor as a result of sometimes serious side effects, which can include sedation, bradycardia, ataxia, vomiting, diarrhea, and hyperglycemia.
Daily administration of oral ivermectin – often for months – also carries a risk of side effects, including dilated pupils, ataxia, sedation, stupor, coma, hypersalivation, vomiting, diarrhea, blindness, tremors, seizures, and respiratory depression.
But the discovery of isoxazoline has “revolutionized” the treatment of demodicosis and other parasitic infestations in dogs, Dr. Rook said, citing quicker resolution of disease and improved quality of life for both the patient and its owner.
Isoxazoline, which Dr. Rook said carries little risk for side effects, is licensed in the United States only as a flea and tick preventive.
Atopic dermatitis
Atopic dermatitis (AD) tends to be similar in people and dogs, according to Charles W. Bradley, DVM, of the University of Pennsylvania School of Veterinary Medicine, Philadelphia. About 10%-30% of children and up to 10% of adults have the disorder, the prevalence of which has more than doubled in recent years, he said.
In dogs, the prevalence is 10%-20%, making it “an extraordinarily common disorder,” he said. Lesions tend to be located on the feet, face, pinnae, ventrum, and axilla/inguinum. Additional sites vary by breed, with Dalmatians tending to get AD on the lips, French Bulldogs on the eyelids, German Shepherds on the elbows, Shar-Peis on the thorax, and Boxers on the ears.
In humans, Staphylococcus aureus is the chief microorganism of concern, said Elizabeth Grice, PhD, of the department of dermatology at the University of Pennsylvania, Philadelphia, who copresented the topic with Dr. Bradley.
“My true love is anything to do with the skin microbiome,” she said. “The more severe the disease, the lower the skin microbiome diversity.”
Though most studies of AD use mice as animal models, dogs would be better, according to Dr. Grice and Dr. Bradley.
That’s because canine AD occurs spontaneously and exhibits immunologic and clinical features similar to those of human AD. They include prevalence, environmental triggers, immunologic profiles, genetic predispositions, lesion distribution, and frequent colonization by Staphylococcus species. In addition, dogs and their owners tend to share the same environment.
A rash of itches
Among dermatology patients – man or beast – itch can outweigh rash as a key focus of concern, according to Brian Kim, MD, of the division of dermatology at Washington University in St. Louis, and codirector for the University’s Center for the Study of Itch. “The problem is my patients don’t complain about their rash; they complain about their itch,” he said. “But we don’t understand the basic question of itch.” In fact, the FDA has not approved any drugs for the treatment of chronic itch, he said.
For dogs, advances have been made with Janus kinase (JAK) inhibitors, which “may function as immunomodulators,” Dr. Kim said. And JAK-1 selective inhibition “may be more effective than broad JAK blockade for itch.”
‘The perfect culture plate’
Lessons can be learned from studying canine AD, which “is immunophysiologically homologous to human AD,” said Daniel O. Morris, DVM, MPH, professor of dermatology, at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. “The main difference: My patients are covered in dense hair coats.” Because of that, systemic treatment is necessary, he said.
Canine AD primarily affects areas where hair is sparse or where the surface microclimate is moist, he said. A dog’s ear canal, which can be 10 times longer than a human’s, harbors plenty of moisture and heat, he said. “It’s the perfect culture plate.”
But, he added, the owners of his patients tend to resist using topical therapies “that could be potentially smeared on the babies and grandma’s diabetic foot ulcer.” So he has long relied on systemic treatments, initially steroids and cyclosporine. But they can have major side effects, and cyclosporine can take 60-90 days before it exerts maximum effect.
A faster-acting compound called oclacitinib has shown promise based on its high affinity for inhibiting JAK-1 enzyme-mediated activation of cytokine expression, including interleukin (IL)-31, he said. “Clinical trials demonstrate an antipruritic efficacy equivalent to both prednisolone and cyclosporine,” he noted. Contraindications include a history of neoplasia, the presence of severe infection, and age under 1 year.
Monoclonal antibody targets IL-31
The latest promising arrival is lokivetmab, a monoclonal antibody that targets canine IL-31, according to Dr. Morris. It acts rapidly (within 1 day for many dogs) and prevents binding of IL-31 to its neuronal receptor for at least a month, thereby interrupting neurotransmission of itch.
But side effects can be serious and common. Equal efficacy with a reduced side effect is the holy grail, he said.
Some doctors are not waiting. “People are throwing these two products at anything that itches,” he said. Unfortunately, they tend to “work miserably” for causes other than AD, he added.
Dr. Gardner, Dr. Elston, Dr. Rook, Dr. Bradley, and Dr. Morris reported no financial conflicts. Dr. Grice’s disclosures include having served as a speaker for GlaxoSmithKline and for L’Oreal France, and having received grants/research funding from Janssen Research & Development. Dr. Kim has served as a consultant to biotechnology and pharmaceutical companies.
NEW YORK – We share more than affection with our dogs and cats. We also share diseases – about which our four-legged furry friends can teach us plenty.
That was the conclusion of speakers at a session on “cases at the intersection of human and veterinary dermatology,” presented at the summer meeting of the American Academy of Dermatology.
“Human health is intimately connected to animal health,” said Jennifer Gardner, MD, of the division of dermatology, University of Washington, Seattle, and a collaborating member of the school’s Center for One Health Research. The One Health framework looks at factors involved in the human, environmental, and animal sectors from the molecular level to the individual level and even to the planetary level.
Dr. Gardner challenged her audience to think beyond their individual areas of expertise. “How does the work you’re doing with a patient or test tube connect up the line and make an impact to levels higher up?” she asked.
The One Health framework also challenges practitioners to look horizontally, at how work done in the human world connects to what’s going on in the veterinary world – that is, how treatments for dermatologic conditions in dogs may one day affect how dermatologists treat the same or similar disorders in humans.
Learning from the mighty mite
For example, the study of mites that live on the skin of animals could eventually shed light on how dermatologists treat mite-related conditions in humans.
Dirk M. Elston, MD, professor and chair of the department of dermatology at the Medical University of South Carolina, Charleston, noted that Demodex mites occur in humans and in pets.
In such cases, “sulfur tends to be my most reliable” treatment, he said, noting that it releases a rotten egg smell. “You’re basically gassing the organism.” Dr. Elston said he frequently gets calls from fellow dermatologists whose antimite efforts have failed with ivermectin and permethrin and does not hesitate to give his advice. “I’m like a broken record,” he said. “Sulfur, sulfur, sulfur, sulfur.”
The Demodex mite affects dogs to varying degrees, depending on where they live, said Kathryn Rook, VMD, of the department of dermatology at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. In North America, demodicosis occurs in 0.38%-0.58% of dogs, and in 25% of dogs in Mexico, she said.
Amitraz, the only Food and Drug Administration–approved treatment for canine demodicosis, is available only as a dip. But it has fallen from favor as a result of sometimes serious side effects, which can include sedation, bradycardia, ataxia, vomiting, diarrhea, and hyperglycemia.
Daily administration of oral ivermectin – often for months – also carries a risk of side effects, including dilated pupils, ataxia, sedation, stupor, coma, hypersalivation, vomiting, diarrhea, blindness, tremors, seizures, and respiratory depression.
But the discovery of isoxazoline has “revolutionized” the treatment of demodicosis and other parasitic infestations in dogs, Dr. Rook said, citing quicker resolution of disease and improved quality of life for both the patient and its owner.
Isoxazoline, which Dr. Rook said carries little risk for side effects, is licensed in the United States only as a flea and tick preventive.
Atopic dermatitis
Atopic dermatitis (AD) tends to be similar in people and dogs, according to Charles W. Bradley, DVM, of the University of Pennsylvania School of Veterinary Medicine, Philadelphia. About 10%-30% of children and up to 10% of adults have the disorder, the prevalence of which has more than doubled in recent years, he said.
In dogs, the prevalence is 10%-20%, making it “an extraordinarily common disorder,” he said. Lesions tend to be located on the feet, face, pinnae, ventrum, and axilla/inguinum. Additional sites vary by breed, with Dalmatians tending to get AD on the lips, French Bulldogs on the eyelids, German Shepherds on the elbows, Shar-Peis on the thorax, and Boxers on the ears.
In humans, Staphylococcus aureus is the chief microorganism of concern, said Elizabeth Grice, PhD, of the department of dermatology at the University of Pennsylvania, Philadelphia, who copresented the topic with Dr. Bradley.
“My true love is anything to do with the skin microbiome,” she said. “The more severe the disease, the lower the skin microbiome diversity.”
Though most studies of AD use mice as animal models, dogs would be better, according to Dr. Grice and Dr. Bradley.
That’s because canine AD occurs spontaneously and exhibits immunologic and clinical features similar to those of human AD. They include prevalence, environmental triggers, immunologic profiles, genetic predispositions, lesion distribution, and frequent colonization by Staphylococcus species. In addition, dogs and their owners tend to share the same environment.
A rash of itches
Among dermatology patients – man or beast – itch can outweigh rash as a key focus of concern, according to Brian Kim, MD, of the division of dermatology at Washington University in St. Louis, and codirector for the University’s Center for the Study of Itch. “The problem is my patients don’t complain about their rash; they complain about their itch,” he said. “But we don’t understand the basic question of itch.” In fact, the FDA has not approved any drugs for the treatment of chronic itch, he said.
For dogs, advances have been made with Janus kinase (JAK) inhibitors, which “may function as immunomodulators,” Dr. Kim said. And JAK-1 selective inhibition “may be more effective than broad JAK blockade for itch.”
‘The perfect culture plate’
Lessons can be learned from studying canine AD, which “is immunophysiologically homologous to human AD,” said Daniel O. Morris, DVM, MPH, professor of dermatology, at the University of Pennsylvania School of Veterinary Medicine, Philadelphia. “The main difference: My patients are covered in dense hair coats.” Because of that, systemic treatment is necessary, he said.
Canine AD primarily affects areas where hair is sparse or where the surface microclimate is moist, he said. A dog’s ear canal, which can be 10 times longer than a human’s, harbors plenty of moisture and heat, he said. “It’s the perfect culture plate.”
But, he added, the owners of his patients tend to resist using topical therapies “that could be potentially smeared on the babies and grandma’s diabetic foot ulcer.” So he has long relied on systemic treatments, initially steroids and cyclosporine. But they can have major side effects, and cyclosporine can take 60-90 days before it exerts maximum effect.
A faster-acting compound called oclacitinib has shown promise based on its high affinity for inhibiting JAK-1 enzyme-mediated activation of cytokine expression, including interleukin (IL)-31, he said. “Clinical trials demonstrate an antipruritic efficacy equivalent to both prednisolone and cyclosporine,” he noted. Contraindications include a history of neoplasia, the presence of severe infection, and age under 1 year.
Monoclonal antibody targets IL-31
The latest promising arrival is lokivetmab, a monoclonal antibody that targets canine IL-31, according to Dr. Morris. It acts rapidly (within 1 day for many dogs) and prevents binding of IL-31 to its neuronal receptor for at least a month, thereby interrupting neurotransmission of itch.
But side effects can be serious and common. Equal efficacy with a reduced side effect is the holy grail, he said.
Some doctors are not waiting. “People are throwing these two products at anything that itches,” he said. Unfortunately, they tend to “work miserably” for causes other than AD, he added.
Dr. Gardner, Dr. Elston, Dr. Rook, Dr. Bradley, and Dr. Morris reported no financial conflicts. Dr. Grice’s disclosures include having served as a speaker for GlaxoSmithKline and for L’Oreal France, and having received grants/research funding from Janssen Research & Development. Dr. Kim has served as a consultant to biotechnology and pharmaceutical companies.
AT THE 2017 AAD SUMMER MEETING
Questions plague platelet-rich plasma’s promise
NEW YORK – If platelet-rich plasma is good enough for Kim Kardashian, what more do you need to know?
Turns out, there’s plenty to know, and plenty more that remains unknown about the procedure, which is sometimes referred to as PRP or, in Kardashian’s case, as a “vampire facial,” according to Terrence Keaney, MD, of the department of dermatology, George Washington University, Washington.
It’s easy to make: draw blood, centrifuge it, and then deliver it. The platelets themselves are not the active substances. For that, you have to look at what the platelets release from their alpha granules. They include a wealth of growth factors, including platelet-derived growth factor, transforming growth factor, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor, and connective tissue growth factor.
That’s not all. “There are 800 other bioactive molecules secreted by platelets,” including cell adhesion molecules, cytokines, antimicrobial peptides, and anti-inflammatory molecules, said Dr. Keaney, founder and director of SkinDC, in Arlington, Va. “You bring it all together, what is PRP? A growth factor/cytokine cocktail.”
But, like the cocktails one can find in a college dorm, compared with the ones found at a bar at an upscale hotel, there can be big differences – depending on who’s doing the mixing.
Still, its reputation as an all-natural, safe product has made it appealing to the public, as well as to doctors in fields beyond dermatology, he said, citing sports medicine, dentistry, otolaryngology, ophthalmology, urology, wound healing, cosmetic medicine, and cardiothoracic and maxillofacial medicine.
The Food and Drug Administration considers it a blood product, which means that it is exempt from the FDA’s traditional regulatory pathways, which would require animal studies and clinical trials. Instead, oversight falls to the FDA’s Center for Biologics Evaluation and Research, which is responsible for regulating human cells, tissues, and cellular- and tissue-based products.
A number of device makers have used the 510(k) application to bring PRP preparation systems to market. Under the application, devices that are “substantially equivalent” to a currently marketed device gain FDA clearance (J Knee Surg. 2015 Feb;28[1]:29-34). The result is that many such systems are available.
Nearly all of the devices have received clearance to produce PRP for use with bone graft materials in platelet-rich products for use by orthopedic surgeons. Other uses of the product, like stimulating hair growth, would be considered off-label.
Nevertheless, the purveyors of PRP have found people willing to part with their money in exchange for the hope that they may be able to hold on to their hair. That is not surprising, given the “pretty meager” therapeutic armamentarium available to them, Dr. Keaney said, citing minoxidil and finasteride – each of which was approved more than 20 years ago.
He bemoaned the lack of standardization for everything from platelet preparation technique to potential applications, which include facial rejuvenation, wound healing, and hair loss. “PRP has hype and it has hope, but it needs help,” he said. “There are lots of clinical questions that need to be answered.”
He added that the data remain thin. “Unfortunately, our clinical data does not match the hype around PRP,” he said, citing a recently published meta-analysis of six studies involving 177 patients (J Cosmet Dermatol. 2017 Mar 13. doi: 10.1111/jocd.12331).
Its conclusion was measured: “Platelet-rich plasma injection for local hair restoration in patients with androgenetic alopecia seems to increase hair’s number and thickness with minimal or no collateral effects. However, the current evidence does not support this treatment’s modality over hair transplantation due to the lack of established protocols,” the authors wrote. The meta-analysis results, they added, “should be interpreted with caution because it consists of pooling many small studies and larger randomized studies should be performed to verify this perception.”
Questions include how to determine the proper concentration and how many times PRP should be centrifuged, Dr. Keaney said. And it is not clear how or how often to deliver PRP. Subdermally? Via microneedle? Both? After traumatizing the skin to increase endogenous activators? Daily? Weekly? Monthly?
“We don’t know,” he said.
And, Dr. Keaney acknowledged, that may not change. “There is little incentive for industry to do a large-scale study,” he said. “If the results aren’t what they look for then you’ve killed your golden goose.”
Still, he has not been dissuaded. “From my standpoint, there’s a good scientific rationale, a proposed mechanism of action, molecular pathways.”
Though the clinical data have been variable, the studies small, and the study designs inconsistent, “there is a trend towards clinical effect,” he said. “If this is done appropriately, using appropriate systems and protocols in your office, this can be a very safe procedure – with injection site discomfort,” he said.
Dr. Keaney has spoken on behalf of a PRP preparation manufacturer.
dermnews@frontlinemedcom.com
NEW YORK – If platelet-rich plasma is good enough for Kim Kardashian, what more do you need to know?
Turns out, there’s plenty to know, and plenty more that remains unknown about the procedure, which is sometimes referred to as PRP or, in Kardashian’s case, as a “vampire facial,” according to Terrence Keaney, MD, of the department of dermatology, George Washington University, Washington.
It’s easy to make: draw blood, centrifuge it, and then deliver it. The platelets themselves are not the active substances. For that, you have to look at what the platelets release from their alpha granules. They include a wealth of growth factors, including platelet-derived growth factor, transforming growth factor, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor, and connective tissue growth factor.
That’s not all. “There are 800 other bioactive molecules secreted by platelets,” including cell adhesion molecules, cytokines, antimicrobial peptides, and anti-inflammatory molecules, said Dr. Keaney, founder and director of SkinDC, in Arlington, Va. “You bring it all together, what is PRP? A growth factor/cytokine cocktail.”
But, like the cocktails one can find in a college dorm, compared with the ones found at a bar at an upscale hotel, there can be big differences – depending on who’s doing the mixing.
Still, its reputation as an all-natural, safe product has made it appealing to the public, as well as to doctors in fields beyond dermatology, he said, citing sports medicine, dentistry, otolaryngology, ophthalmology, urology, wound healing, cosmetic medicine, and cardiothoracic and maxillofacial medicine.
The Food and Drug Administration considers it a blood product, which means that it is exempt from the FDA’s traditional regulatory pathways, which would require animal studies and clinical trials. Instead, oversight falls to the FDA’s Center for Biologics Evaluation and Research, which is responsible for regulating human cells, tissues, and cellular- and tissue-based products.
A number of device makers have used the 510(k) application to bring PRP preparation systems to market. Under the application, devices that are “substantially equivalent” to a currently marketed device gain FDA clearance (J Knee Surg. 2015 Feb;28[1]:29-34). The result is that many such systems are available.
Nearly all of the devices have received clearance to produce PRP for use with bone graft materials in platelet-rich products for use by orthopedic surgeons. Other uses of the product, like stimulating hair growth, would be considered off-label.
Nevertheless, the purveyors of PRP have found people willing to part with their money in exchange for the hope that they may be able to hold on to their hair. That is not surprising, given the “pretty meager” therapeutic armamentarium available to them, Dr. Keaney said, citing minoxidil and finasteride – each of which was approved more than 20 years ago.
He bemoaned the lack of standardization for everything from platelet preparation technique to potential applications, which include facial rejuvenation, wound healing, and hair loss. “PRP has hype and it has hope, but it needs help,” he said. “There are lots of clinical questions that need to be answered.”
He added that the data remain thin. “Unfortunately, our clinical data does not match the hype around PRP,” he said, citing a recently published meta-analysis of six studies involving 177 patients (J Cosmet Dermatol. 2017 Mar 13. doi: 10.1111/jocd.12331).
Its conclusion was measured: “Platelet-rich plasma injection for local hair restoration in patients with androgenetic alopecia seems to increase hair’s number and thickness with minimal or no collateral effects. However, the current evidence does not support this treatment’s modality over hair transplantation due to the lack of established protocols,” the authors wrote. The meta-analysis results, they added, “should be interpreted with caution because it consists of pooling many small studies and larger randomized studies should be performed to verify this perception.”
Questions include how to determine the proper concentration and how many times PRP should be centrifuged, Dr. Keaney said. And it is not clear how or how often to deliver PRP. Subdermally? Via microneedle? Both? After traumatizing the skin to increase endogenous activators? Daily? Weekly? Monthly?
“We don’t know,” he said.
And, Dr. Keaney acknowledged, that may not change. “There is little incentive for industry to do a large-scale study,” he said. “If the results aren’t what they look for then you’ve killed your golden goose.”
Still, he has not been dissuaded. “From my standpoint, there’s a good scientific rationale, a proposed mechanism of action, molecular pathways.”
Though the clinical data have been variable, the studies small, and the study designs inconsistent, “there is a trend towards clinical effect,” he said. “If this is done appropriately, using appropriate systems and protocols in your office, this can be a very safe procedure – with injection site discomfort,” he said.
Dr. Keaney has spoken on behalf of a PRP preparation manufacturer.
dermnews@frontlinemedcom.com
NEW YORK – If platelet-rich plasma is good enough for Kim Kardashian, what more do you need to know?
Turns out, there’s plenty to know, and plenty more that remains unknown about the procedure, which is sometimes referred to as PRP or, in Kardashian’s case, as a “vampire facial,” according to Terrence Keaney, MD, of the department of dermatology, George Washington University, Washington.
It’s easy to make: draw blood, centrifuge it, and then deliver it. The platelets themselves are not the active substances. For that, you have to look at what the platelets release from their alpha granules. They include a wealth of growth factors, including platelet-derived growth factor, transforming growth factor, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor, and connective tissue growth factor.
That’s not all. “There are 800 other bioactive molecules secreted by platelets,” including cell adhesion molecules, cytokines, antimicrobial peptides, and anti-inflammatory molecules, said Dr. Keaney, founder and director of SkinDC, in Arlington, Va. “You bring it all together, what is PRP? A growth factor/cytokine cocktail.”
But, like the cocktails one can find in a college dorm, compared with the ones found at a bar at an upscale hotel, there can be big differences – depending on who’s doing the mixing.
Still, its reputation as an all-natural, safe product has made it appealing to the public, as well as to doctors in fields beyond dermatology, he said, citing sports medicine, dentistry, otolaryngology, ophthalmology, urology, wound healing, cosmetic medicine, and cardiothoracic and maxillofacial medicine.
The Food and Drug Administration considers it a blood product, which means that it is exempt from the FDA’s traditional regulatory pathways, which would require animal studies and clinical trials. Instead, oversight falls to the FDA’s Center for Biologics Evaluation and Research, which is responsible for regulating human cells, tissues, and cellular- and tissue-based products.
A number of device makers have used the 510(k) application to bring PRP preparation systems to market. Under the application, devices that are “substantially equivalent” to a currently marketed device gain FDA clearance (J Knee Surg. 2015 Feb;28[1]:29-34). The result is that many such systems are available.
Nearly all of the devices have received clearance to produce PRP for use with bone graft materials in platelet-rich products for use by orthopedic surgeons. Other uses of the product, like stimulating hair growth, would be considered off-label.
Nevertheless, the purveyors of PRP have found people willing to part with their money in exchange for the hope that they may be able to hold on to their hair. That is not surprising, given the “pretty meager” therapeutic armamentarium available to them, Dr. Keaney said, citing minoxidil and finasteride – each of which was approved more than 20 years ago.
He bemoaned the lack of standardization for everything from platelet preparation technique to potential applications, which include facial rejuvenation, wound healing, and hair loss. “PRP has hype and it has hope, but it needs help,” he said. “There are lots of clinical questions that need to be answered.”
He added that the data remain thin. “Unfortunately, our clinical data does not match the hype around PRP,” he said, citing a recently published meta-analysis of six studies involving 177 patients (J Cosmet Dermatol. 2017 Mar 13. doi: 10.1111/jocd.12331).
Its conclusion was measured: “Platelet-rich plasma injection for local hair restoration in patients with androgenetic alopecia seems to increase hair’s number and thickness with minimal or no collateral effects. However, the current evidence does not support this treatment’s modality over hair transplantation due to the lack of established protocols,” the authors wrote. The meta-analysis results, they added, “should be interpreted with caution because it consists of pooling many small studies and larger randomized studies should be performed to verify this perception.”
Questions include how to determine the proper concentration and how many times PRP should be centrifuged, Dr. Keaney said. And it is not clear how or how often to deliver PRP. Subdermally? Via microneedle? Both? After traumatizing the skin to increase endogenous activators? Daily? Weekly? Monthly?
“We don’t know,” he said.
And, Dr. Keaney acknowledged, that may not change. “There is little incentive for industry to do a large-scale study,” he said. “If the results aren’t what they look for then you’ve killed your golden goose.”
Still, he has not been dissuaded. “From my standpoint, there’s a good scientific rationale, a proposed mechanism of action, molecular pathways.”
Though the clinical data have been variable, the studies small, and the study designs inconsistent, “there is a trend towards clinical effect,” he said. “If this is done appropriately, using appropriate systems and protocols in your office, this can be a very safe procedure – with injection site discomfort,” he said.
Dr. Keaney has spoken on behalf of a PRP preparation manufacturer.
dermnews@frontlinemedcom.com
AT THE 2017 AAD SUMMER MEETING
AAD president sees the specialty as ‘a bright star on the dance floor’
NEW YORK – In a plenary session at the American Academy of Dermatology summer meeting, the AAD president offered an upbeat view of the profession, likening his role in leading the 19,000-member organization to that of a dancer and comparing the specialty itself to “a bright star on the dance floor.”
The specialty, however, is facing an uncertain future. “As the music changes, so must the dance,” Henry Lim, MD, told attendees. “And so it is with American medicine today. Successfully transitioning, adapting to those changes, is especially challenging for all of medicine, including for our specialty.” 
Dr. Lim’s remarks came hours after President Donald Trump’s effort to dismantle the Affordable Care Act had failed. “We are in the middle of a health care system in deep turmoil and uncertainty – as you all saw from the vote this morning,” said Dr. Lim, whose 1-year term began in March.
Dermatology is assuming an ever-greater role as the U.S. population ages, he said. “The fastest-growing segment is people over 85 and last year Hallmark reported it sold 85,000 ‘Happy 100th Birthday’ cards.”
He cited the AAD’s Burden of Skin Disease Report, which found that nearly half of Americans over the age of 65 have at least one skin disease. That may not, however, translate into job security for dermatologists, he cautioned.
“A most concerning statistic from that report is that two in every three patients with skin disease are being treated by nondermatologists,” he said. Those practitioners include primary care physicians, pediatricians, hospitalists, nurse practitioners, and physician assistants. “We all know a major reason for it is access,” said Dr. Lim, who told a reporter prior to his speech that the academy has taken no position on whether it is for or against the Affordable Care Act.
But, he added in his speech, “we have been continuing to meet with individual members of Congress, Health and Human Services leadership, and the FDA – tackling issues eroding our ability to care for patients.”
Dr. Lim, chair emeritus of the department of dermatology and senior vice president for academic affairs at Henry Ford Health System in Detroit, cited in-office compounding, step therapy, narrow network funding for medical research, and scope of practice as examples.
“Listening is the key to understanding,” he noted, and the academy is doing just that. He and the rest of the academy’s leadership have visited with a number of state societies to listen to their concerns. “It is clear to me that, while we have handled many issues well, there are areas where we as an academy can do better,” he said.
Dr. Lim cited the need to “enhance our efforts in advocacy and to improve our communication, including our social media presence.”
The academy itself is in strong shape, with more than 90% of practicing dermatologists as members, he said. That places the AAD among the top specialty societies and means that future growth will likely come from international outreach.
Dr. Lim called on members to join the effort by taking to the dance floor themselves and participating. “Ask not what dermatology can do for you, ask what you can do for dermatology,” he concluded. “With the leadership of our academy listening to all of you and working together with all of you, I’m confident that dermatology will continue to be a bright star on the dance floor.”
NEW YORK – In a plenary session at the American Academy of Dermatology summer meeting, the AAD president offered an upbeat view of the profession, likening his role in leading the 19,000-member organization to that of a dancer and comparing the specialty itself to “a bright star on the dance floor.”
The specialty, however, is facing an uncertain future. “As the music changes, so must the dance,” Henry Lim, MD, told attendees. “And so it is with American medicine today. Successfully transitioning, adapting to those changes, is especially challenging for all of medicine, including for our specialty.”
Dr. Lim’s remarks came hours after President Donald Trump’s effort to dismantle the Affordable Care Act had failed. “We are in the middle of a health care system in deep turmoil and uncertainty – as you all saw from the vote this morning,” said Dr. Lim, whose 1-year term began in March.
Dermatology is assuming an ever-greater role as the U.S. population ages, he said. “The fastest-growing segment is people over 85 and last year Hallmark reported it sold 85,000 ‘Happy 100th Birthday’ cards.”
He cited the AAD’s Burden of Skin Disease Report, which found that nearly half of Americans over the age of 65 have at least one skin disease. That may not, however, translate into job security for dermatologists, he cautioned.
“A most concerning statistic from that report is that two in every three patients with skin disease are being treated by nondermatologists,” he said. Those practitioners include primary care physicians, pediatricians, hospitalists, nurse practitioners, and physician assistants. “We all know a major reason for it is access,” said Dr. Lim, who told a reporter prior to his speech that the academy has taken no position on whether it is for or against the Affordable Care Act.
But, he added in his speech, “we have been continuing to meet with individual members of Congress, Health and Human Services leadership, and the FDA – tackling issues eroding our ability to care for patients.”
Dr. Lim, chair emeritus of the department of dermatology and senior vice president for academic affairs at Henry Ford Health System in Detroit, cited in-office compounding, step therapy, narrow network funding for medical research, and scope of practice as examples.
“Listening is the key to understanding,” he noted, and the academy is doing just that. He and the rest of the academy’s leadership have visited with a number of state societies to listen to their concerns. “It is clear to me that, while we have handled many issues well, there are areas where we as an academy can do better,” he said.
Dr. Lim cited the need to “enhance our efforts in advocacy and to improve our communication, including our social media presence.”
The academy itself is in strong shape, with more than 90% of practicing dermatologists as members, he said. That places the AAD among the top specialty societies and means that future growth will likely come from international outreach.
Dr. Lim called on members to join the effort by taking to the dance floor themselves and participating. “Ask not what dermatology can do for you, ask what you can do for dermatology,” he concluded. “With the leadership of our academy listening to all of you and working together with all of you, I’m confident that dermatology will continue to be a bright star on the dance floor.”
NEW YORK – In a plenary session at the American Academy of Dermatology summer meeting, the AAD president offered an upbeat view of the profession, likening his role in leading the 19,000-member organization to that of a dancer and comparing the specialty itself to “a bright star on the dance floor.”
The specialty, however, is facing an uncertain future. “As the music changes, so must the dance,” Henry Lim, MD, told attendees. “And so it is with American medicine today. Successfully transitioning, adapting to those changes, is especially challenging for all of medicine, including for our specialty.”
Dr. Lim’s remarks came hours after President Donald Trump’s effort to dismantle the Affordable Care Act had failed. “We are in the middle of a health care system in deep turmoil and uncertainty – as you all saw from the vote this morning,” said Dr. Lim, whose 1-year term began in March.
Dermatology is assuming an ever-greater role as the U.S. population ages, he said. “The fastest-growing segment is people over 85 and last year Hallmark reported it sold 85,000 ‘Happy 100th Birthday’ cards.”
He cited the AAD’s Burden of Skin Disease Report, which found that nearly half of Americans over the age of 65 have at least one skin disease. That may not, however, translate into job security for dermatologists, he cautioned.
“A most concerning statistic from that report is that two in every three patients with skin disease are being treated by nondermatologists,” he said. Those practitioners include primary care physicians, pediatricians, hospitalists, nurse practitioners, and physician assistants. “We all know a major reason for it is access,” said Dr. Lim, who told a reporter prior to his speech that the academy has taken no position on whether it is for or against the Affordable Care Act.
But, he added in his speech, “we have been continuing to meet with individual members of Congress, Health and Human Services leadership, and the FDA – tackling issues eroding our ability to care for patients.”
Dr. Lim, chair emeritus of the department of dermatology and senior vice president for academic affairs at Henry Ford Health System in Detroit, cited in-office compounding, step therapy, narrow network funding for medical research, and scope of practice as examples.
“Listening is the key to understanding,” he noted, and the academy is doing just that. He and the rest of the academy’s leadership have visited with a number of state societies to listen to their concerns. “It is clear to me that, while we have handled many issues well, there are areas where we as an academy can do better,” he said.
Dr. Lim cited the need to “enhance our efforts in advocacy and to improve our communication, including our social media presence.”
The academy itself is in strong shape, with more than 90% of practicing dermatologists as members, he said. That places the AAD among the top specialty societies and means that future growth will likely come from international outreach.
Dr. Lim called on members to join the effort by taking to the dance floor themselves and participating. “Ask not what dermatology can do for you, ask what you can do for dermatology,” he concluded. “With the leadership of our academy listening to all of you and working together with all of you, I’m confident that dermatology will continue to be a bright star on the dance floor.”
AT THE 2017 AAD SUMMER MEETING
When patients get the travel bug, dermatologists should beware
NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.
That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.
Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.
Watch out for children
Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.
In the United States, the spirochete infection tends to be caused by the bacterial species Borrelia burgdorferi, which is typically transmitted by a tick bite. Hosts include the white-footed mouse, chipmunks, and even robins. In the Northeastern United States, Lyme season peaks from June through August; children aged 5-10 years of age tend to be at highest risk.
Changes to the skin are an important part of the clinical spectrum, with erythema migrans developing 1-2 weeks after infection and continuing for months. It can affect the cranial nerves, causing Bell’s palsy, meningitis, and carditis. In the late stage, large joint arthritis can occur.
But doctors cannot depend on the classic bull’s eye associated with erythema migrans, since it occurs only rarely in the United States, Dr. Oza pointed out. “More often, it is a homogenous, expanding area.”
Only about one in four children who present with Lyme disease display multiple erythema migrans rashes, he said. And the vector is rarely noticed. “Twenty-five percent recall a tick bite,” he added.
Erythema migrans can also occur among people who do not live in areas where Lyme disease is endemic. So doctors should be alert to Southern Tick–Associated Rash Illness, which is endemic to much of the Southeast – caused by the bite of the Lone Star tick. Unlike Lyme, this disease tends to be self-limiting and does not tend to cause a late-stage illness to develop neurologic or joint-related problems, he said.
Prevention
The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.
Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.
Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.
Aedes aegypti mosquitoes pose multiple threats
Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.
The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.
This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.
Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.
Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.
“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.
Bedbugs
No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.
Mother Nature offers little help, since bedbugs can survive winters. And they are not always easy to notice, since their saliva contains an anesthetic, which can mask the feeling of a bite. “Insects can thus feed undetected for 5-10 minutes,” Dr. Rosen said. But, though experiments have shown them to be competent vectors at spreading disease, “in real life, they have not been demonstrated to be the purveyors of human disease,” he noted.
So far, the best way to get rid of them is “thermal remediation,” which entails heating infested areas to 120-140° F for 5-8 hours.
Also effective, but less practical, would be to set any infested structures ablaze.
Advice for the traveler: Keep your suitcases zipped in hotel rooms, and store them up high or in the shower, since bedbugs have a tough time jumping or gaining traction on porcelain. And make sure you launder your clothes once you get home.
Dr. Rosen, Dr. Martinez, and Dr. Oza had no disclosures.
NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.
That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.
Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.
Watch out for children
Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.
In the United States, the spirochete infection tends to be caused by the bacterial species Borrelia burgdorferi, which is typically transmitted by a tick bite. Hosts include the white-footed mouse, chipmunks, and even robins. In the Northeastern United States, Lyme season peaks from June through August; children aged 5-10 years of age tend to be at highest risk.
Changes to the skin are an important part of the clinical spectrum, with erythema migrans developing 1-2 weeks after infection and continuing for months. It can affect the cranial nerves, causing Bell’s palsy, meningitis, and carditis. In the late stage, large joint arthritis can occur.
But doctors cannot depend on the classic bull’s eye associated with erythema migrans, since it occurs only rarely in the United States, Dr. Oza pointed out. “More often, it is a homogenous, expanding area.”
Only about one in four children who present with Lyme disease display multiple erythema migrans rashes, he said. And the vector is rarely noticed. “Twenty-five percent recall a tick bite,” he added.
Erythema migrans can also occur among people who do not live in areas where Lyme disease is endemic. So doctors should be alert to Southern Tick–Associated Rash Illness, which is endemic to much of the Southeast – caused by the bite of the Lone Star tick. Unlike Lyme, this disease tends to be self-limiting and does not tend to cause a late-stage illness to develop neurologic or joint-related problems, he said.
Prevention
The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.
Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.
Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.
Aedes aegypti mosquitoes pose multiple threats
Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.
The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.
This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.
Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.
Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.
“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.
Bedbugs
No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.
Mother Nature offers little help, since bedbugs can survive winters. And they are not always easy to notice, since their saliva contains an anesthetic, which can mask the feeling of a bite. “Insects can thus feed undetected for 5-10 minutes,” Dr. Rosen said. But, though experiments have shown them to be competent vectors at spreading disease, “in real life, they have not been demonstrated to be the purveyors of human disease,” he noted.
So far, the best way to get rid of them is “thermal remediation,” which entails heating infested areas to 120-140° F for 5-8 hours.
Also effective, but less practical, would be to set any infested structures ablaze.
Advice for the traveler: Keep your suitcases zipped in hotel rooms, and store them up high or in the shower, since bedbugs have a tough time jumping or gaining traction on porcelain. And make sure you launder your clothes once you get home.
Dr. Rosen, Dr. Martinez, and Dr. Oza had no disclosures.
NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.
That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.
Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.
Watch out for children
Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.
In the United States, the spirochete infection tends to be caused by the bacterial species Borrelia burgdorferi, which is typically transmitted by a tick bite. Hosts include the white-footed mouse, chipmunks, and even robins. In the Northeastern United States, Lyme season peaks from June through August; children aged 5-10 years of age tend to be at highest risk.
Changes to the skin are an important part of the clinical spectrum, with erythema migrans developing 1-2 weeks after infection and continuing for months. It can affect the cranial nerves, causing Bell’s palsy, meningitis, and carditis. In the late stage, large joint arthritis can occur.
But doctors cannot depend on the classic bull’s eye associated with erythema migrans, since it occurs only rarely in the United States, Dr. Oza pointed out. “More often, it is a homogenous, expanding area.”
Only about one in four children who present with Lyme disease display multiple erythema migrans rashes, he said. And the vector is rarely noticed. “Twenty-five percent recall a tick bite,” he added.
Erythema migrans can also occur among people who do not live in areas where Lyme disease is endemic. So doctors should be alert to Southern Tick–Associated Rash Illness, which is endemic to much of the Southeast – caused by the bite of the Lone Star tick. Unlike Lyme, this disease tends to be self-limiting and does not tend to cause a late-stage illness to develop neurologic or joint-related problems, he said.
Prevention
The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.
Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.
Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.
Aedes aegypti mosquitoes pose multiple threats
Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.
The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.
This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.
Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.
Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.
“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.
Bedbugs
No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.
Mother Nature offers little help, since bedbugs can survive winters. And they are not always easy to notice, since their saliva contains an anesthetic, which can mask the feeling of a bite. “Insects can thus feed undetected for 5-10 minutes,” Dr. Rosen said. But, though experiments have shown them to be competent vectors at spreading disease, “in real life, they have not been demonstrated to be the purveyors of human disease,” he noted.
So far, the best way to get rid of them is “thermal remediation,” which entails heating infested areas to 120-140° F for 5-8 hours.
Also effective, but less practical, would be to set any infested structures ablaze.
Advice for the traveler: Keep your suitcases zipped in hotel rooms, and store them up high or in the shower, since bedbugs have a tough time jumping or gaining traction on porcelain. And make sure you launder your clothes once you get home.
Dr. Rosen, Dr. Martinez, and Dr. Oza had no disclosures.
AT THE 2017 AAD SUMMER MEETING