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CDA Abstracts
Oral Presentations
Takeaway Message: Varying opinions exist as to how
dysplastic nevi are managed amongst Canadian dermatologists. This article provides valuable insight into how colleagues
across the country are managing this lesion.
O.01
Dysplastic nevus: management by Canadian
dermatologists
O.02
Canadian acne clinical practice guidelines
Priya Sapra1 Charles W. Lynde2 Cheryl Rosen3 Sanjay Siddha3
Yuka Asai2 A Baibergenova3 M Dutil4 S Humphrey5 P Hull6 C
Lynde4 Y Poulin7 N Shear4 Jerry Tan1 J Toole8 C Zip9
1. Royal College of Surgeons in Ireland, Dublin, Ireland; 2. Lynde Center for
Dermatology, Markham, ON; 3. University of Toronto,Toronto, ON
1. University of Western Ontario,Windsor, ON; 2. McGill University, Montreal,
QC; 3. Private practice, Richmond Hill, ON; 4. University of Toronto,Toronto, ON;
5. University of British Columbia,Vancouver, BC; 6. University of Saskatchewan,
Saskatoon, SK; 7. University of Laval, Laval, QC; 8. University of Manitoba,
Winnipeg, MB; 9. University of Calgary, Calgary, AB
Background: The term “dysplastic nevus” (DN) and the
management of DN remains controversial. There are no studies about their management by Canadian dermatologists.
Methods/Results: To assess the current practice of Canadian dermatologists regarding the terminology and treatment
of DN, a survey of 25 questions was emailed to 613 members
of the Canadian Dermatology Association, in French and
English.
Introduction: Acne, a globally burdensome disease, is
estimated to affect 4.5 million Canadians. While a variety of
treatments exist, there are no prior Canadian evidence-based
acne clinical practice guidelines.
179 responses were received. The numbers of participants
who completed each individual question varied. 53% of participants had been practicing dermatology for greater than 20
years (not including residency training). 47% of respondents
make a diagnosis of DN using only clinical criteria. 49% use
complete surgical excision to remove DN; 45% of respondents
use 1-2 mm margins for excision. In addition, 69% of respondents indicated they rarely or never re-excise lesions with
mild atypia when the margins are reported as positive. 46% of
respondents indicated they follow patients with multiple DN
more closely. Similarly, 53% indicated they follow DN patients
with a family history of melanoma more rigorously than if
there was no family history. 78% of participants indicated they
perform a total skin examination in patients with DN; 72%
also recommend skin self-examination for DN patients. However only 17% of respondents advise skin self-examinations in
first-degree relatives of DN patients. Additionally, 46% indicated they follow- their DN patients every 12 months. 66% of
respondents believe that a melanoma is more likely to arise
de novo rather than in a pre-existing DN. 65% of the surveyed
dermatologists do not want the term “dysplastic nevus” to be
abandoned.
Objective: To develop evidence-based acne clinical practice
guidelines adapted to the Canadian health care environment.
Methods: Quality evaluation, using a standardized instrument, of evidence-based acne clinical practice guidelines was
performed to identify those of highest methodological quality
and best suited to adaptation. Methodology for adaptation
was congruent with established recommendations. Updated
systematic literature search and critical evaluation of studies
fulfilling selection criteria of prospective trials in acne was undertaken for treatments available in Canada. Study grading and
overall levels of evidence were established by 2 independent
raters. Recommendation levels for treatment were established
by expert panel voting using an online Delphi process for
comedonal, mild-moderate inflammatory and severe inflammatory acne.
Results: Based on quality appraisal, the European S3 Acne
guidelines were used as the primary adaptation source. Systematic search results for this adaptation found 40 articles
updating topical therapies, 67 were found to meet inclusion
criterias; of 10 articles on systemic therapies, 5 articles were
deemed eligible for inclusion. A search for alternative therapies such as diet found 10 studies, of which 3 were included;
7 of 14 articles on physical therapies were deemed eligible.
The highest recommendations were: topical retinoids, benzoyl
peroxide (BPO), fixed dose clindamycin/ BPO and adapalene/
BPO for comedonal acne; fixed dose clindamycin/ BPO and
adapalene/BPO for mild-moderate inflammatory acne along
with consideration of systemic antibiotics and oral contraceptives for more extensive involvement; and oral isotretinoin
monotherapy for severe acne.
Conclusions: Canadian dermatologists continue to use the
term “dysplastic nevus”. There is no apparent consensus on
making a diagnosis of DN on clinical features only, and on the
various aspects of the treatment of DN.
Learning Objective: Results will aid in providing dermatologists with the opinions of their Canadian colleagues, so as to
eventually reach a consensus on the management of dysplastic
nevi.
A1
CDA Abstracts
Conclusion: Evidence-based recommendations for acne
management were developed by adaptation, following established methodological recommendations, of a previous high
quality guideline. This adaptation included updating of systematic searches from the latter and including treatments available
in Canada.
Conclusion: These results will aid in providing Canadian dermatologists with better treatment of Hidradenitis Suppurativa.
Learning Objective: To review successes and challenges
that Canadian dermatologists are experiencing in treating
patients with Hidradenitis Suppurativa.
Takeaway Message: Hidradenitis Suppurativa is a chronic
inflammatory skin disorder that Canadian dermatologists find
frustrating to treat. Newer agents will hopefully provide better
outcomes for our patients.
Learning Objective:
1. for comedonal acne, highest recommendations were for
topical retinoids, benzoyl peroxide (BPO), fixed dose
clindamycin/ BPO and adapalene/BPO
2. for mild-moderate inflammatory acne, highest recommendations were for fixed dose clindamycin/ BPO and adapalene/BPO for mild-moderate inflammatory acne along
with consideration of systemic antibiotics and oral contraceptives for more extensive involvement; 3. for severe
acne, highest recommendations were for oral isotretinoin
Takeaway Message:
O.04
Doxycycline and the rare side effect of acute
pancreatitis - a case study and literature
review
Hadal El-Hadi; Karen Holfeld; Andre Grobler
University of Saskatchewan, Saskatoon, SK
1. Canadian acne clinical practice guidelines are evidencebased and developed by adaptation
2. High quality evidence can guide recommendations for acne
treatment
3. Strength of recommendations are provided for each of
comedonal, mild-moderate inflammatory and severe acne.
Introduction: Doxycycline is used very commonly to treat
skin conditions such as acne and rosacea by dermatologists.
However, many dermatologists are unaware of the very rare
side effect of pancreatitis from the administration of doxycycline. Although uncommon for pancreatitis to occur, the
frequent prescription of doxycycline by dermatologists warrants a case study and literature review of the rare side effect
of pancreatitis, given the severity of the disease.
O.03
Methods, Results: A patient had perioral dermatitis in
which doxycycline was prescribed to treat her condition.
Within a week of doxycycline use, the patient was admitted to
the emergency department with a raised amylase compatible
with a pancreatitis. Ruling out other causes of acute pancreatitis, it was concluded that the patient had doxycycline-induced
pancreatitis. Follow-up visit post discharge revealed complete resolution of previous symptoms. A literature review of
doxycycline-induced pancreatitis shows that it is thought to be
caused either by a hypersensitivity reaction or by the generation of a toxic metabolite. It is not always clear which of these
mechanisms is operative.
Hidradenitis suppurativa: Canadian
dermatologists perspective
Ambika Gupta2 Charles W. Lynde1 Sanjay Siddha1 John N. Kraft1
1. University of Toronto,Toronto, ON; 2. University of Ottawa, Ottawa, ON
Background: Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease with a relapsing course. There is a lack
of evidence-based guidelines for appropriate treatment which
is very frustrating for both dermatologists and patients.
Objective: A survey is being conducted to determine if
Canadian dermatologists believe that there is an unmet need
in treating patients with HS. Information is being collected on
dermatologists’ goals, level of satisfaction and challenges in
treating patients, along with therapies that dermatologists are
using.
Conclusions: Pancreatitis is a rare side effect of doxycycline
use and patients and dermatologists should be cognizant of
this side effect. While medicines are regarded as a common
cause of acute pancreatitis, doxycycline induced pancreatitis
is rarely reported. Prescribers should have a high index of
suspicion for doxycycline-induced pancreatitis in patients with
acute pancreatitis without an obvious cause, particularly if it
is recurrent. Where doxycycline has been implicated in the
aetiology of a patient’s acute pancreatitis, the patient should
not be re-exposed to that medication.
Methods: Using survey monkey technology. A survey of
Canadian dermatologists is being conducted to determine if
they have used biologics in treating patients with HS and if so,
whether or not they have noticed an improvement in symptoms and patients’ quality of life.
Results: The results of the survey will be presented and
discussed.
A2
CDA Abstracts
Conclusion: The risk of developing PsA in patients with psoriasis appears to be greater in those with a higher PASI score,
nail disease and a higher BMI.
Learning Objective:
• acute pancreatitis is a rare side effect of doxycycline use
• patients and dermatologists should be cognizant of this side
effect
Takeaway Message:
Learning Objective: To understand the risk factors for
developing psoriatic arthritis in patients with psoriasis
Takeaway Message: The risk of developing PsA in
patients with psoriasis appears to be greater in those with a
higher PASI score, nail disease and a higher BMI.
• the use of doxycycline can have the rare side effect of acute
pancreatitis
• f doxycycline has been implicated in the aetiology of a
patient’s acute pancreatitis, the patient should not be reexposed to it
O.06
Differentiating arteriovenous malformation
from infantile hemangioma of the lip
O.05
Michele Ramien1, 2 Jérôme Coulombe1 Afshin Hatami1 Julie
Powell1
Risk factors for new onset of psoriatic
arthritis in a prospective cohort with
psoriasis
1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of
Dermatology, University of Ottawa, Ottawa, ON
Cheryl F. Rosen; Lihi Eder; Arane Thavaneswaran;Vinod Chandran; Amir Haddad; Dafna D. Gladman
The International Society for the Study of Vascular Anomalies
divides vascular birthmarks into tumors and malformations.
Malformations are present from birth and neither proliferate
rapidly nor resolve spontaneously. They are further divided
into slow and fast flow. The lip has high background vascularity, making it difficult to differentiate a high flow arteriovenous
malformation (AVM) from proliferating infantile hemangioma
(IH) on the basis of imaging.
Toronto Western Hospital,Toronto, ON
Background: To study patients with new onset of psoriatic
arthritis (PsA), the Toronto Psoriasis Cohort (TPC) was established in 2006.
Methods/Results: Patients with psoriasis without inflammatory arthritis or spondyloarthritis (PsC), as determined by
a rheumatologist, are enrolled and assessed annually for the
development of PsA. 593 patients are enrolled in the TPC;
40 have developed PsA. To compare these patients to those
without arthritis, a 1:2 match was carried out. New onset
PsA patients were matched by duration of psoriasis at latest
assessment, with 2 patients from the TPC without arthritis.
The Wilcoxon test was used for continuous variables and the
McNemar test was used for categorical variables. The groups
had similar percentages of men (new onset PsA: 57.5% vs. PsC:
66.3%). Median (IQR) age at diagnosis of PsC was the same in
both groups (new onset PsA: 26 (26) vs. PsC: 25 (19) p=0.39).
The percentage who ever smoked was the same (65.8%), with
similar numbers having diabetes (5.1% vs. 5.0%) and a history
of heart disease or hypertension (38.2%, new onset PsA vs.
25% in PsC ). There was no statistically significant difference in
the use of DMARDs or biologics. There was a statistically significant difference in the most recent PASI score, with a higher
median (IQR) PASI score in those who developed PsA; 4 (9.2)
for those with new onset PsA and 3.5 (4.5) for those with PsC
(p=0.02). More patients with new onset PsA had nail involvement, 72.5% compared to 53.8% of those with PsC, p <0.0001.
The median (IQR) BMI was greater in those who developed
PsA, 29.7 (9.7) vs. 27.1 (5.5) in those with PsC alone.
We present 2 cases of AVM of the lip in whom accurate
diagnosis was delayed as a result of imaging (ultrasound with
Doppler, MRI) favoring the diagnosis of IH. Our two patients
exhibited a strikingly similar initial presentation (stage I/dormant), with large geographic well-demarcated red-violaceous
patches involving the lower lip that evolved into thick plaques
with lip eversion by 4 months of age (stage 2/expansion). Both
patients had involvement of the inferior alveolar gingiva and
experienced significant bleeding with eruption of anterior
primary teeth. Retrospective revision of the initial imaging
studies revealed features that could have supported an earlier
diagnosis of AVM.
When a hemangioma behaves atypically, alternative diagnoses
should be considered. We discuss in detail the clinical and radiologic features of our cases to promote recognition, diagnosis, and appropriate management of AVM of the lip.
A3
CDA Abstracts
but recent research has found a V600E BRAF mutation in
about 50% of cases, which could lead to new therapeutic options. We report a case of this unusual disease.
Methods/Results: A 65 year old female patient was sent
to us by her hepatologist for severe pruritus due to sclerosing
cholangitis with hepatic failure rapidly evolving over 7 months.
A thorough investigation which included a PET-scan was previously done and revealed a bilateral perirenal infiltration and
hypermetabolic bone lesions. A perirenal biopsy showed a
histiocytic infiltration with positive immunostaining for CD68
and negative for CD1a. The diagnosis of a non-Langerhans cell
histiocytosis with multiorgan infiltration was made. Upon skin
examination of the patient, 10 small purple to brown, asymptomatic, slightly hyperkeratotic, papules were noticed on her
torso. A biopsy was done and revealed a dermal infiltration
of foamy histiocytes with positive immunostaining for CD68
which confirmed a skin manifestation of the same disease.
Unfortunately, the patient died 1 month later from hepatic
complications and massive abdominal bleeding from ruptured
varicose veins due to portal hypertension.
Conclusion: Given the rarity of this disease, the diagnosis requires a high level of clinical suspicion. It is therefore
important for the dermatologist to be aware of such rare
skin manifestations which usually present as xanthoma-like
papules. Unfortunately, the prognosis is usually poor with a 5
year survival rate of 68%, and there is no curative treatment.
The response to the first line agent interferon-alpha seems to
be the most prominent in the cutaneous foci with encouraging
results regarding the targeting of interleukin-1 as well as BRAF
inhibitors.
Learning Objective: To highlight clinical and radiologic
features that suggest the diagnosis of an AVM over an IH in the
lip area.
Learning Objective: Review the manifestations of the
Erdheim-Chester Disease and the new advances in treatment
options.
Takeaway Message: In highly vascularized areas, it is
difficult to distinguish AVM from IH on the basis of imaging
alone; clinical progression plays an important role in accurate
diagnosis.
Takeaway Message:
1. Erdheim-Chester disease is a rare form of systemic nonLangerhans cell histiocytosis which classically presents
itself with bone pain secondary to histiocytic infiltration.
2. Cutaneous manifestations are rare and consist of xanthoma-like papules.
3. Treatment options are limited; Interferon-alpha remains
the first line therapy. Treatment strategies targeting interleukin-1 as well as BRAF inhibitors seem promising.
O.07
An interesting case of non-Langerhans
cell histiocytosis with skin manifestations:
Erdheim-Chester Disease
Sophie Vadeboncoeur; Benoît Côté; Annie Belisle
Université de Montréal, Montréal, QC
Introduction: Erdheim-Chester disease is a very rare form
of progressive non-Langerhans cell histiocytosis which classically presents itself with bone pain secondary to histiocytic
infiltration. Extraosseous involvement is frequent and can affect almost every organ with a predilection for the lungs, liver,
kidneys, heart and central nervous system with skin being an
exceptional site of involvement. The etiology is still unknown
A4
CDA Abstracts
O.08
Primary systemic (AL) amyloidosis
masquerading as pseudoxanthoma elasticum:
recognizing a novel clinicopathological
pattern
Heidi Wat; Douglas Wu; Muhammad Mahmood; Alain Brassard
University of Alberta, Edmonton, AB
Background: Primary systemic (AL) amyloidosis has a
variety of cutaneous manifestations. In this case, we present a
novel clinicopathological pattern of AL amyloidosis.
Observations: A 57 year old woman with a history of AL
amyloidosis manifesting as macroglossia and bilateral carpal
tunnel syndrome presented with skin-colored to yellow cobblestoned plaques to the neck and bilateral antecubital fossa.
Although clinically similar to pseudoxanthoma elasticum (PXE),
the skin changes were found to be due to amyloid deposition
primarily around the pilosebaceous unit but also within the
papillary and reticular dermis based on multiple skin biopsies.
There was no amyloid deposition around elastic fibers on both
light and electron microscopy. Retinal examination did not
demonstrate presence of angioid streaks and cardiac magnetic
resonance imaging (MRI) was unremarkable. Previous reports
of PXE-like plaques in AL amyloidosis have been reported
as part of a rare entity termed amyloid elastosis, which is
characterized by the pathological finding of amyloid encasing
elastic fibers. However, our case demonstrates several important clinical and pathological differences from this entity. Most
notably, there was no dermal elastic fiber involvement, limited
cutaneous and systemic involvement and a fairly indolent
course with better response to therapy.
Conclusions and Relevance: Identification of this atypical presentation of AL amyloidosis has important implications
for early detection and rapid treatment of a potentially aggressive and fatal disease. The lack of elastic fiber involvement establishes the uniqueness of this case and further study may be
required to determine if this histological finding has prognostic
significance.
Learning Objective: The objective of this study is to identify a novel clinicopathological entity that may aid in the early
detection of primary systemic amyloidosis.
Takeaway Message:
• The cutaneous manifestations of AL amyloidosis are varied,
and being aware of atypical dermatological presentations
may lead to earlier diagnosis and treatment.
• This entity is distinct from amyloid elastosis, notably due to
the absence of amyloid encasing elastic fibres.
• Patients presenting with lesions mimicking PXE may be distinguished based on skin biopsy (and electron microscopy),
lack of oral lesions, and ophthalmologic examination.
A5
CDA Abstracts
O.09
YI.01
Clinical recognition of melanoma by
dermatologists and non-dermatologists
Melanoma and non-melanoma skin cancer
detection based on polarization mapping
of speckle images - an in-vivo noninvasive
technique
Michal Martinka1, 3 Richard I. Crawford1, 4 Shannon Humphrey1, 2
1. University of British Columbia,Vancouver, BC; 2. Department of Dermatology
and Skin Science,Vancouver, BC; 3. Faculty of Medicine, University of British
Columbia,Vancouver, BC; 4. Department of Pathology and Laboratory Medicine,
Vancouver, BC
Bahman Sotoodian
University of Alberta, Edmonton, AB
PGY1 Dermatology Resident, University of Alberta
Background: The incidence of melanoma is increasing annually in Canada. Consequently there has been a rise in the
number of patients presenting with pigmented skin lesions to
dermatologists and non-dermatologists.
Objective: Clinically distinguishing melanoma from other
pigmented skin lesions could be challenging. The current gold
standard for diagnosis of melanoma is biopsy. Our study objective is to demonstrate that different skin lesions, malignant
vs. benign, could be distinguished using a novel in-vivo noninvasive optical method.
Objective: This retrospective study is designed to assess
the ability of physicians of different specialties to accurately
recognize melanoma.
Material & Methods: When a laser beam illuminates a
skin lesion, an interference pattern, known as a speckle image,
is formed. We simultaneously captured the speckle images
using two cameras, each with a polarizer oriented to the coand cross-polarization direction of the laser source. Through a
pixel-by-pixel registration between the two polarized images, we constructed a degree of linear polarization (DOLP)
map. The distribution of the DOLP map reveals that tissues
respond at different polarization directions. We hypothesize
that the distribution of a DOLP map, expressed statistically as
mathematic moments, could be used as a diagnostic parameter
for skin lesions.
Methods: Pathology reports of biopsies submitted to Vancouver Coastal Health with a clinical diagnosis of melanoma
were reviewed (January - July 2013). The clinical diagnoses
made by dermatologists, general practitioners and family physicians (GP/FP), and all other specialists were correlated with
the final histopathological diagnosis.
Results: The dermatologists, GP/FP’s and all other specialists
achieved diagnostic accuracies of 24.75% (50 of 205), 3.52%
(9 of 240) and 12.75% (14 of 107), respectively. Dermatologists diagnosed the most melanoma (50) and had the highest
diagnostic accuracy (24.75%). The clinical diagnosis rendered
by GP/FP’s matched the histopathological diagnosis in only
3.52% of biopsies. GP/FP’s also diagnosed the lowest number
of melanomas (9) and biopsied the most skin lesions (240). All
other specialists performed better than GP/FP’s in accuracy
(12.75%) but only performed half as well as dermatologists.
Results: We examined 22 MM, 76 SK, 44 nevi, 27 BCC, and
11 SCC skin lesions under two light sources. All malignant cases were confirmed by biopsy. The DOLP maps for these skin
lesions were constructed. The first 4 mathematical moments
were calculated from the DOLP maps, and we found the 3rd
and 4th order moments of the red & blue lasers showed
significant differences between the mean of some benign
pigmented and malignant lesions. The initial ROC analysis for
MM vs. SK, 4th moment from blue laser, resulted in an AUC =
0.838 with p = 0.0001. The similar comparison using red laser
resulted in AUC = 0.856 with p=0.0001.
Conclusion: Although the diagnostic accuracy of dermatologists was significantly better than the other groups, the majority of patients with suspicious skin lesions present to a family
or general practitioner first. Thus, there is considerable value
in providing more training and education to non-dermatologists as it can have a meaningful impact on patient care.
Conclusion: Our innovative approach towards skin cancer
had demonstrated great promise in influencing the diagnosis of
melanoma and other skin lesions. Our method would substantially assist dermatologists in deciding whether to biopsy the
lesions or not.
Learning Objective: Generate awareness of the importance of adequate dermatology training of non-dermatologists
in accurate pigmented lesion diagnosis to improve patient care.
Takeaway Message:
1. Dermatologists have significantly better clinical accuracy in
recognizing melanoma when compared to non-dermatologists.
2. There is value in providing more training and education in
accurate diagnosis of melanoma to non-dermatologists as
it can have a meaningful impact on patient care.
A6
CDA Abstracts
SYCP1, cTAGE1 and GTSF1 were expressed in CTCL, but not
in normal skin or benign inflammatory dermatoses.
Learning Objective: Characterizing skin lesions through
the statistical moments of the depolarization mapping of
speckle images
Learning Objective: Understand how ectopic expression
of Cancer Testis (CT) antigens can be used as novel diagnostic/
prognostic markers or as novel targets for immunotherapy in
CTCL.
Takeaway Message:
1. Polarization of light could be used to differentiate different
types of skin lesions
2. The statistical moment of depolarization maps can potentially differentiate malignant from benign lesions
Takeaway Message: A number of CT antigens are ectopically expressed in CTCL patients and patient-derived cell
lines. Aberrant histone acetylation may explain the mechanism
behind the ectopic expression of these genes. These genes
can be used as diagnostic/prognostic molecular markers or as
novel targets for immunotherapy in CTCL.
YI.02
Ectopic expression of cancer testis antigens
in Cutaneous T-Cell Lymphoma (CTCL)
patients
YI.03
Leflunomide in dermatology and use in
pemphigus vulgaris
Ivan V. Litvinov1 Brendan Cordeiro 1 Hanieh Zargham 1 Yuanshen Huang 2 Kevin Pehr 1 Marc-Andre Doré 3 Martin Gilbert3
Youwen Zhou2 Thomas S. Kupper4 Denis Sasseville 1
Nazli Ghiasi1 Scott Walsh1
1. McGill University, Montreal, QC; 2. University of British Columbia,Vancouver,
BC; 3. Laval University, Quebec City, QC; 4. Harvard University, Boston, MA, USA.
1. University of Toronto,Toronto, ON; 2. Sunnybrook Health Sciences Centre,
Toronto, ON
The pathogenesis of CTCL remains only partially understood.
A number of recent studies attempted to identify novel diagnostic markers and future therapeutic targets. One group of
antigens, cancer-testis (CT) antigens, normally present solely in
testicular germ cells, can be ectopically expressed in a variety
of cancers. Based on previous studies a number of CT antigens
were reported to be ectopically expressed in CTCL patients.
In the current work we test the expression of a subset of CT
genes by RT-PCR in a cohort of CTCL patients, normal skin
samples, lesional skin from benign inflammatory dermatoses
and in 11 patient-derived CTCL cell lines. We correlate such
expression with the p53 status and explore the molecular
mechanisms behind their ectopic expression in these cells.
Our findings demonstrate that SYCP1, SYCP3, REC8, SPO11
and GTSF1 genes are heterogeneously expressed in CTCL
patients and patient-derived cell lines, while cTAGE1 was
found to be robustly expressed in both. Mutated p53 status
did not appear to be a requirement for the ectopic expression
of CT antigens. While T cell stimulation resulted in a significant
upregulation of STAT3 and JUNB expression, it did not significantly alter the expression of CT antigens. Treatment of cells
with Vorinostat or Romidepsin Histone Deacetylase (HDAC)
inhibitors resulted in a significant dose-dependent upregulation
of expression of SYCP1, cTAGE1, REC8 and SPO11 mRNA,
but not protein, in CTCL cell lines, while treatment of cells
with Histone Acetyltransferase (HAT) inhibitor (Anacardic
Acid) significantly downregulated the baseline expression of
SCP1 and SPO11 mRNA. Comparison of expression between
CTCL and non-malignant skin samples demonstrated that
Leflunomide is a weak immunosuppressant which was first
FDA approved for the treatment of rheumatoid arthritis. Although its use in dermatology has been limited, there is good
evidence to support efficiency in the treatment of psoriasis as
well as psoriatic arthritis. There is one previous report of use
in bullous pemphigoid in the literature and no reports of use
in pemphigus vulgaris to date.
We present a case series involving 7 patients with refractory pemphigus vulgaris treated with Leflunomide as a novel
therapy. Subjects were identified though a retrospective chart
review of all patients with a confirmed diagnosis of pemphigus
vulgaris seen between Jan 2002- Jun 2013 at the Sunnybrook
Health Sciences Centre. Subjects had received Leflunomide
at a loading dose of 100 mg daily for 3 days followed by 10
or 20 mg daily. Data collected include duration and severity
of disease, previous treatments and response to Leflumonide
therapy. All patients were monitored with weekly blood work
for the first month and monthly thereafter.
Follow up was done at 6 weeks for 5 patients, all of whom had
some improvement clinically. All subjects received follow up
at 6 months and 100% of participants had significant improvement clinically with 4 patients achieving complete remission.
Beyond the 6 month point, 5/6 patients experienced mild
flares responding to a course of low dose prednisone. Leflunomide was generally well tolerated and no adverse events were
reported. The most common side effect was gastrointestinal
symptoms and thrombocytopenia, not significant enough to
lead to termination of therapy. We conclude that Leflunomide
A7
CDA Abstracts
is a promising novel therapy for pemphigus vulgaris with a
favorable efficacy to side effect profile.
Learning Objective: To learn about the evidence for Leflunomide in dermatology and in particular it’s efficacy as a novel
treatment for pemohigus vulgaris.
Takeaway Message: Leflunomide is a disease modifying
agent with a favourable efficacy to toxicity ratio which can
be used as a third-line agent in the treatment of pemphigus
vulgaris.
YI.04
Treatment of nail psoriasis with intralesional
triamcinolone acetonide using a needle-free
jet-injector
Mélissa Nantel-Battista;Vincent Richer; Isabelle Marcil; Antranik Benohanian
Conclusion: Treatment with triamcinolone acetonide delivered by Med-Jet MBX® is a safe, minimally painful and effective
treatment for nail psoriasis.
Université de Montréal, Montreal, QC
Background: Treating nail psoriasis is challenging. Corticosteroid matrix injection with needle is a conventional treatment but pain is often a limitation.
Learning Objective:
• Becoming more familiar with the NAPSI score for grading
nail psoriasis severity
• Learning about different treatment options for nail psoriasis
• Getting to know better the needle-free injector and their
different clinical applications, especially for the treatment of
nail psoriasis
Takeaway Message:
Objective: Evaluate efficacy and safety of triamcinolone
acetonide needle-free injection with the Med-Jet MBX® in
psoriatic fingernail.
Methods: Seventeen patients were enrolled between January 2012 and January 2013. Four treatments sessions were
scheduled every 4 ± 1 weeks. Clinical efficacy was evaluated
with NAPSI score of target nail differences before and after
the treatment.
• Treatment of nail psoriasis with triamcinolone acetonide
delivered the Med-Jet needle-free injector has shown to be
efficient and minimally painful
• Safety of the local treatment of nail psoriasis with triamcinolone acetonide has been demonstrated in our study using
the Med-Jet
• Before prescribing a systemic treatment for nail psoriasis,
consider the option of the needle-free injector for delivering local treatment
Results: Mean baseline NAPSI score was 6.5 on an 8 points
scale (95% CI 5.652; 7.348) and mean final NAPSI score was
2.8 on an 8 points scale (95% CI 1.859; 3.741), demonstrating
statistically significant treatment efficacy (p-value = 0.0007).
NAPSI score for target nail from baseline to end of treatment
was decreased by 46.25%.
A8
CDA Abstracts
Learning Objective: To evaluate the histological and
clinical outcomes of the contoured staged surgical excision
technique for lentigo maligna of the head and neck, including the optimal surgical margin required for complete tumor
clearance. We propose that a surgical margin larger than the
current standard guideline of 0.5cm is required for complete
tumor clearance of Lentigo Maligna of the head and neck.
YI.05
Outcomes of contoured staged surgical
excision for Lentigo Maligna of the head and
neck
Alexis A. Botkin1 Annie Liu1 An-Wen Chan1, 2, 3 Christian Murray1, 3 Nowell Solish1, 3
Takeaway Message: Our cohort of patients demonstrate
that margins larger than the current surgical guideline of 0.5cm
may be required to obtain complete tumor clearance for lentigo maligna of the head and neck.
1. University of Toronto,Toronto, ON; 2.Women’s College Research Institute,
Toronto, ON; 3.Women’s College Hospital,Toronto, ON
Introduction: The Lentigo Maligna (LM) subtype of melanoma in situ commonly arises on the head and neck with subclinical peripheral extension, introducing functional, cosmetic,
and reconstructive challenges in surgical treatment. Traditional
wide excision with a margin of 0.5cm remains the standard
of care based on consensus recommendations. However, case
series suggest that over half of patients require a larger than
0.5cm surgical margin for tumor clearance. Contoured staged
surgical excision (CSE) is a novel type of staged excision that
ensures 100% margin control with tissue processing under
permanent section.
YI.06
The quality of life impairment in patients
with Hidradenitis Suppurativa: A Canadian
study
Niloofar Anooshirvani; R Gary Sibbald; Afsaneh Alavi
University of Toronto,Toronto, ON
Introduction: Hidradenitis Suppurativa (HS) is a chronic,
debilitating disease of apocrine gland bearing skin involving
the axilla, groin, perianal and perineal skin. The clinical picture
includes solitary nodules, diffuse, painful abscesses, malodorous
drainage, sinus tract formation and scarring. The adverse affect
of this disease on quality of life is imaginable but not extensively studied, especially in the Canadian population.
Methods: A retrospective chart review and survey were
completed for patients who underwent CSE for LM of the
head and neck at Women’s College Hospital in Toronto, from
July 2010 to March 2013. We recorded the total surgical margin size required for complete histological clearance, as well as
post-operative infection and tumor recurrence.
Results: Among 105 patients the surgical margins required
for clearance of LM ranged from 0.3 to 2.5cm. 21% (22/105)
of patients required a margin greater than 0.5cm and 10%
needed 1.5cm or greater margins. Of the 79 survey responders (75% response rate) 1.2% reported a recurrence.
Method: A prospective and retrospective chart review study,
which employed qualitative questionnaires. 31 Patients with a
diagnosis of HS were identified and contacted via telephone to
participate in the study. Once consented 2 Surveys were filled
out over the phone or during the patient visit including DLQI,
SF36V2. Harley score documented based on the patients’
physical exam documented in the chart.
Discussion: Although consensus guidelines currently recommend a 0.5cm surgical margin for lentigo maligna, our data
suggest that a fifth of patients require a larger margin for complete tumor clearance. Contoured staged excision provides a
safe technique for achieving high cure rates for this challenging
tumor.
Results: Mean ± SD DLQI score was 9.1 ± 9 equating to a
moderate effect on patient’s life. There was a positive, significant correlation between Hurley’s staging and DLQI scores.
(rs = 0.51 P=0.003). SF 36V2 determined that the domains
significantly affected by HS are:
• Bodily pain (45.1 ±12.3 P=0.04)
• General health (45 ±12.1 P=0.03)
• Social functioning (44.4 ±11.2 P=0.01)
Conclusions: There is a significant impairment in quality of
life in patients with HS. There is a direct relationship between
the severity of the disease and quality of life impairment. When
comparing physical and mental components of overall health,
this study showed that HS patients have greater impairment in
the physical health component.
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CDA Abstracts
Learning Objective:
Learning Objective: Determine and quantify quality of life
impairment in patients with HS and assess the correlation of
disease severity (based on Hurley’s staging) to quality of life.
1) To understand the risk of malignancy associated with the
different types of myositis.
2) To recognize the subset of patients with the highest risk of
cancer and the change in risk over time.
Takeaway Message: Both Dermatomyositis and to lesser
extent polymyositis are associated with an increase malignancy
risk. The risk extends for several years after diagnosis. Periodic
malignancy screening is recommended in this high risk group.
Takeaway Message: Hidradenitis supprativa is a cutaneous disease that involves young to middle age individuals and
predominantly females. Dermatologists need to consider the
significant quality of life impairment in patients with HS to
outline the management plan accordingly.
YI.07
Risk of malignancy in patients with
dermatomyositis and polymyositis: metaanalysis of population-based studies
YI.08
Raed Alhusayen; Akerke Baibergenova
The frequency of malignant wounds in leg
ulcer patients referred to wound care clinic
at Women’s College Hospital
Sunnybrook Health Sciences Centre,Toronto, ON
Niloofar Anooshirvani2 Farhad Ghassemi1 Afsaneh Alavi1
Background: there is a wide variation in the literature
about the risk of malignancy in dermatomyositis (DM) patients.
1. University of Toronto,Toronto, ON; 2. Universty of Ireland, Dublin, Ireland
Objective: to assess the risk of malignancy among patients
with DM and polymyositis (PM) using population-based studies.
Methods: we searched MEDLINE and EMBASE databases
for population-based studies published in English up to May
2013. The primary outcome was the observed to expected
ratio of malignancy among patients with DM expressed as
standardized incidence ratio (SIR). The risk of malignancy in
PM was a secondary outcome. We also conducted subgroup
analyses to assess the risk among DM patients by gender, time
since diagnosis, age group, and by specific cancer type.
Results: Five studies involving 4802 patients were included.
The pooled SIR for the risk of cancer among DM patients was
4.39 (95% CI, 3.22 - 5.99). PM was associated with a lower but
statistically significant risk of malignancy (SIR 1.75; 95% CI, 1.37
- 2.25). Among DM patients, the risk was higher for men (SIR
5.29; 95% CI, 3.49 – 8.04) than women (SIR 4.56; 95% CI, 2.97
– 7.02). Similarly, the risk was highest in the 1st year after DM
diagnosis (SIR 17.29; 95% CI, 11.08 – 26.99) then decreased
for 1-5 and more than 5 year periods to (SIR 2.7; 95% CI, 1.96
– 3.72) and (SIR 1.37; 95% CI, 1.27 – 1.48), respectively. In European studies, the highest relative risk increase was in ovarian
cancer (SIR 10.36; 95% CI, 6.17 – 17.39) while the most commonly observed cancers were: Lung, colorectal, and Breast.
Conversely, nasopharyngeal cancer was the most commonly
observed malignancy in Taiwan and had the highest increase in
relative risk ( SIR 139.9; 95% CI, 137.8 – 148.1).
Conclusion: DM is associated with a 4-fold increase in the
risk of cancer with men having slightly higher risk than women.
The risk is highest in the 1st year after diagnosis but remains
elevated even beyond 5 years.
Introduction: Chronic wounds are slow to heal with an
increased risk of transforming into malignancy over time.
Skin cancers can present either primarily as an ulcer or as
a secondary malignancy from chronic inflammation within a
longstanding wound.
Methodology: A retrospective cross-sectional study of
patients who were referred to the wound clinic at WCH,
with leg ulcers from 2011-2013 were performed. Those who
received a biopsy of their ulcer were identified and a standard
questionnaire regarding the details of the wound and biopsy
was completed. The rate of the malignancy, patient demographics, wound characteristics and associated disease were
documented.
Results: A total of 1189 patients’ files with leg ulcer were reviewed. Of this population, 151 patients had received a biopsy
of their ulcer. 13.2% (20) of the biopsied ulcer was cancerous (BCC, SCC, Sarcoma and Melanoma). The average age of
patients with malignant ulcers was 81 years old with female
predominance(75% ). The average duration of a malignant ulcer
was 2.9 years with average ulcer size at 14.1 cm2. Overall 12%
of all the files reviewed were biopsied and only 1.7% of all the
total files reviewed were malignant wounds.
Conclusion: The prevalence of malignancy in chronic leg
ulcer series varies from 5 to 15 % depending on the frequency
of skin biopsies and the patient population has been reported.
In our study the prevalence of cancer in the wound biopies
reported 13.2%. While malignancy is a rare complication of leg
ulcers, early and correct diagnosis will reduce the morbidity of
the disease.
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CDA Abstracts
Learning Objective:
Takeaway Message:
1) Determine the prevalence of malignant leg ulcers in the
patients referred to a wound clinic
2) Identify the risk factors associated with malignant ulcers
3) Evaluate the characteristics of a malignant ulcer
Takeaway Message: Any ulcer that is not healing at the
expected rate or has atypical presentations should be biopsied
to rule out malignancy. Treating the underlying cause is the
mainstay of optimal wound care.
• Patients with a personal or family history of atopy are at
increased risk of cutaneous delayed-type hypersensitivity
reactions to common topical consumer product ingredients
and medicaments.
• Intermittent exposure to common topical consumer product ingredients and medicaments poses a higher risk for
the development of cutaneous delayed-type hypersensitivity
reactions.
SS.01
Cutaneous delayed-type hypersensitivity to
topical consumer product ingredients and
medicaments and atopy
SS.02
Pyoderma gangrenosum associated with
alitretinoin therapy
Jonathan Levy; Alain Brassard
University of Alberta, Edmonton, AB
Mark Kirchhof1 Gillian C. de Gannes1, 2
1. Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, BC; 2. Division of Dermatology, Department of Medicine, St. Paul’s
Hospital,Vancouver, BC
Background: A rare side effect of isotretinoin is the development of pyoderma gangrenosum (PG). Here we describe a
case of PG associated with alitretinoin therapy.
Atopy is a genetic predisposition to the development of
allergic reactions and the increased production of IgE upon exposure to environmental antigens. Allergic contact dermatitis
(ACD) is a T-cell mediated cutaneous delayed-type hypersensitivity (CDTH) reaction to topical allergens. We hypothesized
that patients with a personal or family history of atopy would
be at increased risk of developing ACD to topical consumer
products and medicaments.
Case: A 45 year old woman with a long-standing history of
bilateral hand and foot eczema was treated with alitretinoin
after failing topical corticosteroid therapy. She was started on
alitretinoin (30mg once daily) and the dermatitis significantly
improved. However, 5 months following initiation of therapy
she developed a painful ulcer on her left shin. Treatment with
multiple courses of intravenous antibiotics was not effective.
The patient was then referred to our dermatology clinic while
still taking alitretinoin.
For this study, we reviewed the patch test database of the
UBC Contact Dermatitis Clinic from 2008 to 2013. A personal
or family history of atopy was noted. A total of 1515 patients
were included in this study. Our data show that patients with
a personal or family history of atopy are most likely to react
to fragrances, botanicals or cosmeceuticals. They are also at
increased risk of reacting to topical antibiotics, topical steroids
and preservatives. Interestingly we found that a history of
atopy was protective to developing CDTH to vehicle ingredients like propylene glycol.
Our data show that patients with atopy are at increased risk
of developing CDTH to topical consumer product ingredients
and medicaments. An interesting observation from our study
is that topicals used less frequently have an increased risk of
CDTH compared to topicals that are used more frequently.
Learning Objective: Assess the risk of cutaneous delayedtype hypersensitivity reactions to common topical consumer
product ingredients and medicaments in patients with a personal or family history of atopy.
Physical examination revealed two discrete ulcers with violaceous, undermined borders on her left lower leg. Punch biopsy
revealed nonspecific inflammation and ulceration. Superficial
and deep skin cultures were negative for bacteria, fungi, and
mycobacteria. Other investigations including complete blood
count, liver enzymes, and urinalysis were within normal limits,
while hepatitis B surface antigen and antibody to hepatitis C
were negative. Her past medical history is relevant for eczema,
type 2 diabetes mellitus, gastroesophageal reflux disease, and
hypercholesterolemia.
PG was clinically diagnosed and the patient was treated with
tacrolimus 0.1% ointment twice daily. Alitretinoin was stopped
and the ulcer healed within 2 months of discontinuation.
Discussion: To our knowledge this is the first reported case
of PG secondary to treatment with alitretinoin. Only five cases
of PG associated with isotretinoin therapy have been reported,
but PG associated with alitretinoin or any of the other retinoids has never been reported. The mechanism of PG resulting
from retinoid use is unknown, but has been suggested to be
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CDA Abstracts
related to altered neutrophil chemotaxis, increased skin fragility, and/or vascular proliferation.
Learning Objective: To present the first reported case of
pyoderma gangrenosum associated with alitretinoin therapy.
Takeaway Message: In addition to isotretinoin, alitretinoin
can also be rarely associated with pyoderma gangrenosum.
SS.03
• Outline an approach to patient with contact dermatitis to
wound products
Takeaway Message: Allergic and irritant contact dermatitis to wound products or ulcer exudate is a common occurrence. Clinicians should be cognizant of the allergens in these
products and the potential for sensitization. Once contact
dermatitis develops, investigations should be ordered to
determine the etiology or cause, and the dermatitis should be
appropriately treated.
Wound related allergic/irritant contact
dermatitis
SS.04
Afsaneh Alavi Sandy Skotnicki R Gary Sibbald Howard Maibach2
1
1
1
Dominant dystrophic epidermolysis bullosa
treated with minocycline – a case report
1. University of Toronto,Toronto, ON; 2. UCSF School of Medicine, San Francisco,
CA, USA
Jordan Leung1 Paul Kuzel2 Alain Brassard2
1. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB; 2.
Division of Dermatology and Cutaneous Sciences, Department of Medicine,
University of Alberta, Edmonton, AB
Introduction: Contact dermatitis is a common, but underdiagnosed condition associated with chronic wounds. Forty
to eighty percentage of patients with venous leg ulcers have
one or more positive patch test reactions, with most of the
identified allergens relating to previous allergen exposure or a
history of contact dermatitis. Incidence of contact allergic dermatitis in persons with leg ulcers is high related to allergenic
properties of commonly utilized wound care products, long
term exposure to the identified allergens under occlusion, and
the impaired barrier function of the ulcerated skin.
Methodology and results: A literature search on the
irritant and allergic contact dermatitis ( 1994-2014) was performed and combined with the expert opinion. The common
reported irritants /allergens ingredient in wound products
identified and the articles reported the allergies to these products were outlined. The recommendations for the replacement
products and avoidance of allergens outlined.
Conclusion:
Clinically, contact dermatitis in patients with chronic wounds
may present with localized itching, increased pain, discrete or
diffuse periwound dermatitis of varying severity or worsening
of the wound base and margin despite treatment, early diagnosis is critical to decrease patient suffering, avoid antibiotic
overuse and optimize healing environment. Common allergens should be avoided including fragrances, propylene glycol,
colophony, and topical antibiotics. Both allergic and irritant
contact dermatitis occur in patients with wounds, particularly
patients with chronic wounds such as leg ulcers.
Epidermolysis bullosa (EB) is an inherited illness characterized
by fragile skin and spontaneous formation, or formation upon
minor trauma, of vesicles/bullae on various parts of the body.
EB can first be subdivided into one of: EB simplex, junctional
EB, dystrophic EB, and mixed type EB (Kindler syndrome). Each
subtype has mutations in different genes. Dystrophic EB (DEB)
results due to a mutation in the COL7A1 gene. Collagen VII is
critical for the secure attachment of the epidermis to the dermis at a level deep to the basement membrane’s lamina densa.
As a result, mutated collagen VII in DEB is the foundation for
the clinical features seen with this illness. DEB can be further
subdivided into autosomal dominant and autosomal recessive
categories.
One of the main focuses in treatment of epidermolysis bullosa
is prevention of vesicle/bulla formation. Case reports have
described treatment of DEB, with varying effectiveness, using
topical camostat mesylate, minocycline, phenytoin, cyclosporine, topical corticosteroids, high dose tocopherol acetate,
a combination of oral prednisone and DL-alphatocopheryl
acetate, topical tacrolimus, and thalidomide. This case report
describes the successful treatment of a 57-year-old male with
dominant DEB (DDEB) using oral minocycline.
Learning Objective: Recognize the use of minocycline as a
potential treatment option for patients with dominant dystrophic epidermolysis bullosa.
Learning Objective:
• Identify the common allergens in wound products
• Consider contact dermatitis as a cause of non healing ulcers
Takeaway Message: Oral minocycline has been successfully used in the treatment and prevention of wounds for a
57-year-old male with dominant dystrophic epidermolysis
bullosa.
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CDA Abstracts
SS.05
Persistence of IL-17A+ T lymphocytes
and IL-17A expression in psoriatic plaques
refractory to ustekinumab therapy
C Jack1, 3 S. Mashiko2 N. Arbour2 R. Bissonnette3 M. Sarfati2
1. McGill University, Montreal, QC; 2. Université de Montréal, CRCHUM,
Montreal, QC; 3. Innovaderm Research, Montreal, QC
Ustekinumab targets the shared IL-12/-23 p40 subunit, thereby
impairing Th1 and Th17 responses. Most patients with psoriasis treated with ustekinumab improve but do not achieve
complete clearance and present with refractory plaques. We
investigated the mechanisms underlying refractory skin lesions
by examining pro-inflammatory cytokine expression in such
plaques. Cells were isolated from skin biopsies of patients
treated with ustekinumab (n=9) and from untreated patients
(n=9) using a novel and rapid (6hrs) experimental approach.
This method combines enzymatic and mechanical digestion
of skin followed by cytokine analysis by flow cytometry of
cutaneous leukocytes in the absence of in vitro stimulation.
We found that patients treated with ustekinumab have the
same proportion of CD45+ leukocytes, CD3+ T cells and
CD3+ IL-17A+ cells in their plaques as untreated patients.
Real-time PCR confirmed significantly elevated IL-17A mRNA
expression in plaques in both cohorts of patients relative
to non-lesional skin. Unexpectedly, we detected a significant
increase in the proportion of IL-17A+ CD3- CD45+ cells in
plaques of ustekinumab-treated, as compared to non-treated,
patients (0.21 and 1.43% respectively, p<0.009). We conclude
that refractory plaques are infiltrated by IL-17A+ hematopoietic CD45+ cells, whose lineage remains to be defined, and
exhibit elevated levels of IL-17A despite targeting of IL-23 by
ustekinumab.
SS.06
Chronic Spontaneous Urticaria – an
evaluation of an indirect immunofluorescence
method for detecting anti-mast cell IgG
antibodies
Bahar Bahrani; Natasha Gattey; Peter Hull
University of Saskatchewan, Saskatoon, SK
An autoimmune basis is believed to be responsible for about
half of all cases of chronic spontaneous urticaria (CSU) with
specific IgG antibodies directed at the high affinity receptor
sites for IgE on the mast cell. The autologous serum skin test
(ASST) is used to identify this autoimmune form of CSU. Currently, basophil histamine release assay and basophil activation
test (BAT) have been used as an alternative to the ASST. We
have developed an indirect immunofluorescence method to
demonstrate the presence of anti-mast cell antibodies using
skin sections from a patient with severe bullous mastocytosis.
Sections from paraffin embedded blocks of skin biopsied infant
with bullous mastocytosis and cord-blood derived mast cells
were used as substrates. Serum patients with CSU was used,
and fluorescein conjugated human IgG was used to label fixed
antibody. Amongst the bullous mastocytosis slides, positive
indirect immunofluorescence was found in 35 (46.05%) of
the patients (n=76). There was a positive indirect immunofluorescence in 17 (50%) patients who had a positive ASST
(n=34), 49.09% of non-IVIG treated CSU patients (n=55),
and in 61.09% of IVIG treated patients (n=21). Amongst the
cord-blood derived mast cell cytospin slides, positive indirect
immunofluorescence was found in 29 (41.43%) of the patients
(n=70). Positive indirect immunofluorescence was found in
14 (45.16%) patients who had a positive ASST (n=31), 46%
of non-IVIG treated CSU patients (n=50), and in 60% of IVIG
treated patients (n=20). It is possible to detect anti-mast cell
IgG antibodies by indirect immunofluorescence. IgG autoantibodies could be detected in about half of CSU cases examined.
Indirect immunofluorescence should be considered a more
direct and credible indicator of the autoimmune form of CSU.
Learning Objective: An indirect immunofluorescence
method can be used to identify anti-mast cell IgG auto-antibodies.
Takeaway Message: Indirect immunofluorescence should
be considered a more direct and credible indicator of the
autoimmune form of CSU.
SS.07
Indoor tanning policies and their
implementation across Canada
Pavandeep Gill1 Sunil Kalia2
1. Faculty of Medicine, University of British Columbia,Vancouver, BC; 2.
Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, BC
Skin cancer is the most common type of cancer affecting
Canadians today. Ultraviolet radiation (UVR) from tanning
beds is a known carcinogen and exposure to indoor tanning
before age 35 can increase the risk of melanoma – the deadliest form of skin cancer – by 75%. The World Health Organization, Canadian Cancer Society, and the Canadian Dermatology
Association all recommend that the use of tanning beds for
non-­medical purposes be restricted in individuals under age
18. Health Canada also agrees that minors should not use indoor tanning but policies and regulations surrounding tanning
bed usage by minors remain under the control of provincial
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CDA Abstracts
governments. We review the current provincial public health
policies surrounding indoor tanning. After contacting governing provincial health bodies, we also discuss how these policies
and regulations, if any, are being implemented and enforced in
each province across Canada.
Learning Objective: To review the current status of
indoor tanning policies across Canada and what efforts, if any,
are being implemented to enforce them
Seasonal and geographic trends in tanning
Bez Toosi; Sunil Kalia
Department of Dermatology and Skin Science, University of British Columbia,
and Photomedicine Institute,Vancouver General Hospital.,Vancouver, BC
Background: The incidence of skin cancer remains high
and continues to rise. Tanning has been linked to causing skin
cancer. Although tanning practices are assumed to be seasonal,
seasonal patterns in tanning have not been systematically
evaluated. This study explores seasonal and geographic trends
in tanning practices in order to better understand tanning behaviors and to design timely intervention and harm reduction
strategies. It utilizes internet search query data from Google
Trends to test the hypothesis that tanning varies by season
and contrary to general understanding peaks before the active
months (June to August) of summer.
Conclusion: Currently the Canadian educational campaigns
that educate people about the hazards of tanning begin in May
or June. This study suggests interest in tanning practices to be
• Interest in tanning salons is seasonal and is highest in the
months preceding summer.
• The Canadian educational campaigns which attempt to educate people about the hazards of tanning currently start in
May or June after the interest and potential use of tanning
salons have peaked.
• Results support initiation of educational campaigns earlier
during the year.
SS.09
Analysis of STAT4 expression in cutaneous
T-cell lymphoma (CTCL) patients and
patient-derived cell lines
Ivan V. Litvinov1 Brendan Cordeiro 1 Simon Fredholm2 Niels
Odum2 Yuanshen Huang 3 Youwen Zhou3 Thomas S. Kupper4
Anders Woetmann2 Denis Sasseville 1
Objective: To determine the seasonal and geographic effects
on tanning and tanning salons search queries.
Results: Time series revealed peaks in NSV’s in March-April
and troughs in October-November in Canada and the United
States. The peaks and troughs in NSV’s from Australian data
were out of phase by 6 month as compared to the northern
hemisphere counterparts, consistent with a seasonal pattern. Cosinar analysis revealed statistically significant seasonal
effects on NSV’s in all countries. The magnitude of seasonal
increase in NSV’s was similar between Canada, United States
and Australia. The analysis of variance showed no significant
difference between the three countries.
Learning Objective: Appreciate the seasonality and trends
in tanning.
Takeaway Message:
SS.08
Methods: Internet search query data were obtained from
Google Trends. Monthly normalized search volumes (NSV’s)
were determined for the term “tanning” and “tanning salons”,
from January 2004 to December 2013. Using cosinor analysis,
and Kruskal-Wallis one-way analysis of variance, seasonal and
geographic effects were tested for data from Canada, United
States and Australia.
highest in the months preceding summer and prior to the onset of these campaigns. Further studies are needed to confirm
these findings, but these results support having educational
campaigns being initiated earlier during the year.
1. Division of Dermatology, McGill University Health Centre, Montréal, QC; 2.
Department of International Health, Immunology, and Microbiology, University
of Copenhagen, Copenhagen, Denmark; 3. Department of Dermatology and
Skin Science, University of British Columbia,Vancouver, BC; 4. Harvard Skin
Disease Research Center, Department of Dermatology, Brigham and Women’s
Hospital, Harvard University, Boston, MA, USA
Introduction: Deregulation of STAT signaling has been implicated in the pathogenesis for a variety of cancers, including
CTCL. Recent reports indicate that loss of STAT4 expression
is an important prognostic marker for CTCL progression and
is associated with the acquisition of T helper 2 cell phenotype
by malignant cells. However, little is known about the molecular mechanism behind the downregulation of STAT4 in this
cancer.
Methods: In the current work we test the expression of
STAT4 and STAT6 via RT-PCR in CTCL lesional skin samples
and in immortalized patient-derived cell lines. In these malignant cell lines we correlate the expression of STAT4 and
STAT6 with the T helper (Th) phenotype markers and test the
effect of Histone Deacetylase (HDAC) inhibitiors and siRNAmediated knock down of miR-155 on STAT4 expression.
Results: Our findings demonstrate that STAT4 expression
correlates with Th1 phenotype, while STAT6 is associated with
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CDA Abstracts
the Th2 phenotype. Our results further document that STAT4
and STAT6 genes are inversely regulated in CTCL. Treatment
with HDAC inhibitors upregulates STAT4 expression, while at
the same time decreases STAT6 expression in MyLa cells. Also,
siRNA-mediated knock down of miR-155 leads to upregulation in STAT4 expression in MyLa cells.
Conclusions: In summary, our results suggest that loss of
STAT4 expression and associated switch to Th2 phenotype
during CTCL progression may be driven via aberrant histone
acetylation and/or upregulation of oncogenic miR-155 microRNA.
Learning Objective: Loss of STAT4 in CTCL is associated
with progressive disease and concomitant switch from Th1 to
Th2 phenotype in malignant T lumphocytes. This molecular
change may be medicated through abnormal histone acetylation and/or upregulation of miR-155 oncogenic microRNA.
SS.10
Geographic distribution of Cutaneous T-Cell
Lymphoma cases in Houston and Texas: a
comparison of the MD Anderson and Texas
Cancer Registries
Results: Our findings, based on the MDACC database document geographic clustering of patients in three communities
within the Houston metropolitan area, where CTCL incidence
rates were 5-20 times higher than the documented population rate and patients with this rare cancer were residing
along the same street/highway. Moreover, Fisher’s exact test
analysis of incidence rates in these communities over time
suggests a significant increase after ~2005. Analysis of the TCR
database defined the CTCL population rate for the state to
be 5.77 [95% CI 5.52, 6.03] cases per million individuals per
year, confirmed the observations from the MDACC database
and further highlighted additional putative areas of geographic
clustering for CTCL across Texas.
Conclusions: Our study documents geographic clustering
of CTCL cases and argues for the existence of yet unknown
external triggers for this rare cancer. Identification of additional CTCL clusters around the world will potentially help
identify these triggers and will bring us closer to preventing
this disease.
Learning Objective: Review demographic trends for
Cutaneous T-Cell Lymphoma over the past ~15 years and
describe recent findings on geographic clustering of CTCL in
Houston and Texas.
Ivan V. Litvinov1 Michael T. Tetzlaff2 Elham Rahme3 Youssef
Habel3 David R. Risser4 Pamela Gangar2 Michelle A. Jennings2
Kevin Pehr 1 Victor G. Prieto2 Denis Sasseville 1 Madeleine
Duvic5
SS.11
1. Division of Dermatology, McGill University Health Centre, Montreal, QC;
2. Department of Pathology, Section of Dermatopathology,The University of
Texas MD Anderson Cancer Center, Houston,TX, USA; 3. Division of Clinical
Epidemiology, McGill University Health Centre, Montreal, QC; 4. Cancer
Epidemiology and Surveillance Branch,Texas Cancer Registry, Department
of State Health Services, Austin,TX, USA; 5. Department of Dermatology,The
University of Texas MD Anderson Cancer Center, Houston,TX, USA
Evaluating morbidity and association with
autoimmune thyroiditis of chronic urticaria
in children
Elena Netchiporouk
McGill University, Montreal, QC
Introduction: The majority of skin cancers are caused by
external and sometimes preventable agents including Human
Papilloma Virus, Merkel cell polyomavirus or exposure to sun,
arsenic or radiation. Reports of occurrence of Mycosis Fungoides in married couples and families raise the possibility that
there might be an important environmental trigger for this disease. While it was suggested that Cutaneous T-Cell Lymphoma
(CTLC) arises from inappropriate T cell stimulation, currently
no definitive preventable trigger has been identified.
Methods: In the current work we analyzed by region, zip
code, age, sex and ethnicity the demographic data of 1047
patients from Texas, who were seen in a CTCL clinic at the
MD Anderson Cancer Center during 2000-2012 (the MDACC
database) and 1990 patients that were recorded in the Texas
Cancer Registry (TCR database) between 1996-2010. Subsequently data from both databases was cross analyzed and
compared.
Chronic urticaria (CU) is defined when hives occur for at least
6 weeks. Recent studies suggest that autoimmunity including
targeting either the mast cell IgE receptor, the IgE molecule
or auto-antigens (i.g. thyroid antigens) may account for almost
50 % of spontaneous CU cases. The pathogenesis of CU and
its effect on quality of life (QoL) are not well established in
children. We aimed to establish a registry of CU in children to
assess autoimmunity, QoL and factors affecting QoL. Between
January 2013 and 2014, we recruited 35 children. Participants
were queried on demographics, clinical history and QoL (CUQ2oL) through a validated questionnaire. In addition, participants filled the urticaria activity score (UAS). Blood tests were
drawn to assess basophile activation, thyroid autoimmunity
and confirmatory tests were performed when applicable to di-
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CDA Abstracts
agnose inducible forms. The Wilcoxon Rank Sum test and multivariate regression analysis were used to assess autoimmunity
and factors associated with impaired QoL respectively. Our
findings reveal that the majority of children were males (57%)
presenting at a median age of 8 years (IQR: 3.75-12.0). Thyroiditis was reported in 17.1% of family members, but TSH and
anti-thyroid peroxidase were normal in all patients. Physical
forms occurred in 17.1 % of patients. Mean CD63 expression
was 5.3% and was comparable to CD63 levels in controls. The
mean weekly quality of life (UAS) score over 3 months was
6.5 on a scale of 42, which indicates a mild disease. Increased
age at onset (OR=2.2, 95%CI) was associated with decreased
QoL in the functionality domain and higher UAS (OR=2.16)
with worse sleep domain. In conclusion, CU in children was
not associated with thyroiditis or autoimmunity. Older age of
onset and higher UAS may affect the quality of life in pediatric
population. Our cohort will be followed for 10 years to study
the natural history of CU.
Learning Objective:
• To understand the role of autoimmunity in the pathogenesis
of chronic urticaria in children.
T•o determine the impact of CU on the quality of life in pediatric population.
• To assess factors affecting the quality of life in children.
Takeaway Message:
• Compared to adults, the implication of autoimmunity and
thyroiditis seems to be less important in pediatric CU.
• Most children have a mild disease and good control with
anti-histamines only.
• Older age of onset and higher urticarial activity score may
affect the quality of life in pediatric population.
Methods: Commonly presenting dermatologic issues
(n=136) were used to determine patterns for changes in
colour, shape, and topography. The proportion of each type of
presentation was calculated accordingly. Correlations were
determined by observing trends within paired characteristics.
Results: Colour changes within the studied conditions were
due to changes in pigmentation (26.2%) and vascular components (73.8%). Topographically, conditions presented with elevated lesions (58.2%), flat (20.9%), or lacked structure (15.7%).
Elevated lesions presented as papules/plaques (61.5%), nodules
(17.9%), vesicles (17.9%) or scars (2.6%). Flat lesions presented
as macules/patches (85.7%) or scaly lesions (14.3%). Pigmented
lesions were histologically in the dermis (48.5%) and epidermis
(51.5%) and topographically presented as flat (63.6%), elevated
(30.3%), and depressed (6.1%). Pigmented lesions presented as
macules/patches (60.1%) and papules/plaques (24.2%).Vascular
lesions were histologically found in the dermis (78.5%) and
epidermis (21.5%) and presented as elevated (65.6%), lacked
structure (22.6%), flat (6.4%), or depressed (5.4%). Lesions
with no colour change had equal prevalence in the dermis and
epidermis.
Conclusion: Lesions tended to present with clusters of
traits in a characteristic manner within the commonly presenting skin conditions analyzed. Elevated lesions were more
common and usually presented as papules. Flat lesions usually
presented as macules. Pigmented lesions tended to be flat and
presented almost equally in the dermis and epidermis.Vascular
lesions were more often elevated and found within the dermis.
Recognition of these visual patterns can be used to elucidate
underlying pathomechanisms rapidly. Educational tools can
be tailored toward this line of reasoning to fill the paucity in
teaching and improve the diagnosis of dermatologic conditions
by primary care physicians.
SS.12
SS.13
Evaluation of the prevalence of dermatologic
clinical presentation visual patterns for the
improvement of dermatology education
Scurvy in a pediatric leukemia patient
presenting as phrynoderma and perifollicular
purpura
Joseph E. Marinas1 Hermenio Lima2
Jeffery Cowger1 Sydney Harris-Janz2 Donna Johnston2 Jacqueline Halton2 Nordau Kanigsberg1 Carly Kirshen1
1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton,
ON; 2. Division of Dermatology, Department of Medicine, McMaster University,
Hamilton, ON
1. Department of Dermatology, University of Ottawa, Ottawa, ON; 2. Children’s
Hospital of Eastern Ontario, Ottawa, ON
Introduction: Dermatology is a visual discipline in which
specialists diagnose lesions using rapid pattern recognition.
Diagnosis of these conditions requires a gestalt of clinical,
histological, immunological, genetic, and morphological features
which may present in a characteristic pattern.
Background: Inadequate energy intake is an undesirable yet
frequently observed complication in children with leukemia
receiving chemotherapy. Chronic malnutrition in this population may result in depletion of several nutrients. Ascorbic acid
(vitamin C) is an antioxidant and essential cofactor in several
biological reactions including the synthesis of collagen, prosta-
A16
CDA Abstracts
glandin metabolism, fatty acid transport, and norepinephrine
synthesis. Deficient levels of ascorbic acid, below 11umol/L
(0.2 mg/dL), can occur in as little as three months and result
in scurvy, a clinical syndrome, largely due to impaired collagen
synthesis resulting in disordered connective tissue. Mucocutaneous manifestations of scurvy include follicular keratotic
plugging, perifollicular purpura, corkscrew hairs, lower extremity edema with ecchymoses as well as bleeding, swelling and
ecchymoses of gingiva and the loss of teeth.
SS.14
Teaching dermatology to internal medicine
residents: evaluating the effectiveness of an
educational intervention
Monica K. Li1 Steve Doucette2 Laurie M. Parsons1
1. University of Calgary, Calgary, AB; 2. Research Methods Unit, Capital Health,
Halifax, NS
Case Description: We report the case of a 10-year-old
male with T-Cell ALL in the interim maintenance phase of protocol AALL0434 who presented in hospital with perifollicular
purpura and follicular keratotic plugging of the posterolateral
aspect of the arms, buttocks, posterior thighs, calves and shins.
Prior to initiation of chemotherapy, the patient had a diet
that was deficient in fruits and vegetables. Since the initiation of chemotherapy, the patient had consistently poor food
intake, specifically limited in fruit and vegetables, that led to a
severe weight loss of 18.5% of his baseline body weight. Based
on the cutaneous findings a serum ascorbic acid level was
ordered and demonstrated a serum concentration of less than
5 umol/L, indicative of deficiency. The patient was started on
treatment doses of ascorbic acid at 125 mg three times daily
for 7 days, then once daily for a period of 3 months to normalize serum levels of ascorbic acid.
Conclusion: Chronic malnutrition in pediatric chemotherapy patients can lead to nutritional deficiencies. Although scurvy
is a relatively rare complication, screening for ascorbic acid
deficiency through patient physical exam and dietary assessment is an important consideration in this population.
Learning Objective: To describe the cutaneous manifestations and treatment of scurvy.
Takeaway Message: Chronic malnutrition in pediatric
chemotherapy patients can lead to nutritional deficiencies.
Although scurvy is a relatively rare complication, screening
for ascorbic acid deficiency through patient physical exam
and dietary assessment is an important consideration in this
population.
Background: Internists often encounter dermatologic issues, yet studies have shown that internal medicine trainees
perform poorly at diagnosing skin diseases, and have suboptimal education in dermatology. Specifically, there is no published data comparing different educational interventions in
dermatology and its impact on long-term knowledge retention
in internal medicine residents.
Objective: We aim to evaluate the impact of teaching dermatology to internal medicine trainees, and compare different
educational methods on long-term knowledge retention.
Methods: A prospective, interventional study design was
used. Trainees of the Internal Medicine residency program at
the University of Calgary were randomized into two groups
to receive didactic or group-based education. Dermatology
teaching was provided once monthly for three consecutive months, with pre- and post-tests administered for each
educational intervention. A final test to evaluate long-term
knowledge retention will be administered three months after
the last educational intervention. Only test scores of trainees
who provided consent to the study were analyzed.
Results: Preliminary findings show improvement of scores
from pre- to post-test following dermatology education. Near
significant difference was found in test scores associated
with the first teaching intervention (median pre-test 51% to
post-test 55.2%, p-value 0.11, n=13), and a significant increase
was found in test scores associated with the second teaching intervention (median pre-test 33.4% to post-test 59.6%,
p value 0.03, n=6). No statistical difference in improvement
of test scores were observed between didactic teaching and
group-based learning methods. Further analysis of demographic factors that may affect the acquisition of knowledge, on test
scores for the third teaching intervention, and on knowledge
retention will be performed when the data becomes available.
Conclusion: Preliminary results of our study support the
importance of dermatology education for internal medicine
trainees. Further analysis will provide insights that may contribute to the development of effective dermatology curricula
for this important group of care providers.
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CDA Abstracts
Learning Objective: To provide insights on the impact of
a dermatology educational intervention for internal medicine
trainees.
Learning Objective: To discuss both the success of the
“Case of the Week” blog and the hurdles that have been encountered during its set-up and execution.
Takeaway Message: Dermatology education has the potential to directly impact the competence of internal medicine
trainees in managing cutaneous problems.
Takeaway Message: A blog is an effective web-based tool
to augment Dermatology education.
SS.15
Evaluation of the “Case of the Week” blog as
a web-based education tool for dermatology
residents
Fiona Lovegrove; Jane Wu; Scott Walsh
University of Toronto Dermatology Division,Toronto, ON
Online resources have become an increasingly significant component of medical education. In particular the “blogosphere”
– the internet’s community of web logs (colloquially known
as “blogs”) – continues to expand at a fervent pace. In such a
visual specialty as Dermatology, a blog provides an excellent
forum for the presentation and discussion of patient cases.
The “Case of the Week” blog is a resident-initiated project
that was created for use by the Dermatology residents, fellows
and teaching faculty at the University of Toronto (UofT). Each
post summarizes an interesting case presented at the weekly
citywide patient viewing rounds with the patient history,
physical examination findings, photographs, and discussion
questions. The aim of the blog is to be a study resource for
residents as well as to share references and ideas discussed at
rounds.
From its inception in September 2012, there have been 46
posts of patient cases and 8 “clinical pearls” (short posts that
share a specific idea or resource related to a case discussed at
rounds). The cases have ranged from common presentations
such as lichen planus and tinea corporis, to the more esoteric
– e.g. purigo pigmentosa and lipoid proteinosis. In 2013, the
website had 5284 page views from 542 visits of an average 5
minute, 47 second duration. Information from the posts has
been used for presentations at national conferences as well as
material in OSCE stations for UofT dermatology in-training
exams.
This presentation will further discuss both the success of
the “Case of the Week” blog and the hurdles that have been
encountered during its set-up and execution. These include
technical issues as well as patient consent and privacy concerns. The future of this project is open to possibilities such as
expansion to include other medical education resources, however the most important future direction will be to maintain
the blog as a valuable educational tool for UofT’s residents and
associated dermatologists.
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CDA Abstracts
Poster Presentations
utilizing combinations of other light-based and energy systems such as intense pulsed light, ultrasound, radiofrequency,
and various injectable treatments, are warranted to further
advance the art and science of rejuvenation.
P1.01
Efficacy and safety of facial rejuvenation via
the sequential combined use of multiple laser
modalities
Anil Kurian1 Douglas Wu1 William Groff2 Richard E. Fitzpatrick2
1. University of Alberta, Edmonton, AB; 2. Cosmetic Laser Dermatology Goldman, Butterwick, Fitzpatrick, Groff & Fabi, San Diego, CA, USA
Background: Facial rejuvenation via ablative resurfacing
has the potential to achieve excellent outcomes, but adverse
events and downtime can be significant. Conversely, the side
effect profile of non-ablative modalities is considerably less, but
the clinical efficacy is often also substantially reduced. However, the safety and efficacy of combining multiple rejuvenating
laser modalities has yet to be fully explored.
Objectives: In this study, we present a novel sequential
multi-modal laser protocol that efficiently and selectively
targets specific components of the photoaging process while
simultaneously producing significant global facial rejuvenation
in a single treatment session safely.
Conclusions: With excellent results and the requirement
for only one treatment session, patients are well-served with a
multi-modal approach to facial rejuvenation. Additional studies
Takeaway Message: With excellent results, good safety
profile and the requirement for only one treatment session,
patients are well-served with a multi-modal approach to facial
rejuvenation. Additional studies utilizing combinations of other
light-based and energy systems such as intense pulsed light,
ultrasound, and radiofrequency , and various injectable treatments, are warranted to further advance the art and science
of rejuvenation.
P1.02
Comparing syringe injectability of
triamcinolone acetonide for keloid
management
Anthony Vo1 Gloria Rockwell1 Marc Doumit2
Methods: A retrospective chart review was performed of
patients receiving combination sequential multi-modal laser
rejuvenation of the face at our center between January 1, 2010
and January 1, 2013. Fifty patients treated by two independent
physicians were selected at random for further analysis. Standardized clinical photographs were obtained of each patient
prior to treatment and follow up post-treatment at both
short and long term intervals. Clinical criteria were scored
from standardized numerical scales and included evaluation
of dyspigmentation, rhytides, telangiectasia, and skin texture,
overall percentage improvement and healing time. A patient
satisfaction survey was conducted to assess perceived overall improvement, lifestyle disruption, pain or discomfort, and
overall satisfaction.
Results: All measured clinical parameters achieved significant improvement. Overall improvement was measured at a
sustained 60% over the long term. Healing time was measured
at 9 ± 4 days (mean ± SD) and lifestyle disruption during the
week immediately post-treatment was rated at 2.4 out of 4
(mild to moderate). Twenty-eight out of fifty patients responded to the survey, reporting overall patient satisfaction as high,
measuring on average 3.1 out of 4.
Learning Objective: With excellent results, good safety
profile and the requirement for only one treatment session,
patients are well-served with a multi-modal approach to facial
rejuvenation.
1.The Ottawa Hospital, Ottawa, ON; 2. University of Ottawa, Ottawa, ON
Purpose: Injections of triamcinolone acetonide (TA) into
a keloid is often difficult and uncomfortable for a physician
due to the injection force required. Altering the syringe and
needle parameters can help reduce this force, but there are no
evidence-based guidelines. The purpose of this study was to investigate the effects of various syringe and needle parameters
on the injection force of TA, in order to determine a combination that is ergonomically feasible for keloid injections.
Methods: 5 common syringes, ranging from 1 to 5mL in size,
and 3 needle gauges(25G, 27G, 30G) varying in lengths(1336mm) were used. A load cell was used to generate and
measure the injection force. The effects of syringe size,
injection speed(1,3,5mm/sec), needle length and gauge were
determined by injecting stock TA suspensions(40mg/ml). The
most ergonomic needle-syringe combination was determined
and compared to a combination commonly used in practice, by
injecting into an excised keloid sample. Intraclass correlation
coefficient(ICC) and independent t-test were used to determine reliability and significance respectively.
Results: Increasing the speed of the injection, syringe
size, needle length and gauge significantly increased the
injection force required(p<0.001). 25G needles were less
likely to clog with the TA suspensions(failure rate:33%) than
27G/30G(failure rate:85% and 100% respectively)(p<0.001).
The 1mL polycarbonate syringe with a 25G 16mm needle re-
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CDA Abstracts
quired the lowest injection force. This combination required a
maximum of 25.0N to inject into an excised keloid, compared
to the common needle-syringe combination (39.9N). Each
experiment was repeated at least four times. ICC for all tests
were greater than 0.407.
Methods: This was a multi-center, observational study collecting PROs in patients initiating (naïve) or receiving ongoing (maintenance) onabotA treatment. All patients provided
baseline demographics. HU was the primary outcome measure
obtained from the SF-12® Health Survey using the SF-6D,
collected at baseline, week four post-treatment and up to five
subsequent injection visits (SV). Mean and 95% confidence
interval for baseline and change from baseline HU scores were
calculated. The safety cohort included enrolled patients who
received ≥1 treatment.
Conclusions: The combination of syringe and needle significantly affected the injection force of TA. Increasing the speed
of injection, syringe size, needle length and gauge significantly
increased the force of injection. The 1 mL polycarbonate
syringe with a 25G 16mm needle is an ergonomically feasible
combination for keloid injections.
Learning Objective: Understand the effects of various
needle and syringe parameters on the injection force of triamcinolone acetonide into keloids and to apply this knowledge in
order to be more ergonomic and to have a higher chance of
injection success.
Takeaway Message:
1. Increasing the speed of injection, syringe size, needle length
and gauge significantly increases the injection force of
triamcinolone acetonide. By adjusting these parameters, a
lower injection force required can be achieved.
2. 25G needles are less likely to clog with stock triamcinolone acetonide suspensions(40mg/ml) (injection failure
rate:33%) than 27G/30G needles(injection failure rate:85%
and 100% respectively)
3. The 1 mL polycarbonate syringe with a 25G 16mm needle
is an ergonomically feasible combination for keloid injections.
P1.03
Evaluation of the baseline demographics
and health utility in adults receiving
onabotulinumtoxinA (BOTOX®) for the
treatment of hyperhidrosis in a prospective
observational cohort study: MOBILITY®
Robert Miller2 Meetu Bhogal1 Grace Trentin1
1. Allergan, Inc., Markham, ON; 2. Dalhousie University, Halifax, NS
Results: 288 hyperhidrosis patients between 14-81 years old
(mean=32.5, SD=11.5) were enrolled, with 33 completing. The
majority were female (N=222, 77.1%) and Caucasian (N=265,
92.0%). 151 (52.4%) were naïve and 137 (47.6%) maintenance. Baseline HU scores were similar in naïve (mean=0.782,
SD=0.129) and maintenance (mean=0.799, SD=0.115) patients. Improvements in HU scores were observed up to
SV3 in naïve (mean change=0.025, SD=0.122) and remained
around baseline up to SV2 in maintenance (mean change=0,
SD=0.132) patients. Thereafter, HU scores decreased (mean
change≤-0.066); however, data was based on a reduced sample
size (N=37, 12.8% by SV3). Overall, mean HU scores increased
or were maintained at the time of the patients’ last treatment
visit. The hyperhidrosis cohort reported 3 non-serious adverse
events in 1 patient.
Conclusions: The majority of hyperhidrosis patients
enrolled in MOBILITY® were female, Caucasian, and naïve
to onabotA treatment. Although study completion rate was
low, due to variable treatment needs in this population, data
indicates that onabotA treatment can improve or maintain HU
in hyperhidrosis patients.
Learning Objective: To evaluate baseline demographics
and health utility in hyperhidrosis patients receiving onabotulinumtoxinA treatment in Canada.
Takeaway Message: The majority of hyperhidrosis
patients enrolled in MOBILITY® were female, Caucasian,
and naïve to onabotulinumtoxinA treatment. Data indicates
that onabotulinumtoxinA treatment can improve or maintain
health utility in hyperhidrosis patients.
Dr. Rob Miller is a member of CDA.
Introduction: While studies have reported on the efficacy
of onabotulinumtoxinA (onabotA) on clinical outcomes, patient reported outcome (PRO) data is limited. MOBILITY® is
designed to evaluate health utility (HU) related to the clinical
use of onabotA across several indications. The objective here
is to evaluate baseline demographics and HU in hyperhidrosis
patients receiving onabotA treatment in Canada.
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CDA Abstracts
P2.01
A case of “ice-pack dermatosis”: a coldinduced dermatosis that histologically
mimics cutaneous lupus erythematosus
Learning Objective: To recognize the clinical and histopathologic features of “ice-pack dermatosis.”
Takeaway Message:
Catherine Villeneuve-Tang;Vincent Richer; Benoît Côté; Annie
Bélisle
Université de Montréal, Montreal, QC
We present the case of a 38-year-old woman with a prior
diagnosis of cutaneous lupus erythematosus (LE) of the right
shoulder. Her skin disease had shown little improvement over
two years despite treatment with antimalarials and dapsone.
She also suffered from complex regional pain syndrome of the
right shoulder due to past shoulder injury. She presented to
the emergency department with fatigue, icterus, and gastrointestinal symptoms. Work-up revealed severe hemolytic anemia,
which was attributed to dapsone. Dapsone was subsequently
discontinued.
On examination, violaceous retiform patches with focal ulceration were observed on her right shoulder. During hospitalization, it was discovered that she had been applying ice to her
right shoulder for up to 6 hours per day for relief of chronic
pain. This form of analgesia had not been previously documented in her medical chart. Two previous punch biopsies were
reviewed. Both biopsies demonstrated a superficial and deep
perivascular and perieccrine lymphocytic infiltrate.Vacuolar
change with keratinocyte necrosis and mildly increased dermal
mucin were also noted. One of the biopsies also demonstrated
a significant lymphocytic vasculitis, while the other demonstrated a slight lymphocytic panniculitis.
The patient’s condition was compatible with “ice-pack dermatosis,” a cold-induced dermatosis due to chronic ice-pack
therapy that has recently been described in the literature.
Patients may present with erythematous to violaceous retiform plaques with superficial ulceration at the site of ice-pack
contact. Histopathologic findings show similar features to
cold panniculitis, perniosis, and cutaneous LE. The patient was
encouraged to minimize ice application, and her analgesia
was optimized. On follow-up, her condition had improved. It
is important to inquire about all forms of self-administered
analgesia in patients who present with skin changes at a site
of chronic pain. Recognizing that “ice-pack dermatosis” can
histologically resemble cutaneous LE will help to prevent iatrogenesis in patients.
1) “Ice-pack dermatosis” is a cold-induced dermatosis that
can histologically mimic cutaneous lupus erythematosus
(LE).
2) Recognizing that “ice-pack dermatosis” can lead to cutaneous LE-like histopathologic changes will facilitate appropriate diagnosis and treatment.
P2.02
Pretibial myxedema: case presentation and
review of treatment options
Whan B. Kim2 Nisha Mistry1 Afsaneh Alavi1 Cathryn Sibbald1
Ronald G. Sibbald1
1. University of Toronto,Toronto, ON; 2. McMaster University, Hamilton, ON
Introduction: Pretibial myxedema (PM) is a rare autoimmune manifestation of Graves’ disease, often presenting 12-24
months after the diagnosis of Graves’ disease and usually after
the onset of severe Graves’ opthalmopathy. Clinically, over 50%
of patients develop diffuse, nonpitting edema of shins, and less
often present with plaques, nodules; or elephantiasis lesions
mimicking lymphedema.
Case: A 57-year-old woman presents with 12 month history
of lower leg pain and pruritus aggravated by sitting. She has
bilateral, non-pitting edema of the anterior shins, and slight
periorbital edema without exophthalmos. Since treatment of
Graves’s disease with radioactive iodine a year previously, the
patient has remained euthyroid on levothyroxine. A punch
biopsy of the dorsal foot was consistent with PM. The patient
was treated with clobetasol propionate 0.05% daily and 20-30
mmHg knee high support stockings. After minimal improvement eight months later, intralesional steroid injections were
infiltrated into the dermal tissue. The symptoms improved
within 6 weeks and the treatment regimen was continued.
However, in 2013, the PM recurred with local erythema and
woody edema. The TSH level was on the lower end of normal (sTSH 0.36, Free T4 18) that prompted a decrease in
L-thyroxine. Dermatologic treatment continued with topical
and intralesional steroid injections and a new pair of support
stockings.
Methods and Results: A literature review was undertaken
of the evidence-based treatment modalities for symptomatic PM. The mainstay of treatment is topical corticosteroid
(mid or high-potency) applied directly to the lesions with or
without occlusion. Compression therapy (support stockings or
compressive bandages) may control associated venous edema.
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CDA Abstracts
Intralesional corticosteroid injections have been successful in
several reports; however, long-term effects must be further
investigated before routine use be recommended. Treatment
of associated hyperthyroidism has not been shown to impact
current PM lesions, but maintaining a euthyroid state may
prevent recurrence.
Conclusions: PM should be considered in patients with
history of Graves’ disease. PM is commonly asymptomatic and
self-limited; in severe cases, topical corticosteroid, compressive
therapy, and intralesional corticosteroid injections are possible
treatment options.
Learning Objective:
• Differentiate pretibial myxedema from lymphedema as a
rare autoimmune manifestation of Graves’ disease
• Provide an update on the management of this uncommon
condition
Takeaway Message: Pretibial myxedema is commonly asymptomatic and likely to resolve with time; however, cosmetic
issues, impaired function, or localized discomfort may arise, in
which case topical corticosteroid, compressive therapy, and
intralesional corticosteroid injection may be considered as
treatment options.
P2.03
Apremilast, an oral phosphodiesterase
4 inhibitor, in patients with moderate to
severe psoriasis: results from the randomized
treatment withdrawal phase of a phase 3,
randomized, controlled trial (ESTEEM 1)
Shane Silver1 Kim Papp2 Peter Foley3 Kristian Reich4 Craig
Leonardi5 Leon Kircik6 Sergio Chimenti7 ChiaChi Hu8 Randall
M. Stevens8 Robert M. Day8 Christopher E. Griffiths9
1. DermAdvances Research,Winnipeg, MB; 2. Probity Medical Research,
Waterloo, ON; 3. Skin & Cancer Foundation Inc., St.Vincent’s Hospital,
Melbourne, ,VIC, Australia; 4. SCIderm Research Institute and Dermatologikum
Hamburg, Hamburg, Germany; 5. Saint Louis University School of Medicine, St.
Louis, MO, USA; 6. Physicians Skin Care, PLLC, Louisville, KY, USA; 7. University
of Rome Tor Vergata, Rome, Italy; 8. Celgene Corporation,Warren, NJ, USA; 9.
Dermatology Centre, University of Manchester, Manchester, United Kingdom
APR30 patients who achieved PASI-75 were re-randomized
(1:1, blinded) to continue APR30 or receive placebo. Upon loss
of PASI-75, patients re-randomized to placebo resumed APR30.
At Week 16, significantly more APR30 patients achieved PASI75 (33.1%) and PASI-50 (58.7%) vs. placebo (5.3% and 17.0%;
P<0.0001). Mean/median percent change from baseline in
PASI was -52.1%/-59.0% (APR30) vs. -16.7%/-14.0% (placebo)
(P<0.0001, mean change). PASI responses were generally maintained through Week 32. Similar PASI responses were achieved
at Week 32 in placebo patients switched to APR30 at Week 16.
In the randomized treatment withdrawal phase, 61.0% of 77
patients randomized to continue APR30 from baseline at Week
32 had PASI-75 at Week 52, and 75.3% had ≥70% improvement
in PASI from baseline; mean percent change from baseline in
PASI was -81% to -88% from Weeks 32-52. In patients who received APR30 from baseline and were re-randomized to placebo at Week 32 (n=77), 11.7% had PASI-75 at Week 52. Median
time to PASI-75 loss in patients re-randomized to placebo was
5.1 weeks. 70.3% of patients re-randomized to placebo who
lost response and restarted APR30 regained PASI-75 response
after treatment re-initiation. AE incidence did not increase
over time. Most common AEs were diarrhea, URTI, nausea,
nasopharyngitis, and headache. Most AEs were mild/moderate
and did not lead to discontinuation. Serious AEs (serious infections, malignancies, and cardiovascular events) and laboratory
changes were consistent with prior APR studies.
Conclusions: Over 52 weeks, APR30 was effective in moderate/severe psoriasis. APR30 demonstrated an acceptable
safety profile and was generally well-tolerated.
Learning Objective: The objective of ESTEEM 1 is to
describe the long-term (52-week) efficacy of apremilast 30 mg
BID in patients with moderate to severe plaque psoriasis.
Takeaway Message: Apremilast significantly reduced
the severity of moderate to severe psoriasis over 16 weeks,
with response generally maintained in patients remaining on
apremilast for 52 weeks. Apremilast demonstrated an acceptable safety profile and was generally well-tolerated for up to
52 weeks with no new safety or laboratory findings compared
with previous phase 2 studies.
Introduction: Apremilast (APR), an oral phosphodiesterase 4 inhibitor, works intracellularly to regulate inflammatory
mediators.
Methods/Results: ESTEEM 1 randomized patients with
moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%, sPGA
≥3) 1:2 to placebo or apremilast 30 mg BID (APR30). At Week
16, all placebo patients switched to APR30. At Week 32, all
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CDA Abstracts
P2.04
Biologic treatment utilization in patients
with moderate to severe psoriasis: a
Canadian healthcare system perspective
drugs and determine characteristics of inadequate responders, including longitudinal treatment pathways and reasons for
discontinuations or switching.
Takeaway Message: Moderate to severe chronic plaque
psoriasis patients treated with biologics may optimize their
treatment by escalating the dose, reducing dosing intervals or
ultimately switching to another treatment.
Wayne Gulliver1, 2 Valerie Gregory3 Sam Khalil3 Usha Mallya4
1. Memorial University of Newfoundland, Faculty of Medicine, St. John’s, NL;
2. NewLab Clinical Research Inc., St. John’s, NL; 3. Novartis Pharmaceuticals
Canada Inc., Dorval, QC; 4. Novartis Pharmaceutical Corporation, East Hanover,
NJ, USA
P2.05
HLA-Cw6 polymorphisms may help predict
response to biologic therapy in patients with
chronic plaque psoriasis
Introduction: Psoriasis is a common chronic, recurring
skin disease and estimates of its prevalence range from 0.5%
to 4.6% worldwide (Lebwohl M (2003), American Academy of
Dermatology (2011)). Due to the high prevalence of psoriasis,
the severity of the disease, and the costs associated with various treatments, its economic burden is elevated (Fowler JF et
al (2008)).
Wayne Gulliver
1. Memorial University of Newfoundland, Faculty of Medicine, St. John’s, NL;
2. NewLab Clinical Research Inc., St. John’s, NL
There are currently four available biologic treatments for
moderate to severe psoriasis in Canada, namely Enbrel®
(etanercept), Humira® (adalimumab), Remicade® (infliximab),
Stelara® (ustekinumab). The objectives of this study were
to describe the treatment patterns of moderate to severe
psoriasis patients taking these biologic drugs and determine
characteristics of inadequate responders, including longitudinal treatment pathways and reasons for discontinuations or
switching.
Methodology/Results: This was a retrospective cohort
study using data abstracted from medical records of confirmed
cases of psoriasis patients who received biologic treatments.
The medical records were obtained from a private dermatology clinic in St. John’s, Newfoundland (NewLab Clinical
Research Inc.).
The study population consisted of moderate to severe psoriasis patients who attended NewLab Clinical Research Inc.
(NewLab) between 2008 and 2012 with a confirmed diagnosis
of psoriasis by a dermatologist, specifically chronic plaque-type
psoriasis diagnosed for at least 6 months before study index
date.
To date response to biologics has been based on clinical observation and no genetic markers have been found to predict
response to treatment. In 1993 our research suggested that
HLA-Cw6 was a susceptibility gene for psoriasis. Our data also
suggested that HLA-Cw6 was linked to both the age of onset
of psoriasis as well as the need for patients to require photo
or systemic therapy for psoriasis treatment. Since that time
our knowledge of psoriasis genetics and pharmacogenomics
has advanced significantly. With the introduction of biologic
therapy we now have the tools we need to treat this severe
and relentless disease. Biologics offer us not only improved
therapeutic benefit but a much more favorable safety profile.
As there is variability in the response of patients to biologics
single-nucleotide polymorphisms that may identify responders and non-responders would be of benefit. HLA-Cw6 has
been implicated in the past as a marker to biological response
(Gulliver, AAD 2009). Recent studies also suggest that it may
predict clinical response to ustekinumab (Talamonti, BJD 2013).
Using the Newfoundland Labrador founder population we
genotyped HLA status on 91 patients who were treated with
biologics and then classified the patients into two groups:
1 - patients with a clinical response (PASI 75 response); 2 patients who were non-responders (PASI < 75) or who have
discontinued treatment.
Independent sample t-tests for continuous variables and
Chi-square test for categorical variables were used to compare data between treatment groups (Enbrel® (etanercept),
Humira® (adalimumab), Remicade® (infliximab), Stelara®
(ustekinumab). Comorbidities were presented by age, sex,
severity of psoriasis and treatment group, where possible.
This study demonstrates the Newfoundland Labrador founder
population and HLA-Cw6 status may be helpful in predicting response to certain biologics (Etanercept, Adalimumab,
Ustekinumab, Infliximab).
A total of 220 moderate to severe chronic plaque-type psoriasis patients were identified and treated with biologics.
Learning Objective: To describe the treatment patterns
of moderate to severe psoriasis patients taking these biologic
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CDA Abstracts
Parameter
Etanercept
(N=10)
Adalimumab
(N=25)
Infliximab
(N=23)
Ustekinumab
(N=33)
Total
(N=91)
Methods and Results: We have retrospectively reviewed
the charts of all DART patients from the two-year period,
July 2011 to June 2013. The data collected includes: patient
age, gender, dermatologic diagnosis, rheumatologic diagnosis,
biopsies performed, treatment, number of follow-up visits, and
co-morbidities. Our chart review revealed that a total of 320
patients were seen (248 female, 72 male). Mean age was 49
years for men, and 47 years for women. The most common
rheumatologic diagnoses were systemic lupus erythematosus
(58 cases seen), rheumatoid arthritis (49), psoriatic arthritis
(41) and undifferentiated connective tissue disease(25). The
most common dermatologic diagnoses were dermatitis (60),
psoriasis (40), cutaneous lupus (25), alopecia (21), and infections (16). 78 patients had biopsies. The median number of
follow-up visits was 1 (range 0-15).
Non-responders (or discontinued treatment):
HLA Cw6 +
3
(60%)
5
(45.46%)
3
(27.27%)
1
(20%)
12
(37.5%)
2
(40%)
6
(54.54%)
8
(72.73%)
4
(80%)
20
(62.5%)
HLA Cw6 +
3
60%)
7
(50%)
9(
75%)
21
(75%)
40
(67.8%)
HLA Cw6 -
2(
40%)
7
(50%)
3
(25%)
7
(25%)
19
(32.2%)
HLA Cw6 Responders:
Learning Objective: In the Newfoundland and Labrador
founder population not only is HLA-Cw6 a susceptibility gene
but preliminary data suggest it may be able to predict response to certain biologics.
Takeaway Message: This study demonstrates the Newfoundland Labrador founder population and HLA-Cw6 status
may be helpful in predicting response to certain biologics. This
is very preliminary data and results should be confirmed in a
larger study.
P2.06
Conclusions: The majority of our patients are females with
diagnoses of systemic lupus erythematosus or rheumatoid
arthritis. Skin conditions seen were both related and unrelated to the underlying rheumatologic diagnosis. Dermatitis,
a non-rheumatologic-associated condition, was very common,
possibly due to its high incidence in the general population
and a clinical appearance that may be suggestive of connective tissue disease. Our data also supports that lupus patients
often present with rashes unrelated to the underlying lupus.
Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic
patients are experiencing.
DART clinic review: experiences from a
combined dermatology and rheumatology
clinic
Learning Objective: To gain awareness of the common
dermatologic conditions that rheumatologic patients are
experiencing.
Michael Samycia2 Collette McCourt1 Kam Shojania3 Sheila Au4, 2
Takeaway Message:
1. Department of Dermatology, Royal Victoria Hospital, Belfast Health
and Social Care Trust, Belfast, Ireland; 2. Department of Dermatology and
Skin Science, University of British Columbia,Vancouver, BC; 3. Division of
Rheumatology, Department of Medicine, St. Paul’s Hospital and Providence
Health Care, University of British Columbia,Vancouver, BC; 4. Division of
Dermatology, Department of Medicine, St. Paul’s Hospital and Providence
Health Care,Vancouver, AB
1. Dermatitis, psoriasis, cutaneous lupus and alopecia are
highly represented in rheumatologic patients seen in our
clinic.
2. Skin problems in rheumatologic patients may not be related to the underlying condition.
3. Rheumatologists and dermatologists can both benefit from
being aware of the dermatologic conditions that rheumatologic patients are experiencing.
Objectives: The combined Rheumatology and Dermatology Treatment Clinic (DART Clinic) in Vancouver is a novel
multi-disciplinary teaching clinic, where patients with both
skin and rheumatologic issues are concomitantly assessed by
both specialties. The purpose of this study is to determine the
number of patients seen in clinic, patient demographics, and
most common diagnoses. The information that we gain will be
used for quality improvement and to help guide the education of rheumatologists, dermatologists, residents and medical
students in our clinic.
P2.07
Zoster vaccination of patients on biologics
Eric E. Roszell; Lyn Guenther
Schulich School of Medicine and Dentistry - University of Western Ontario,
London, ON
Introduction: Herpes zoster(HZ) causes significant morbidity. Incidence rates appear to be increased in patients with
A24
CDA Abstracts
psoriasis, rheumatoid arthritis, inflammatory bowel disease,
and other autoimmune conditions who receive biologics. It
is currently recommended that these patients receive immunization against HZ before receiving immunosuppressive
treatments including biologics. Traditionally it has not been
recommended to vaccinate immunosuppressed patients with
live vaccines such as the zoster or varicella vaccine due to the
fear of infection from the vaccine. In this article we review the
current evidence regarding the safety and efficacy of zoster
vaccination in patients on biologics.
P2.08
Omalizumab in dermatology: a review of the
literature
Justin Chia; P. Régine Mydlarski
Division of Dermatology, Department of Medicine, University of Calgary,
Calgary, AB
Methods: A systematic literature search was performed on
PubMed for articles published between May 25th, 2006 and Jan
20th, 2014. All articles discussing HZ and zoster vaccination
in patients with autoimmune diseases, including patients on
biologics, were reviewed.
Results: Patients on biologics have a higher incidence of
herpes zoster, but it is unclear if this is attributable to the biologics or due to the underlying disease. Retrospective cohort
studies found no adverse effects of zoster vaccination during
biologic treatment up to 42 days post vaccination. Hazard
ratios calculated from these studies found a decreased risk of
HZ two years post vaccination. One case of vaccine viral strain
(Oka) retinal necrosis in an IBD patient on multiple immunosuppressants including a biologic was reported after chickenpox vaccination. This vaccine contains the same OKA virus
as the zoster vaccine, but the concentration is 1/14th. Heattreated zoster vaccine, although not strongly immunogenic, has
been shown to be safe in immunocompromised patients.
Conclusion: There is an increased need for HZ prevention
in patients on biologics. Current data suggests that vaccination
of biologic patients against zoster appears safe and effective in
preventing HZ. Larger studies are necessary to confirm these
results.
Learning Objective: This study was undertaken to review
the literature on the safety and efficacy of vaccination against
zoster in patients who are on biologics.
Takeaway Message: Live vaccines such as the zoster
vaccine have been traditionally contraindicated in patients on
biologics, however several biologic patients have received the
zoster vaccine without ill effects.Vaccination of these patients is efficacious and may prevent zoster. The development
of OKA virus retinal necrosis in an immunosuppressed IBD
patient after receipt of the chickenpox vaccine, which contains 1/14th the concentration of virus as the zoster vaccine,
suggests that it is premature to recommend routine zoster
vaccination while on biologic treatment until larger studies are
done.
Introduction: Omalizumab (Xolair®; Roche/Genetech and
Novartis Pharmaceuticals Inc.) is a recombinant humanized
monoclonal antibody that inhibits the binding of IgE to the
high-affinity IgE receptor (FcεRI) on the surface of mast cells
and basophils. By reducing surface-bound IgE on FcεRI -bearing
cells, omalizumab impairs the release of inflammatory mediators. Treatment with omalizumab also reduces the number
of FcεRI receptors on basophils and may also decrease other
autoreactive IgE antibodies. Omalizumab has been approved
for use in asthma, and new reports show promise in a variety
of dermatological diseases. Herein, we review the literature on
omalizumab in dermatology and discuss the safety, efficacy and
mechanisms of action for this emerging therapy.
Methods: A search of the PubMed, Embase, and MEDLINE
databases was performed (1990-2013) using the key words
“omalizumab” and “Xolair” in combination with the following:
“skin”, “dermatology”, “dermatological”, “cutaneous”, “pemphigus”, “pemphigoid”, “epidermolysis bullosa”, “vesiculobullous”,
“papulosquamous”, “psoriasis”, “dermatitis”, “eczema”, “hyperIgE syndrome”, “urticaria”, “angioedema”, “collagen vascular
disease”, “vasculitis”, “lupus”, “dermatomyositis”, “scleroderma”,
“cryoglobulinemia”, “vitiligo”, “alopecia”, “granulomatous disease” and “graft versus host disease”. The data was extracted
and the levels of evidence were graded in accordance with
recommendations from the Oxford Centre for EvidenceBased Medicine.
Results: A total of 61 dermatology-related publications were
identified. They included reports on the use of omalizumab in
chronic urticaria (34), atopic dermatitis (20), bullous pemphigoid (3), Churg-Strauss syndrome (2), and hyper-IgE syndrome
(2). The safety and efficacy of omalizumab were also evaluated.
Conclusions: Omalizumab has demonstrated therapeutic
efficacy in a variety of recalcitrant immune-mediated and autoimmune skin disorders. It is a safe and effective treatment for
use in chronic idiopathic urticaria (grade of recommendation:
A). Randomized clinical trials with long-term follow-ups are
warranted to firmly establish the role of omalizumab in the
treatment of dermatologic disease.
Learning Objective:
1. To review the current literature on the use of omalizumab
in dermatology.
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CDA Abstracts
2. To understand the potential mechanisms of action for
omalizumab.
Takeaway Message: Omalizumab is an anti-IgE monoclonal antibody that demonstrates efficacy and safety in the
treatment of chronic idiopathic urticaria. It is a promising new
therapy for many recalcitrant immune-mediated and autoimmune skin disorders.
patients receiving higher doses while they may impact efficacy
at lower doses.
Learning Objective: Evaluate the impact of two baseline
variables that may influence the effectiveness of biologics, body
weight and prior biologic use, on the response to ixekizumab
treatment.
P2.09
Impact of body weight and prior biologic
use on the effectiveness of ixekizumab in
patients with moderate to severe psoriasis in
a Phase 2 study
P2.10
Efficacy of etanercept combined with topical
therapy in patients with moderate-to-severe
plaque psoriasis: results from the REFINE
study
Kim Papp1 Craig Leonardi2 Michael Heffernan 3 Janelle Erickson 3 Youb Chalabi3
1. Probity Medical,Waterloo, ON; 2. St. Louis University School of Medicine,
Dermatology, St. Louis, United States, St. Louis, MO, USA; 3. Eli Lilly, Indianapolis,
IN, USA
Kim A. Papp1 Kirk Barber2 Robert Bissonnette3 Marc Bourcier4
Charles W. Lynde5 Yves Poulin6 Jennifer Shelton7 Jack Toole8
Andrew Vieira9 Melanie Poulin-Costello7
Introduction: Ixekizumab, an anti-IL-17A monoclonal
antibody, has been shown to be effective in patients (pts) with
moderate-to-severe chronic plaque psoriasis following 20
weeks of therapy in a Phase 2 study
1. Probity Medical Research,Waterloo, ON; 2. Kirk Barber Research, Calgary,
AB; 3. Innovaderm Research, Montreal, QC; 4. Dermatology Clinic, Moncton, NB;
5. Lynde Centre for Dermatology, Markham, ON; 6. Centre Dermatologique
du Quebec Metropolitain, Quebec, QC; 7. Amgen Canada Inc., Mississauga,
ON; 8. University of Manitoba,Winnipeg, MB; 9. Formerly Amgen Canada Inc.,
Mississauga, ON
Material & Methods: A total of 142 pts were randomized
to receive subcutaneous injections of 10, 25, 75, or 150 mg of
ixekizumab or placebo at weeks 0, 2, 4, 8, 12, and 16. Randomization was stratified according to body weight (<100 kg or
≥100 kg) and by prior biologic use. Regression analyses were
performed using PASI 75 response or absolute PASI improvement at Week 12 as the dependent variable, and age, gender,
race, duration of disease, baseline body weight, ixekizumab
dose, baseline PASI score, and prior biologic use as independent variables.
Introduction: Combination therapy is often used to treat
moderate-to-severe plaque psoriasis (PsO). However, data
from randomized clinical trials to formally evaluate the efficacy of topical corticosteroids as adjunct therapy to systemic
agents are limited.
Results: Prior biologics were used in 59 pts (42%) and 52
pts (37%) had ≥100 kg body weight with overall mean body
weight of 94 (± 26) kg (range 51-180 kg). In the regression
analyses of the overall population (all dose groups), baseline
body weight was significantly associated with PASI improvement (p=0.045) and PASI 75 response rate (p=0.012) at Week
12 while prior biologic use and other baseline characteristics
were not. In the low dose group, absolute PASI improvement
was 13±7 for pts weighing <100 kg and 10±8 in pts weighing
≥ 100 kg (p=0.111), while in the high dose group, the PASI improvement was 15±5 for pts weighing <100 kg and 16±7 in pts
weighing ≥ 100 kg (p=0.558). In the high dose group, the PASI
75 response rate was 83% in pts with prior biologic use and
82% in pts who were naïve to biologic therapy (p=1.0).
Conclusions: Body weight and prior biologic use did not
appear to have a major impact on the efficacy of ixekizumab in
Takeaway Message: Ixekizumab, an anti-IL-17A monoclonal antibody, has been shown to be effective in patients (pts)
with moderate-to-severe chronic plaque psoriasis following 20
weeks of therapy in a Phase 2 study
Methods/Results: In the phase 3b, randomized, open-label
REFINE study, moderate-to-severe PsO patients received
etanercept (ETN) 50mg twice weekly (BIW; initial dose) for
12 weeks. Subjects were then randomized (1:1) to ETN 50mg
BIW or ETN 50mg once weekly (QW; maintenance dose)
plus topical agent, as needed, for an additional 12 weeks to
achieve a clear/almost clear static physician global assessment
(sPGA). Endpoints included percent change in Psoriasis Area
and Severity Index (PASI) from week 12 (W12) to week 24
(W24); sPGA status; PsO-affected body surface area (BSA);
and 50% improvement in PASI (PASI50), PASI75, and PASI90.
From W12 to W24, the mean change in PASI (95% CI) in
patients on ETN-BIW (N=140) was 17.0% (3.1%, 30.9%) vs.
0.9% (-13.0%, 14.8%) in those on ETN-QW + topical (N=142).
At W24, 53.5% (45.3%, 61.7%) and 45.4% (37.2%, 53.6%) in the
ETN-BIW and ETN-QW + topical arms, respectively, achieved
a clear/almost clear sPGA status. The mean change (95% CI) in
A26
CDA Abstracts
affected BSA from W12 to W24 was similar between groups
(ETN-BIW: 15.6% [-4.4%, 35.6%] vs. ETN-QW + topical: 10.7%
[-9.3%, 30.7%]). At W24, the proportions (95% CI) of patients
on ETN-BIW achieving PASI50, PASI75, and PASI90 were
78.2% (71.4%, 85.0%), 59.2% (51.1%, 67.2%), and 32.4% (24.7%,
40.1%), respectively. The proportions (95% CI) of patients on
ETN-QW + topical achieving PASI50, PASI75, and PASI90 at
W24 were 88.7% (83.4%, 93.9%), 60.3% (52.2%, 68.4%), and
27.0% (19.6%, 34.3%), respectively.
Conclusions: Moderate-to-severe PsO patients receiving
a maintenance dose of ETN (50mg QW) plus topical therapy
demonstrated similar clinical benefit compared with patients
continuing on the initial dose of 50mg BIW.
Learning Objective: To understand the efficacy and safety
of combination etanercept plus topical therapy in patients with
moderate-to-severe plaque psoriasis
Takeaway Message: Combination therapy with etanercept
plus topical corticosteroid provided similar clinical benefit
compared with etanercept alone in patients with moderate-tosevere plaque psoriasis.
P2.11
Maintenance of clinical response with longterm brodalumab (AMG 827) therapy: week
96 results from an open-label extension
study in psoriasis patients
achieved PASI75, 85.1% (79.0, 90.1) had PASI90, and 62.9%
(55.2, 70.0) had PASI100. At W48, 93.3% (95% CI = 88.4, 96.6)
achieved PASI75, 83.0% (76.4, 88.4) had PASI90, and 61.8%
(53.9, 69.3) had PASI100. At W96, 89.5% (95% CI = 83.6, 93.9)
achieved PASI75, 78.4% (71.1, 84.7) had PASI90, and 52.9%
(44.7, 61.1) had PASI100. Treatment-emergent AEs occurred
in 93.4% of patients. The most common AEs included nasopharyngitis (25%), upper respiratory tract infection (18%), and
arthralgia (13%). AEs ≥ grade 3 occurred in 22 (12.2%) patients
and serious AEs (SAEs) in 12 (6.6%) patients. Treatment-related
AEs were reported in 26.5% of patients (5 [2.8%] ≥ grade 3
and 3 [1.7%] SAEs). Before W48, one esophageal adenocarcinoma and one fatal aortic aneurysm rupture were reported.
Conclusions: From week 8 through W96, the majority
of patients achieved PASI100. The most frequent AEs were
predominantly ≤ grade 2. Based on these results, further studies of brodalumab in moderate-to-severe PsO patients are
warranted.
Learning Objective: To understand the long-term efficacy
and safety of brodalumab in patients with moderate-to-severe
plaque psoriasis
Takeaway Message: Brodalumab long-term safety and
efficacy appear to warrant further investigation based on the
positive long-term risk:benefit ratio.
P2.12
Kim A. Papp1 Craig Leonardi2 Alan Menter3 Jean-Paul Ortonne4
Elizabeth H. Thompson5 Cassandra E. Milmont5 Ajay Nirula5
Paul Klekotka5
1. Probity Medical Research,Waterloo, ON; 2. St. Louis University, St. Louis, MO,
USA; 3. Baylor University Medical Center, Dallas,TX, USA; 4. Hopital de l’Archet,
Nice, France; 5. Amgen Inc.,Thousand Oaks, CA, USA
Introduction: Brodalumab (anti-interleukin-17 receptor
monoclonal antibody) has shown efficacy in moderate-tosevere plaque psoriasis (PsO). Brodalumab long-term efficacy
and safety was assessed in an open-label extension (OLE)
study in patients rolling over from a phase 2 dose-ranging trial.
Methods/Results: In the parent study (NCT00975637),
patients received placebo or brodalumab (70, 140, or 210mg
every 2 weeks [Q2WK] or 280mg every 4 weeks). Patients in
the OLE initially received brodalumab 210mg Q2WK. Following a protocol amendment approximately one year after study
start, subjects ≤100kg switched to 140mg Q2WK. Outcomes
included Psoriasis Area and Severity Index 75 (PASI75), PASI90,
PASI100, and adverse events (AEs). Of 181 subjects enrolled,
165 remained on study at week 48 (W48; 48 on 140mg; 117
on 210mg) and 153 at week 96 (W96; 105 on 140mg; 48
on 210mg). At week 12 (W12), 95.4% (95% CI = 91.2, 98.0)
Long-term safety and tolerability of
apremilast, an oral phosphodiesterase 4
inhibitor, in patients with moderate to
severe psoriasis: results from a phase 3,
randomized, controlled trial (ESTEEM 1)
Lorne Albrecht1 Kristian Reich2 Kim Papp3 Craig Leonardi4
Leon Kircik5 Peter Foley6 Sergio Chimenti7 Kamal Shah8
ChiaChi Hu8 Randall M. Stevens8 Robert M. Day8 Christopher
E. Griffiths9
1. Probity Medical Research, Surrey, BC; 2. SCIderm Research Institute and
Dermatologikum Hamburg, Hamburg, Germany; 3. Probity Medical Research,
Waterloo, ON; 4. Saint Louis University School of Medicine, St. Louis, MO, USA;
5. Physicians Skin Care, PLLC, Louisville, KY, USA; 6. Skin & Cancer Foundation
Inc., St.Vincent’s Hospital, Melbourne,VIC, Australia; 7. University of Rome Tor
Vergata, Rome, Italy; 8. Celgene Corporation,Warren, NJ, USA; 9. Dermatology
Centre, University of Manchester, Manchester, United Kingdom
Background: Apremilast (APR), an oral phosphodiesterase 4
inhibitor, works intracellularly to regulate inflammatory mediators.
Methods/Results: ESTEEM 1 randomized patients with
moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%,
A27
CDA Abstracts
sPGA ≥3) 1:2 to placebo or apremilast 30 mg BID (APR30).
At Week 16, all placebo patients switched to APR30 through
Week 32. At Week 32, patients treated with APR30 at baseline who achieved PASI-75 were re-randomized (1:1, blinded)
to continue APR30 or receive placebo. Upon loss of PASI-75,
patients re-randomized to placebo resumed APR30. The APRexposure period (patients who received APR, regardless of
when initiated [Weeks 0-52]) included 804 patients treated
with APR30 (567.8 patient-years). During the APR-exposure
period, adverse events (AEs) in ≥5% of patients were diarrhea
(18.7%), URTI (17.8%), nausea (15.3%), nasopharyngitis (13.4%),
tension headache (9.6%), and headache (6.5%). These AEs did
not appear to increase over time and no new significant AEs
emerged with continued APR exposure. AEs were predominantly mild/moderate in severity. Severe AEs occurred in 6% of
patients with no clear trend or pattern observed. Discontinuation rate due to AEs was low during the APR-exposure period
(7.3%). In APR-treated patients reporting diarrhea and nausea,
more than half occurred within 2 weeks of the first dose, were
predominantly mild in severity, and generally resolved within
1 month. The occurrence of serious AEs was 4.2% and no
specific serious AE was reported for >3 patients during the
APR-exposure period. No imbalance in rates of major adverse
cardiac events, serious/systemic opportunistic infections, or
malignancies between APR and placebo was observed. No
cases of tuberculosis reactivation were reported. Over the
APR-exposure period, changes in laboratory parameters were
transient, and no trend was observed.
Conclusions: APR demonstrated an acceptable safety profile
and was generally well-tolerated for up to 52 weeks with no
new/unexpected safety findings compared with previous phase
2 studies.
Learning Objective: The objective of ESTEEM 1 is to describe the long-term (52-week) safety of apremilast 30 mg BID
in patients with moderate to severe plaque psoriasis.
Takeaway Message: Apremilast demonstrated an acceptable safety profile and was generally well-tolerated for up to
52 weeks. Most AEs were mild or moderate in severity and
did not lead to discontinuation. There were no new safety or
laboratory findings compared with previous apremilast phase
2 studies.
P2.13
Phase 2 study of brodalumab (AMG827) for
moderate-to-severe plaque psoriasis: week
12 results on efficacy and safety in patients
with psoriatic arthritis
Kim A. Papp1 Alan Menter2 Jean-Paul Ortonne3 Bruce Strober1,
4 Greg Kricorian5 Elizabeth H. Thompson5 Cassandra E. Milmont5 Ajay Nirula5 Paul Klekotka5
1. Probity Medical Research,Waterloo, ON; 2. Baylor University Medical Center,
Dallas,TX, USA; 3. Hopital de l’Archet, Nice, France; 4. University of Connecticut
School of Medicine, Farmington, CT, USA; 5. Amgen Inc.,Thousand Oaks, CA,
USA
Introduction: Psoriasis (PsO) patients with psoriatic arthritis (PsA) may be challenging to treat. This phase 2, double-blind
study assessed brodalumab efficacy and safety in PsO patients
with and without PsA.
Methods/Results: Moderate-to-severe PsO patients were
randomized to brodalumab (70, 140, or 210mg every 2 weeks
or 280mg every 4 weeks) or placebo and stratified by history
of self-reported PsA. Endpoints included Psoriasis Area and
Severity Index 75 (PASI75), PASI100, and adverse events (AEs).
Of 198 subjects enrolled, 46 (23.2%) had self-reported PsA.
At baseline, these patients had similar/more severe PsO than
those without PsA (mean disease duration 24.3 vs. 17.3 years;
mean PASI score 19.7 vs. 18.9; mean affected body surface
area 26.6% vs. 22.9%). The proportions (95% CI) of subjects
with PsA achieving PASI75 at week 12 (W12) were: 37.5% (8.5,
75.5), 70mg arm; 81.8% (48.2, 97.7), 140mg arm; 91.7% (61.5,
99.8), 210mg arm; 37.5% (8.5, 75.5), 280mg arm. Of patients
without PsA, the proportions achieving PASI75 at W12 were:
32.3% (16.7, 51.4), 70mg arm; 75.0% (55.1, 89.3), 140mg arm;
78.6% (59.0, 91.7), 210mg arm; 73.5% (55.6, 87.1), 280mg arm.
The proportions of patients with PsA achieving W12 PASI100
were: 0% (0.0, 36.9), 70mg arm; 63.6% (30.8, 89.1), 140mg
arm; 58.3% (27.7, 84.8), 210mg arm; 12.5% (0.3, 52.7), 280 mg
arm. Of patients without PsA, the proportions achieving W12
PASI100 were: 12.9% (3.6, 29.8), 70mg arm; 28.6% (13.2, 48.7),
140mg arm; 64.3% (44.1, 81.4), 210mg arm; 32.4% (17.4, 50.5),
280mg arm. PASI 75/100 was not reached in the placebo arm
at W12. Treatment-emergent AEs occurred in 57.1% (PsA) and
63.3% (without PsA) of patients receiving placebo and 71.8%
(PsA) and 73.9% (without PsA) receiving brodalumab.
Conclusions: Brodalumab treatment was associated with
significant clinical improvements and similar levels of benefit
in individuals with moderate-to-severe PsO, with and without
PsA.
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CDA Abstracts
Learning Objective: To understand the efficacy and safety
of brodalumab in patients with moderate-to-severe plaque
psoriasis
Takeaway Message: Brodalumab treatment was associated with significant clinical improvements and similar levels
of benefit in individuals with moderate-to-severe PsO, with
and without PsA. Similar levels of treatment-emergent AEs
were observed among patients receiving brodalumab, with and
without PsA.
P2.14
Measuring the self-reported satisfaction
scores of patients receiving different
psoriasis treatments and their
dermatologists
Conclusion: Interim data suggests that patients on biologic
therapy for ≥9 months (and their physicians) are more satisfied with current therapy than patients taking non-biologic
therapy or newly prescribed/initiated biologic therapy (and
their physicians), and satisfaction correlates with disease
severity. Physicians treating biologic-experienced patients were
more likely to agree with their patients’ satisfaction levels than
were physicians treating patients on non-biologics. Longitudinal
results from the newly prescribed/initiated group may provide
insight into changes in satisfaction following initiation of a
biologic.
Learning Objective: To describe psoriasis patient satisfaction with treatment and identify drivers of satisfaction.
Takeaway Message: Patients on biologic therapy for 9
months or longer, as well as their dermatologists, are more
satisfied with their current therapy as compared to patients
on non-biologic therapy, or those patients newly prescribed or
initiated on a biologic.
Vincent Ho1 Kim Papp2, 3, 6 Neil H. Shear4 Wayne P. Gulliver2
Yves Poulin5
1. University of British Columbia,Vancouver, BC; 2. Memorial University, St. John’s,
NL; 3. K. Papp Clinical Research Inc.,Waterloo, ON; 4. University of Toronto,
Toronto, ON; 5. Laval University, Quebec City, QC; 6. Probity Medical Research
Inc.,Waterloo, ON
Introduction: This observational study was designed to describe patient satisfaction with psoriasis treatment and identify
its drivers.
Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on
non-biologic therapy for >3 months and candidates for/already
on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for
≥9 months). During a routine visit, dermatologists completed
a questionnaire about the patient. Patients completed a similar
questionnaire at home. These interim analyses are qualitative.
Biologic-experienced patients (n=66) were more satisfied with
current therapy than non-biologic patients (n=48) or newly
prescribed/initiated patients (n=35), based on a 5-point rating
(5 = extremely satisfied); mean scores 4.33 vs. 3.73 vs. 3.71.
Physicians were more satisfied with the current therapy of
their biologic-experienced patients (n=167; mean score 4.43)
than their non-biologic patients (n=119; mean score 3.19).
More biologic-experienced patients (50%) agreed with the
statement “I feel as good as I possibly could when it comes to
my psoriasis” than non-biologic patients (19%) or newly prescribed/initiated patients (17%); physician ratings were similar.
Biologic-experienced patients were more likely to describe
their current psoriasis severity as very mild or mild, nonbiologic patients were more likely to describe it as moderate
or severe, and newly prescribed/initiated patients were split
among very mild, mild, moderate, and severe.
P2.15
Comparison of dermatologist and patient
rankings of psoriasis medication attributes
Kim Papp1, 6, 3 Neil H. Shear2 Wayne P. Gulliver1 Yves Poulin4
Vincent Ho5
1. Memorial University, St. John’s, NL; 2. University of Toronto,Toronto, ON; 3.
Probity Medical Research Inc.,Waterloo, ON; 4. Laval University, Quebec City,
QC; 5. University of British Columbia,Vancouver, BC; 6. K. Papp Clinical Research
Inc.,Waterloo, ON
Introduction: This observational study was designed to
compare patient and physician valuations of psoriasis treatment attributes.
Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on
non-biologic therapy for >3 months and candidates for/already
on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for
≥9 months). During a routine visit, dermatologists completed a
questionnaire about the patient, patients completed a questionnaire at home. These interim analyses are qualitative.
A29
CDA Abstracts
Most important psoriasis treatment attributes (matches
bolded):
Treatment group
Attributes
most valued by
patients
Attributes physicians believed
were most valued
by patients
Attributes most
valued by physicians
1. Efficacy,
2. Long-term
efficacy,
3. Tie: Safety
/ Physician/
pharmacist
recommendation
(n=66)
1. Efficacy,
2. Safety,
3. Side effects
(n=167)
1. Efficacy,
2. Safety,
3. Side effects
(n=158)
Newly prescribed/
initiated on a
biologic
1. Efficacy,
2. Physician/
pharmacist
recommendation,
3. Tie: Long-term
efficacy / Side
effects (n=35)
1. Efficacy,
2. Safety,
3. Side effects
(n=118)
1. Efficacy,
2. Safety,
3. Side effects
(n=68)
Non-biologic
1. Efficacy,
2. Long-term
efficacy,
3. Physician/
pharmacist
recommendation
(n=86)
1. Safety,
2. Efficacy,
3. Side effects
(n=173)
1. Efficacy,
2. Safety,
3. Side effects
(n=119)
Biologic-experienced
P2.16
Assessment of psoriasis treatment attributes
that drive patient satisfaction
Neil H. Shear1 Wayne P. Gulliver2 Yves Poulin3 Vincent Ho4 Kim
Papp2, 6, 5
1. University of Toronto,Toronto, ON; 2. Memorial University, St. John’s, NL;
3. Laval University, Quebec City, QC; 4. University of British Columbia,Vancouver,
BC; 5. Probity Medical Research Inc.,Waterloo, ON; 6. K. Papp Clinical Research
Inc.,Waterloo, ON
Introduction: This observational study assessed whether
psoriasis treatment attributes most valued by patients also
provided the greatest satisfaction in their current therapy.
Methods and results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on
non-biologic therapy for >3 months and candidates for/already
on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for
≥9 months). During a routine visit, dermatologists completed a
questionnaire about the patient, patients completed a separate
questionnaire at home. These interim analyses are qualitative.
Physician valuation of attributes depended on the agent biologic-experienced patients were taking, with those prescribing infliximab (n=16) most valuing efficacy, those prescribing etanercept (n=44) most valuing safety, those prescribing adalimumab
(n=37) most valuing side effect profile, and those prescribing
ustekinumab (n=61) highly valuing all three factors.
Conclusion: Interim data suggest physicians and psoriasis
patients generally agree on important treatment attributes.
Physicians do not always accurately predict these attributes’
relative importance to patients: long term efficacy is valued
by patients, but is not considered as strongly by physicians.
The physician misconception that patients in the non-biologic
group most value safety may suggest a barrier to initiating
these patients on a biologic.
Learning Objective: Compare patient and dermatologist
valuations of psoriasis treatment attributes
Takeaway Message: Dermatologists and their patients
generally agree on important treatment attributes. However,
results suggest a common misconception among dermatologists that patients on a non-biologic most value safety, when
these patients indicated they valued efficacy as most important.
Treatment attributes most important to biologic-experienced
patients (n=66): efficacy, long-term efficacy, and safety and physician/pharmacist recommendation (tied). Efficacy was the attribute these patients were most satisfied with in their current
therapy, followed by side effects, and safety (average overall
satisfaction rating: 4.33/5). Ustekinumab patients were satisfied with efficacy and side effects, adalimumab and etanercept
patients identified cost, and infliximab patients identified longterm efficacy and frequency of administration. Patients newly
prescribed/initiated on a biologic (n=35) most valued efficacy,
physician/pharmacist recommendation and long-term efficacy/
side effects (tied). Attributes they were most satisfied with:
efficacy, side effects, and safety (average overall satisfaction rating: 3.73/5). Non-biologic patients (n=86) most valued efficacy,
long-term efficacy, and physician/pharmacist recommendation.
Attributes they were most satisfied with: efficacy, long-term
efficacy, and safety (average overall satisfaction rating: 3.71/5).
Conclusion: Most patients across all groups valued efficacy
and indicated they were most satisfied with this attribute
in their current therapy. The low overall satisfaction of the
newly prescribed/initiated biologic and non-biologic groups
suggests room for improvement in their psoriasis treatment.
Satisfaction with treatment attributes was dependent on the
biologic prescribed; ustekinumab provided the highest rate of
efficacy satisfaction. Long-term efficacy was valued by biologicexperienced and newly prescribed/initiated patients, but not
identified as an attribute they were most satisfied with in their
current therapy.
A30
CDA Abstracts
Learning Objective: Assess whether psoriasis treatment
attributes most valued by patients also provide the greatest
satisfaction in their current therapy
Discussion: This is the first report that we are aware of
describing eczema in the context of CVID in an adult. The
underlying mechanism of both diseases is relatively unknown
but involves a complex interplay between the barrier function
of the skin and the immune system in eczema. Disregulation
of the humoral immune system, depending on the mechanism,
can have pro-inflammatory consequences and in a susceptible
patient perhaps contribute to impaired barrier function of the
skin and thus drive atopic dermatitis
Takeaway Message: Most psoriasis patients across all
types of treatment highly value efficacy in a treatment and
indicated they were most satisfied with this attribute in their
current therapy. Satisfaction with treatment attributes was
dependent on the biologic prescribed; ustekinumab provided
the highest rate of efficacy satisfaction
P2.17
Learning Objective: Call the attention for the possibility
of Atopic Dermatitis in a CVID patients
Takeaway Message: It is possible that this association has
not been described because the difficult of establishing the
diagnosis at CVID.
A 61-year-old male with a history of
common variable immunodeficiency and
atopic dermatitis
Tim Olynych; Heather Bocz; Judah A. Denburg; Hermenio C.
Lima
P2.18
McMaster University, Hamilton, ON
Introduction: Atopic Dermatitis is a clinical diagnosis
characterized by: pruritis, xerosis, eczematous changes, with a
chronic fluctuating course. Here we present a case of atopic
dermatitis in a 61-year-old man with common variable immunodeficiency (CVID). Eczematous rashes are associated with
primary immunodeficiencies such as SCID, Omenn syndrome,
IPEX, Wiskott-Aldrich Syndrome, hyper-IgE syndrome, but
there is little reported with CVID. Our patient had late onset
atopic dermatitis and his lesions were advanced and difficult to
treat.
Case Description: A 61-year-old white male with a history
of CVID presented with a pruritic, erythematous, maculopapular rash on his face, neck, shoulders, chest, groin, and flexor
surfaces of his limbs. This rash had been variably present for
3 years, and was exacerbated by heat, stress, and perspiration;
however, recently it had become progressively more advanced.
Review of systems was negative. He reported no childhood
history of allergic rhinitis, asthma, or eczema, but had a possible seafood allergy. Family history was noncontributory. On
examination, the rash was highly lichenified, with scattered
vesicles that wept clear fluid. Bloodwork revealed lymphopenia
(0.8x10^9/L with CD4 of 180 (23%), CD4/CD8 ratio of 0.4),
mild eosinophilia (0.5x10^9/L), IgA 0.64, IgG 4.36, IgM 0.91,
and negative ANA/inflammatory markers. A biopsy 3 years ago
suggested nummular eczema or contact atopic dermatitis. A
repeat ruled out other possible diagnoses.
His itch was refractory to antihistamines and topical steroids
but responsive to prednisone. His is currently being treated
with clobetasol 0.5% and doxepine 10mg. He has not restarted
IVIG.
Differences in psoriasis patient and
dermatologist perception of treatment
discussion and decision making
Wayne P. Gulliver1 Yves Poulin2 Vincent Ho3 Kim Papp1, 6, 4 Neil
H. Shear5
1. Memorial University, St. John’s, NL; 2. Laval University, Quebec City, QC;
3. University of British Columbia,Vancouver, BC; 4. Probity Medical Research Inc.,
Waterloo, ON; 5. University of Toronto,Toronto, ON; 6. K. Papp Clinical Research
Inc.,Waterloo, ON
Introduction: This observational study investigated treatment decision-making processes in psoriasis.
Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10
on non-biologic therapy for >3 months and candidates for/
already on systemic therapy; 10 newly prescribed or initiated
on biologic therapy; 10 biologic-experienced (taken ≥1 biologic
for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed
a questionnaire at home. These interim analyses are qualitative. Biologic-experienced patients (n=66) and their physicians
(n=167) differed in perceptions of how current treatment
was decided: 64% of patients said the physician and patient
discussed options and decided together (vs 43% of physicians).
42% of physicians said they discussed options with the patient
then decided themselves (vs 26% of patients). Among newly
prescribed/initiated patients (n=35), 49% said they made the
decision with their physician (vs 32% of physicians [n=68]);
49% of physicians said they made the choice themselves (vs
29% of patients). In non-biologic patients (n=53) and their physicians (n=119) 47% of patients and 42% of physicians claimed
a joint decision, and 28% of patients and 42% of physicians said
A31
CDA Abstracts
after discussion, the patient chose. Average number of visits
to select therapy was 3.31 (n=61) in the newly initiated/prescribed group, and 2.47 in biologic experienced (n=114) and
non-biologic (n=96) patients.
tive. Interim results showed at baseline, biologic-experienced
patients (n=66) were more satisfied with current therapy than
non-biologic patients (n=48), or newly prescribed/initiated
patients (n=35), (mean scores 4.33 vs. 3.73 vs. 3.71 out of 5,
where 5 = extremely satisfied). More non-biologic patients
(42%) and newly prescribed/initiated patients (48%) agreed
with the statement “There is still a lot of room for further
improvement when it comes to my psoriasis” than biologicexperienced patients (12%). Biologic-experienced patients
taking ustekinumab (n=26) were more satisfied than those
taking etanercept (n=15), adalimumab (n=13) or infliximab
(n=8) (mean satisfaction scores 4.58, 4.20, 4.38 and 3.75, respectively); their physicians’ responses were similar (4.62, 4.43,
4.38 and 4.06, respectively). After three months, mean satisfaction rose to 4.30 among newly prescribed/initiated patients
(n=33), and remained comparatively stable among biologicexperienced patients (4.23; n=26) and non-biologic patients
(3.5; n=28).
Conclusion: Patients prescribed biologics believed they
played a greater role in treatment decisions than did their
physicians. This was reversed in patients taking non-biologic
agents, suggesting patients on biologics feel more engaged
in decision-making. The increased number of visits to select
therapy for newly prescribed/initiated patients compared to
patients switching within treatment groups suggests transitioning to a biologic can be an involved process. A biologic
discussion early in a patient’s treatment course may help with
a successful and appropriately timed transition to a biologic.
Learning Objective: Compare perceptions of the treatment decision making process in psoriasis between dermatologists and their patients
Takeaway Message: Patients prescribed a biologic felt
engaged in decision-making and they believed they played a
greater role in the treatment decision than did their physicians
and patients taking non-biologic agents or newly prescribed/
initiated on a biologic. As the process of decision making takes
longer when initiating a biologic, it is important to begin discussions early in a patient’s treatment.
P2.19
Satisfaction with psoriasis treatment
experience in biologic-experienced, naïve or
newly initiated patients
Conclusion: Biologic-experienced patients and newly prescribed/initiated patients at three month follow-up showed
the highest satisfaction levels among treatment groups. This
suggests after at least three months of treatment, patients find
biologic therapy is a highly satisfying treatment experience.
Sustained satisfaction ratings in the biologic experienced group
at baseline and three months suggests longitudinal satisfaction with the biologic treatment experience. Among biologics,
ustekinumab provided the most satisfying treatment experience.
Learning Objective: Compare psoriasis patient satisfaction among biologic-experienced, naive, and newly initiated
patients over time
Yves Poulin1 Vincent Ho2 Kim Papp3, 4, 5 Neil H. Shear6 Wayne P.
Gulliver3
Takeaway Message: Among treatment groups (biologicexperienced, naive, and newly initiated), patients on a biologic for at least 3 months reported the highest satisfaction
with their treatment experience. Of the biologic examined,
ustekinumab provided the most satisfying treatment experience for patients.
1. Laval University, Quebec City, QC; 2. University of British Columbia,Vancouver,
BC; 3. Memorial University, St. John’s, NL; 4. K. Papp Clinical Research Inc.,
Waterloo, ON; 5. Probity Medical Research Inc.,Waterloo, ON; 6. University of
Toronto,Toronto, ON
Introduction: This observational study compared satisfaction among treatment groups at baseline and after three
months to capture satisfaction through different treatment
experiences.
Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10
on non-biologic therapy for >3 months and candidates for/
already on systemic therapy; 10 newly prescribed or initiated
on biologic therapy; 10 biologic-experienced (taken ≥1 biologic
for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed
a questionnaire at home. These interim analyses are qualitaA32
CDA Abstracts
P2.20
Assessment of dermatologist satisfaction
when considering a treatment change in
psoriasis patients
Takeaway Message: Dermatologists planning to switch
biologic therapy perceive their patient satisfaction to be lower
than in patients in which a dose adjustment or addition of a
medication is being considered. Patients on etanercept and
ustekinumb showed the highest and lowest propensity to
change treatment, respectively.
Vincent Ho1 Kim Papp2, 4, 5 Neil H. Shear3 Wayne P. Gulliver2
Yves Poulin6
1. University of British Columbia,Vancouver, BC; 2. Memorial University, St.
John’s, NL; 3. University of Toronto,Toronto, ON; 4. K. Papp Clinical Research
Inc.,Waterloo, ON; 5. Probity Medical Research Inc.,Waterloo, ON; 6. Laval
University, Quebec City, QC
P3.01
Introduction: This observational study was designed to describe patient satisfaction with psoriasis treatment and identify
its drivers. Specifically, this study examined perceived satisfaction by physicians in patients on a biologic whose physicians
are considering treatment changes.
Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10
on non-biologic therapy for >3 months and candidates for/
already on systemic therapy; 10 newly prescribed or initiated
on biologic therapy; 10 biologic-experienced (taken ≥1 biologic
for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed a
questionnaire at home. These interim analyses are qualitative.
Interim results show physician rate of considering treatment
change versus the current treatment of the biologic-experienced patient.
Current biologic
Patients for which
treatment change
considered, % (n)
% of patients who
switched medications
Etanercept
23 (44)
7
Adalimumab
22 (37)
5
Infliximab
19 (16)
6
Ustekinumab
13 (61)
0
Learning Objective: Assess drivers of treatment changes
in psoriasis patients on a biologic therapy
Leprosy: a case to recognize
Farheen Mussani1 Irene Lara-Corrales2
1. Division of Dermatology, University of Toronto,Toronto, ON; 2.The Hospital for
Sick Children,Toronto, ON
Introduction: Leprosy is a slowly progressive infectious
disease, caused by mycobacterium leprae, which can lead to
significant mutilation as well as irreversible morbidity. While
the primary organs affected are the skin and peripheral nervous system, leprosy can have a number of very distinct clinical
presentations. This disease is currently only endemic in tropical
and subtropical regions; however, given the diverse ethnic
background of the Canadian population, this disease should
not be forgotten in the Canadian context.
Methods and Results: We report a case of a 15-year-old
male from the Philippines who immigrated to Canada with
his family four years prior to his presentation to the Pediatric
Dermatology clinic at The Hospital for Sick Children. He had a
five-year history of a slowly progressive loss of sensation of his
face and arms and a flexion contracture of the right hand. One
year prior to his assessment, he started to develop a distinct
infiltrative papulo-nodular and plaque-like eruption on his face,
back, chest and arms. This was biopsy proven on presentation
to Dermatology as leprosy.
A literature review of leprosy diagnosis and treatment, especially in the North American context, was conducted.
Among physicians considering any change (n=32), 71% gave
these patients a moderate, severe or very severe score on
PGA. Physicians considering switching medications believed
their patients to be less satisfied with current treatment than
physicians considering dose adjustments or adding medications
(mean satisfaction scores: 2.8, 3.84, and 4.0, respectively).
Conclusions: While leprosy is not endemic in North America, given the diversity of the countries of origin of those in
Canada, especially in Toronto, in patients presenting with loss
of sensation with skin findings a diagnosis of leprosy should be
considered and ruled out.
Conclusions: Physicians planning to switch their biologicexperienced psoriasis patients to another medication perceive
those patients to be less satisfied than do physicians planning
to adjust doses or add medications. Ustekinumab patients appeared to have the lowest propensity to switch their biologic
treatment.
Learning Objective: The objective of this study was to
highlight a pediatric case of leprosy diagnosed recently at The
Hospital for Sick Children and review the literature on the
diagnosis and treatment of the disease.
A33
CDA Abstracts
Takeaway Message:
1. Leprosy should be suspected in anyone with loss of sensation and skin findings.
2. Multibacillary therapy remains the mainstay of treatment of
leprosy.
3. The emergence of drug resistance poses a threat to leprosy control programs.
P3.02
Combination cryotherapy and intralesional
amphotericin B for chromoblastomycosis: a
case report and review of the literature
ery(11). Intralesional antifungal administration may enhance
drug delivery, and cryotherapy provides tissue necrosis and
enhanced penetration. Our case suggests this combination is a
potential alternative, especially if barriers or contraindications
exist to systemic agents.
Learning Objective: To present a case of Chromoblastomycosis, review treatment challenges, and introduce a potential
therapeutic alternative.
Takeaway Message: Cryotherapy combined with intralesional amphotericin is a potential alternative for the treatment
of Chromoblastomycosis in patients who are not candidates
for systemic therapies.
Cathryn Sibbald; Afsaneh Alavi; R Gary Sibbald; Jay S. Keystone
P3.03
University of Toronto,Toronto, ON
Chronic larva currens following tourist travel
to the Gambia more than 20 years ago
Background: Chromoblastomycosis is a deep fungal infection resulting from penetration of fungi into the skin, usually
after trauma. It is more common in tropical and subtropical
countries with isolated organisms including Fonsecaea pedrosoi, Phialophora. verrucosa, Cladosporium carrioni, and Rhinocladiella aquaspersa. Therapy is challenging, requiring long-term
systemic treatment(1). For resistant cases, systemic antifungals
have been combined with cryotherapy (2-5). Despite reports
of intralesional amphotericin monotherapy (6-10), there is
limited evidence on combination therapy of cryotherapy with
intralesional antifungals.
Kristy Bailey1 Alexis Danylo2 Andrea Boggild1
1. University of Toronto,Toronto, ON; 2. University of Laval, Laval, QC
Background: We present a case of chronic larvae currens
following tourist travel more than 20 years ago
Conclusion: This case highlights several important features of larvae currens and strongyloidiasis including the long
incubation period, the cutaneous findings, and the possibility
of unmasking an autoimmune disease with increased strongyloides burden. Strongyloidiasis is a life-long infection unless
treated. A high index of suspicion is needed to prevent chronic
symptoms being worked up by expensive tests and referrals
and to prevent fatal dissemination.
Case: A 32 yr old female presented with a 6-year history
of verrucous lesions on her knee and lower leg following an
injury she sustained in St Lucia. After 6 months of systemic
itraconazole at 200mg daily, there was no improvement. A biopsy confirmed Fonsecaea pedrosoi, sensitive to itraconazole.
Despite an increase in the dose of itraconazole to 400mg
daily for 5 months followed by 4 months of combination with
terbinafine, the lesions progressed.
Given cost constraints of alternative systemic therapies, treatment with weekly cryotherapy and biweekly intralesional amphotericin was trialed, with good rapid clinical response. By 10
weeks, the lesions had significantly improved, and by 6 months,
only residual post inflammatory hyper and hypopigmentation
associated with discrete small plaques of resolving fungal infection remained (images available).
Learning Objective: Several important features of larvae
currens and strongyloidiasis are discussed as it relates to the
case including the long incubation period, the cutaneous findings, and the possibility of unmasking an autoimmune disease
with increased strongyloides burden.
Takeaway Message: A high index of suspicion is needed
to prevent chronic symptoms being worked up by expensive
tests and referrals and to prevent fatal dissemination.
Discussion and Conclusion: Both itraconazole and
terbinafine are considered first line agents for Fonsacaea
Pedrosi, their primary differences being mechanistic (itraconazole is fungistatic whereas terbinafine is fungicidal). Failure of
response to systemic treatment in this case despite in vitro
sensitivity to itraconzole may have been related to the fibrotic
nature of our patient’s lesions that led to limited drug delivA34
CDA Abstracts
P3.04
A novel method for confirming the diagnosis
of cutaneous deep fungal and atypical
mycobacterial infections
Mohammad Pannu; Shane Silver; Rochelle Van De Velde; Tarek
Afifi
University of Manitoba,Winnipeg, MB
Confirming the diagnosis of cutaneous deep fungal and atypical
mycobacterial infections can be problematic. A positive culture
is the diagnostic gold standard. Unfortunately, false negative culture results are common and present a roadblock to
initiating appropriate treatment.1 Although a diagnosis may be
clinically suspected, treatment durations are lengthy and drug
resistance and toxicities are a concern with inappropriate use.
Therefore, initiating treatment without diagnostic confirmation
is not recommended. We present two patients that demonstrate a novel method for enhancing the diagnostic yield of
tissue culture in cutaneous deep fungal and atypical mycobacterial infections.
The first patient, a 48-year-old male, presented with a nonhealing ulcer on the right lateral ankle. A diagnosis of blastomycosis was suspected clinically. Histology showed a yeast-like
organism suggestive of blastomycosis. Multiple cultures failed
to grow blastomycosis. The patient was evaluated by infectious
disease, who felt infection had been adequately ruled out. The
patient was seen by a colleague, who treated him with clobetasol cream and intralesional steroids. The patient returned
to clinic for reassessment. Post steroids, a positive culture was
obtained and the patient responded to antimicrobial therapy.
The second patient, a 63-year-old male, presented with a
1-year history of a vegetative plaque on his left hand. Two
biopsies from the referring doctor revealed suppurated
granulomatous inflammation, suspicious for infection. Stains for
organisms were negative. Two subsequent biopsies for tissue
culture were negative. Given the serendipitous experience
with the first patient, 10 days of clobetasol cream was applied
to the lesion under occlusion. M.marinum was then successfully cultured. Appropriated antimicrobial therapy was curative.
Although both diagnoses mentioned were strongly suspected
clinically, repeated cultures were negative. Topical clobetasol
application, presumably allowing increased organism load due
to local immune suppression, increased the sensitivity of culture. Both patients were then treated successfully.
Learning Objective: After reading the presented cases, the
reader should better appreciate the difficulty in confirming the
diagnosis of cutaneous deep fungal and atypical mycobacterial
infections. It should be understood that a diagnosis should be
confirmed prior to treatment initiation. Finally, local immune
suppression, obtained by application of clobetasol under occlusion, may be a useful method of converting a false negative
culture into a true positive culture.
Takeaway Message: When a cutaneous deep fungal or
atypical mycobacterial infection is strongly suspected, negative
culture results cannot be considered definitive. The application of a potent topical steroid may increase the likelihood
of obtaining a positive culture, thus allowing for appropriate
diagnosis and treatment.
P3.05
Dermatologic conditions in the returning
Canadian traveller: surveillance report from
CanTravNet surveillance data, 2009- 2012
Michael S. Stevens1 Jennifer Geduld2 Michael Libman3 Brian
Ward3 Anne McCarthy8 Jean Vincelette10 Wayne Ghesquiere11
Jan Hajek7 Susan Kuhn9 Kevin C. Kain6, 4 Andrea K. Boggild4, 5
1. University of Toronto Dermatology Residency Program,Toronto, ON; 2.Travel
and Migration Health Division, Infectious Disease Prevention and Control
Branch, Public Health Agency of Canada, Ottawa, ON; 3. Division of Infectious
Diseases, Department of Microbiology, and JD Maclean Centre for Tropical
Diseases, McGill University Health Centre, Montreal, QC; 4.Tropical Disease
Unit, Division of Infectious Diseases, Department of Medicine, University
Health Network and the University of Toronto,Toronto, ON; 5. Public Health
Ontario Laboratories, Public Health Ontario,Toronto, ON; 6. SAR laboratories,
Sandra Rotman Centre for Global Health,Toronto, ON; 7. Division of Infectious
Diseases, Department of Medicine, University of British Columbia,Vancouver,
BC; 8.Tropical Medicine and International Health Clinic, Division of Infectious
Diseases, Ottawa Hospital and the University of Ottawa, Ottawa, ON; 9. Section
of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine,
Alberta Children’s Hospital and the University of Calgary, Calgary, AB;
10. Hôpital Saint-Luc du Centre hospitalier de l’Université de Montréal
(CHUM), Montreal, QC; 11. Infectious Diseases,Vancouver Island Health
Authority, Department of Medicine, University of British Columbia,Victoria, BC
Introduction: Canadians are increasingly travelling to tropical and developing countries. Travel acquired dermatological
conditions have been reported to be among the leading causes
of medical problems in travellers. However, a multi-centre
analysis of the spectrum of dermatologic conditions acquired
by a broad range of Canadian travellers has been lacking. The
purpose of this paper was two fold: (1) to provide a comprehensive, Canada specific surveillance summary of travel related
dermatologic conditions in a cohort of returned Canadian
travellers and immigrants, and (2) to provide a summary of the
appropriate confirmatory diagnostic testing for the most common tropical dermatological diseases.
Methods and Results: Data on Canadian travellers
returning with a primary dermatologic diagnosis presenting to
A35
CDA Abstracts
a CanTravNet Surveillance Network site between September
of 2009 and September of 2012 were extracted and analyzed.
During the study period, 6639 patients presented to CanTravNet sites across Canada; Just over 16% or 1076 patients,
were diagnosed with an ascertainable travel related primary
dermatological diagnosis. The majority of individuals seen during this surveillance period were travelling for the purpose of
tourism (N=754, 70.1%). Arthropod bites (N=162, 21.5%), rash
(N=141, 18.7%), cutaneous larva migrans (N=98, 12.2%), and
skin and soft tissue infection (N=92, 12.2%) were the most
common dermatologic diagnoses issued to returning Canadian
tourists. The top dermatologic diagnoses varied based on the
reason for travel. In immigrants, the most frequent dermatologic diagnoses were leprosy (N=15, 24%), rash (N=13, 20.6%),
pruritis of unknown origin (N=7, 11.1%) and cutaneous leishmaniasis (N=6, 9.5%).
Conclusions: This analysis of surveillance data has detailed
the spectrum of travel related dermatological conditions
presenting to CanTravNet sites across Canada and provides an
epidemiological framework for Canadian physicians encountering these patients. In addition, we have summarized the
confirmatory diagnostic testing for the most common tropical
dermatological diseases in returning Canadian travellers.
Learning Objective: At the end of this activity the participant will be more aware of the spectrum of primary dermatological conditions seen in the returning Canadian traveller
and will be more familiar with the appropriate confirmatory
diagnostic testing.
Takeaway Message: It is important to be familiar with the
most common primary dermatological conditions in returning Canadian travellers and how to effectively diagnose these
dermatoses, in order to prevent misdiagnosis or a delay in the
diagnosis of these patients.
the form of heat. Fungicidal effects are experienced at temperatures above 55°C with a pulsed release of photons for
more than 10 minutes. The 300 microsecond 1064nm pulsed
Nd:YAG Laser offers a promising way to target onychomycosis.
Methods: We examined the results of a series of 6 patients
with onychomycoisis treated with the 300 microsecond
1064nm pulsed Nd:YAG laser. Most of these patients were
previously treated with various topical and oral anti-fungal
agents over a prolonged period of time with minimal improvement.
Results: Upon follow-up, there were partial to complete
clearing of the nail plates. Patients experienced minimal
adverse effects and tissue necrosis did not occur in any of
the treatments. In the market, there are many lasers that have
been granted FDA approval for the treatment of onychomycosis. These lasers include: PinPointe™ FootLaser™ (PinPointe
USA, Inc.), Cutera GenesisPlus™ (Cutera, Inc.), Q-Clear™
(Light Age, Inc.), CoolTouch VARIA™ (CoolTouch, Inc.), and
JOULE ClearSense™ (Sciton, Inc.). However, a comparison of
the relative efficacy of these aforementioned lasers and the
duration of treatment still remains to be investigated.
Conclusion: The 300 microsecond 1064nm pulsed Nd:YAG
laser can be a helpful modality in the treatment of onychomycosis given the treatment options are limited and may be
an additional option in the treatment for onychomychosis
especially when patient cannot tolerate or respond to oral
antifungals due to underlying medical conditions.
Learning Objective: To educate the benefits of using the
300 microsecond 1064nm pulsed Nd:YAG laser treatments for
onychomycosis.
Takeaway Message: The 300 microsecond 1064nm pulsed
Nd:YAG laser can be an effective treatment modality of resistant onychomycosis.
P3.06
A case series of successful treatment of
onychomycosis using a 1064nm pulsed
Nd:YAG Laser
Joseph Doumit1 Jeewanjit Gill2 Alexandra Zhang1
1. Cleveland Clinic, Cleveland, OH, USA; 2. University of Ottawa, Ottawa, ON
Background: Onychomycosis can be quite resistant to oral
and topical treatments. Lasers offer another route of treatment and use the principle of photothermolysis to eradicate
the causative organisms. This technology exploits the differences in laser energy absorption and thermal conductivity
between the fungal infection and surrounding tissue. When
the photons are absorbed by mycelia, they release energy in
P3.07
Secondary syphilis
Andrew A. Simone
Private Practice,Toronto, ON
Patients initials: G.B. Age: 45 Gender: Male
Body region: Perineal Skin
History:
45 year old male “BUMPS OF SKIN” in PERINEUM, not itchy
or painful
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CDA Abstracts
• patient “surfed the net”, closest thing that he could find was
“PRURITIC PAPULES OF PREGNANCY”, but he commented “I am not pregnant!”
• girlfriend ‘LULU’ suggested to “use TEA TREE OIL”
• girlfriend ‘SUGAR’ suggested “ACCUPUNCTURE”
o although her mother said “REFLEXOLOGY” is the
answer and added “Don’t go to a dermatologist – they
don’t know nothing”
• girlfriend ‘HONEY’ told him “Your best bet is a NATUROPATH” and “try NOXZEMA”
• his neighbor ‘BORIS’ thought it could be “POISON IVY that
is not itchy”, he told the patient “I got me a good SALVE
from Europe. (HEIL-U WUNDJALBE) I use it for everything.”
• Medical student in our office said “PORPHYRIA CUTANEA
TARDA INVERSUS” (upside down Porphyria)
o the patient denied sun exposure in this area
• Infectious Disease Residents said “STAPH AUREUS PYODERMA”
Physical Examination
• 20 round or oval mushroom like papules and plaques
• lesion NON TENDER but MALODOROUS
• SKIN BIOPSY: inflammatory infiltrate – lymphocytes and
PLASMA CELLS
• Blood for HIV – negative
• Blood for SYPHILIS – POSITIVE – EARLY SYHILIS
o SYPHILIS RPR Quantitation Reactive 1:32
Dx: CONDYLOMA LATA of SECONDARY SYPHILIS
Learning Objective: How to identify syphilis in later
stages.
Takeaway Message:
1. Many patients do not remember a primary chancre – “no
pain”
2. Secondary syphilis- 50% Condylomata lata, 50% maculopapular eruption
3. Pustular syphilis HIV+ patients
4. Cases of congenital syphilis were presented at the pediatric update in 2007 by Perla Langsang MD
5. Since 1998 a 10 fold increase in syphilis
6. 90% of 508 cases in Toronto in 2009 affected men. 60%
were HIV+
7. 2012- 3 cases of NEUROSYPHILIS (CMAJ, April 2, 2013).
This means that 10 and 20 syphilis’ were not diagnosed.
8. Syphilis is the great IMPOSTER. Do blood tests for syphilis
& HIV.
9. If individuals engage in “risky” exposures, suggest blood
test.
10.Patient was presented who had diffuse eruption of Necrotic papules and nodules. DX. Syphilis (JAMA Dermatology Dec. 2013)
11.Dr. William Osler “If you see a tattoo do a blood test for
syphilis”
12.World Wide epidemic of syphilis. Eg. Syphilis was eliminated in China, now it is increasing.
13.Increase in sexually transmitted infections (STIs) in older
people – the “BLUE PILL” (Rivers, Jason Jan/Feb 2014)
Rx: BENZATHINE PENICILLIN G 2.4 million U IM x 2
P3.08
Course:
• Next two days very sick, lack of appetite, weak could not go
to work (Jarisch–Herxheimer reaction)
• 7 days post Rx, pt. commented “I feel good and all my spots
are going away”
A case of primary cutaneous blastomycosis
on the nasal tip
Jane Wu; Trevor Champagne; Renita Ahluwalia
Division of Dermatology, Department of Medicine, University of Toronto,Toronto,
ON
Background: Blastomycosis is a fungal infection endemic to
North America, caused by the dimorphic fungus Blastomyces
dermatitidis. The disease is usually contracted by inhalation of
the organism, which is most commonly found in soil, leading to
pulmonary infection and secondary cutaneous dissemination.
Primary cutaneous blastomycosis from direct inoculation of
the skin is an uncommon presentation. In Ontario, the disease
has been primarily described to affect northern regions, with
isolated case reports in the southern areas. Clinically, blastomycosis presents as papulopustules and well-demarcated
A37
CDA Abstracts
verrucous or granulomatous plaques on the skin, often with
ulceration.
The patient had noted a 10-pound weight loss over the past
6 months. The remainder of the review of symptoms was
non-contributory. Previous treatments for the lesions included topical steroids and a course of oral antibiotics, neither
providing benefit. The patient’s past medical history included
diabetes and gastro-esophageal reflux disease. Her medications were metformin and omeprazole. On exam, there were
numerous pink and yellow-brown papules and nodules on the
patient’s cheeks, ears, and eyebrows. Many papules were confluent and coalesced into plaques, giving the patient a Leoninefacies appearance.
Objective: We report a case of a healthy man from Lake
Simcoe, Ontario, presenting with primary cutaneous blastomycosis involving the nasal tip.
Methods: This 76-year-old man presented with a six-month
history of verrucous papules and pustules on the nose, a
thirty-pound weight loss, and progressive shortness of breath
on exertion. The skin lesions initially started as a small pustule,
which then became crusted and was associated with intermittent bleeding. For several months prior to his visit, he
was treated with topical and oral antibiotics as phymatous
rosacea with no improvement. A biopsy done showed a deep
fungal infection suspicious for blastomycosis, which was later
confirmed by serology. The patient was seen by the Infectious
Diseases service and additional investigations showed no evidence of pulmonary or systemic involvement. He was started
on itraconazole with excellent response and rapid resolution
of both the cutaneous and systemic manifestations.
Investigations: Skin biopsy showed a non-langerhans cell
histiocytosis, undetermined type. Bloodwork showed a microcytic anemia, elevated ESR, elevated triglycerides, normal liver
and renal function. Chest x-ray was unremarkable.
Favoured diagnosis: Non-langerhan’s histiocytosis: Eruptive xanthogranulomas vs. progressive nodular histiocytosis.
Discussion: Histiocytoses are a diverse group of proliferative disorders with a common CD34-positive progenitor cell
in the bone marrow. They can be grouped into langerhans and
non langerhans cell varieties based on the type of histiocyte
causing the disease. These disorders are rare but important
to recognize as they can involve multiple organs and can be
associated with underlying hematologic malignancy.
Conclusion: This case provides evidence that blastomycosis may be endemic to Southern Ontario and that clinicians
should have a high index of suspicion for this infection when
presented with non-resolving granulomatous or verrucous lesions. Prompt treatment with a systemic antifungal agent, such
as itraconazole, is important in the management of blastomycosis.
Learning Objective:
Learning Objective: To present a case of primary cutaneous blastomycosis in Southern Ontario and to review the clinical features of blastomycosis as well as the treatment options.
Takeaway Message: Clinicians should have a high index of
suspicion when presented with non-resolving granulomatous
or verrucous lesions and consider blastomycosis in the differential diagnosis. A thorough workup and prompt treatment
with a systemic antifungal agent is important in the management of blastomycosis.
1. To describe an unusual case of non-langerhans cell histiocytosis.
2. To review approach to histiocytoses as well as their associated systemic features.
3. To review the appropriate work-up and management for a
patient in whom a diagnosis of non langerhans cell histiocytosis is being considered.
Takeaway Message: Histiocytoses are rare skin conditions that dermatologists should be aware of given their association with underlying malignancy and systemic disease.
P3.09
An unusual case of non-langerhans cell
histiocytosis
Anna C. Chaplin;Yvette Miller-Monthrope
University of Toronto Division of Dermatology, Department of Medicine,Toronto,
ON
A 53-year-old woman presented to our dermatology clinic
with a 6-month history of eruptive pink and yellow-brown
papules and nodules that initially involved the face, but progressed to involve the cheeks, ears, and eyebrows as well. The
lesions were slightly pruritic, but otherwise asymptomatic.
P4.01
Drug-induced AGEP: a case series and review
of patch-testing guidelines
Ashley C. O’Toole; Melanie Pratt; Jennifer Beecker; Julie Lacroix
University of Ottawa, Ottawa, ON
PGY2 Dermatology Resident
Background: Acute generalized exanthematous pustulosis
(AGEP) is a significant adverse cutaneous reaction most often
induced by drugs and also by acute infections.
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CDA Abstracts
Clinically, this eruption was most consistent with a chemotherapy-induced lupus-like reaction.
Objective: We present a case series of AGEP caused by two
commonly used medications, topical Benzocaine and oral Hydroxyzine, in two patients who went on to have positive patch
test results to their respective drug.
Methods: We completed a review of the literature for similar cases using PubMed and Medline, as well as a review of the
current Consensus Guidelines in Contact Dermatitis.
Results: There are no previously reported cases of AGEP
secondary to Benzocaine use. AGEP caused by Hydroxyzine is
also extremely rare – having been reported in the literature
on only two other occasions.
Conclusion: The relationship between each drug, Hydroxyzine and Benzocaine, and the development of AGEP is established. The guidelines for patch testing in AGEP is defined.
Learning Objective: We wish to review the pathophysiology of Acute Generalized Exanthematous Pustulosis (AGEP)
and discuss the role of patch testing in drug eruptions.
Takeaway Message: The relationship between each drug,
Hydroxyzine and Benzocaine, and the development of AGEP is
established. The guidelines for patch testing in AGEP is defined.
P4.02
Gemcitabine-induced subacute cutaneous
lupus erythematosus-like eruption
responding to insulin therapy in a patient
with pancreatic cancer
Lauren Lam; Duane Barber; Susan Poelman
University of Calgary, Calgary, AB
A 73 year old woman underwent pancreaticoduodenectomy
for Stage IIB pancreatic adenocarcinoma. Gemcitabine was
initiated due to regional lymph node metastasis. No other new
medications were initiated.
Five months later, she developed an erythematous, pruritic
patch on her left upper chest and nailfold erythema.
Within the next 4 months, similar patches developed on her
scalp, back, mons pubis, right forearm, and bilaterally on the
hands and anterior tibial surfaces. Gemcitabine was discontinued one month later.
Histopathology was consistent with sub-acute cutaneous lupus
erythematosus (SCLE), although a non-specific drug eruption
could not be ruled out.
The pathogenesis of chemotherapy-induced SCLE is unknown.
Other reports suggest antigens are targeted towards nucleosomes released during chemotherapy-induced apoptosis.
Trunk, limb, scalp and pubic lesions resolved 7 months after
initial presentation with topical corticosteroid therapy. Eight
months after the initial eruption, she started insulin due to
pancreatic insufficiency secondary to pancreaticoduodenectomy. Within days, the chest lesion resolved. However, hand and
nailfold lesions persisted.
Autoimmune serology revealed negative ANA, anti-Ro, La, Sm,
histone and Scl-70 antibodies.
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CDA Abstracts
Table 1. Characteristics of Reported Cases vs. This Case
Reported Cases*
This Case
Doxorubin with cyclophosphamide, capecitabine, docetaxel,
fluorouracil, paclitaxel,
tamoxifen, gemcitabine
Gemcitabine
Eruption
Morphology
Erythematous, scaly, nonscarring, often annular plaques
on the neck, upper trunk, back,
arms, and dorsal hands
Erythematous, pruritic patch
on her left upper chest, scalp,
back, mons pubis, right
forearm, and bilaterally on
the hands and anterior tibial
surfaces
Duration of Eruption
Days to 6 months
7-8 months
Offending Agent(s)
P4.03
Shiitake mushroom-induced flagellate
dermatitis
Jill Greenspoon1 Tom Szakacs2
Symptom Resolution 2 weeks to 6 months after
withdrawing offending agent
7-8 months, however hand
and nailfold lesions still persist
Therapy Inducing
Resolution
Spontaneous, Topical Corticosteroid
Topical Corticosteroid, Insulin
Autoimmune
Serology
90% of cases Anti-Ro positive
Negative ANA, anti-Ro, La, Sm,
histone and Scl-70 antibodies
Hypothesized
Pathogenesis
Inflammatory infiltrate
Insulin may protect against
gemcitabine-induced apoptosis in human keratinocytes
1. Division of Dermatology, University of Toronto,Toronto, ON; 2. Infectious
Diseases, Brant Community Healthcare System, Brantford, ON
Background: Few case reports have discussed a relationship
between a flagellate dermatitic rash and the ingestion of raw
or cooked shiitake mushrooms. It is most commonly reported
in patients from eastern Asia; however there have been recent
reports in both Europe and North America. The pathogenesis
is largely unknown; however it is speculated to be a toxinmediated phenomenon as opposed to an allergic reaction.
Shiitake mushroom dermatitis is often treated symptomatically,
as its course is benign and the rash typically resolves on its
own within a few weeks.
*Wiznia LE, Subtil A, Choi JN. Subacute Cutaneous Lupus Eyrthematosus Induced by
Chemotherapy. JAMA Dermatol. 2013;149(9):1071-5.
Learning Objective: This case demonstrates the necessity for dermatologists to have an index of suspicion for SCLE
in chemotherapy patients with eruptions, even with negative
autoimmune serology.
Takeaway Message:
• Numerous cases of chemotherapy-induced Subacute Cutaneous Lupus Erythematosus have been reported to respond
either spontaneously or with topical steroid therapy.
• This patient’s time course, morphology, distribution and
histology resemble other reported cases. However, this
case was unique in that it responded to insulin therapy, and
autoimmune serology was negative.
• This case suggests that insulin may protect against gemcitabine-induced apoptosis in human keratinocytes and
may be an area worth further investigation. In experimental
models, insulin upregulates anti-apoptosis pathways.
Methods and Results: A 44 year old previously healthy
male chef presented with a 7-day history of an intensely
pruritic non-resolving rash on his trunk. He noted a history of
eating a rehydrated shiitake mushroom the evening prior to
eruption of the rash. On examination, he had well-demarcated
erythematous linear grouped papules in a flagellated pattern
most severely on his back, as well as affecting his abdomen,
forearms and upper thighs. He denied any systemic symptoms.
No biopsies were obtained, as a clinical diagnosis was clear.
The patient was treated with prednisone 50mg for a total
of five days. Follow up after completion of prednisone and
avoidance of shiitake mushrooms showed significant improvement in redness and amount of pruritus. No new lesions had
appeared.
Conclusions: We present a typical presentation of flagellate
dermatitis secondary to shiitake mushroom ingestion.
Learning Objective: To become familiar with a rare toxininduced benign skin reaction
Takeaway Message:
1. Shiitake dermatitis is a rare toxidermic reaction with a
unique, recognizable clinical appearance
2. This case describes the typical eruption and clinical course
of the reaction.
3. Although the association between shiitake mushrooms and
cutaneous eruptions is very uncommon, dermatologists
should be aware of this relationship.
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CDA Abstracts
P4.04
Cutaneous adverse events during
vemurafenib therapy
P4.05
Shivani F. Chandrakumar1 Jensen Yeung2, 3, 4
Pustular psoriasis complicated with acute
generalized exanthematous pustulosis
simulating toxic epidermal necrolysis
1. Queen’s University, Kingston, ON; 2. University of Toronto,Toronto, ON;
3. Sunnybrook Hospital,Toronto, ON; 4.Women’s College Hospital,Toronto, ON
Mariam Abbas; Danielle Desjardins; Karen Holfeld; June Zimmer
Background: Vemurafenib, an oral agent that selectively
targets the BRAF V600E mutation, has recently emerged as the
mainstay of treatment in patients with BRAF-positive stage IV
melanoma. However, a spectrum of cutaneous adverse events
has been associated with this agent. The objective of this study
was to review clinical data regarding the frequency and severity of the common dermatologic side effects associated with
vemurafenib.
University of Alberta, Department of Dermatology and Cutaneous Sciences,
Edmonton, AB
Methods: The adverse event data from phase I, II, and III
randomized controlled trials of vemurafenib were reviewed
and summarized; case series and non-controlled studies evaluating the safety of vemurafenib therapy were used to further
characterize these events.
Conclusion: A spectrum of cutaneous adverse events which
range from non-malignant findings such as rash, alopecia,
and pruritus to malignant side effects, namely squamous cell
carcinoma (SCC), were observed in patients on vemurafenib
therapy. SCC is the most commonly reported Grade 3 adverse
event in clinical trials; however, SCCs and keratoacanthomas associated with vemurafenib therapy are easily treated
by simple excision of the lesion without discontinuation of
vemurafenib. Benign vemurafenib-induced side effects generally
tend not to be severe or life-threatening, with most patients
managed by dose interruptions, dose reductions, or topical
therapies. Thus, awareness of potential adverse events coupled
with routine dermatological assessment and timely management will allow for optimal therapeutic benefit in patients
receiving vemurafenib therapy.
Learning Objective: A review of dermatologic side effects
induced by vemurafenib therapy for malignant melanoma.
Takeaway Message: A large proportion of patients in
clinical trials experienced a high rate of cutaneous adverse
events while on vemurafenib therapy. However, these side
effects generally were not severe or life-threatening and were
managed with relative ease.
Introduction: Pustular psoriasis of the digits (acrodermatitis continua of Hallopeau) may be localized to one or
more digits for an extended period of time. Characteristically this presents with tender, diffusely eroded, and fissured
pustular plaques on one or more digits. Transition to other
forms of psoriasis and to generalized pustular psoriasis has
been reported. These patients have an increased risk of acute
generalized exanthematous pustulosis (AGEP) compared to
the general population. Pustular psoriasis is often considered
therapy resistant.
Methods/Results: We report the case of a 54-year-old
Caucasian woman who presented with a pustular psoriasis
flare complicated by AGEP. Treatment course included hospital admission, cyclosporine, acitretin, and discontinuation
of cephalexin. Her psoriasis is currently being managed with
ustekinumab successfully.
Conclusion: The precipitating factor in the course of treatment is thought to be cephalexin. When treating patients with
pustular psoriasis the occurrence of drug-induced complications should be carefully examined. Our case suggests that
avoidance of β-lactam antibiotics in these patients is warranted
unless absolutely indicated.
Learning Objective:
1) Avoidance of β-lactam antibiotics in a pustular psoriasis
flare is recommended to avoid drug induced complications
2) Management of pustular psoriasis remains complex, with
the utility of certain biologics to be determined.
Takeaway Message:
1) Our case suggests that avoidance of β-lactam antibiotics in
patients with pustular psoriasis is warranted unless absolutely indicated.
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CDA Abstracts
P4.06
Toxic epidermal necrolysis (TEN) in recessive
dystrophic epidermolysis bullosa status post
hematopoetic stem cell transplant
Dusan Sajic1 Christina Boull2 Jakub Tolar2 Sara Hylwa2 Kristen
Hook2 Ingrid Polcari2 John Wagner2
1. University of Toronto,Toronto, ON; 2. University of Minnesota, Minneapolis,
MN, USA
Herein we present the first reported case of TEN in a patient with recessive dystrophic epidermolysis bullosa (RDEB).
Prior to developing TEN, the 3 year old male in question was
treated with a hematopoetic stem cell transplant (HSCT). On
day 16 days post-transplant, the patient was hospitalized due
to fever in the setting of immunosuppression with cyclosporine and mycophenolate mofetil.Vancomycin and ceftazidime
were empirically started, with transition to single-agent
cefepime after 24 hours. Past exposure to all medications was
documented. On hospital day (HD) 3 he developed a pink
papular rash that became vesiculobullous with progressive skin
sloughing distinct from his EB lesions. Work-up failed to reveal
an infectious source. Initial exam by dermatology on HD 11
showed erythema covering 98% of his BSA with denuded skin
[Fig.1]. No milia or bullae were present and Nikolsky sign was
negative. Photophobia, hemorrhagic sloughing of the oral mucosa, and urethral erosions were noted. TEN was confirmed by
a biopsy showing full thickness epidermal necrosis with sparse
inflammation [Fig.2]. SCORTEN scores, calculated retrospectively, were 1 on day one and 3 on day three of his skin eruption. He had no other extra-cutaneous findings suggestive of
graft-versus-host disease.
Extensive chart review and time course of his skin eruption
suggested vancomycin as the inciting agent. Literature review
of the 5 previously reported cases of vancomycin-induced
TEN supports this time course. In all cases the patient was
immunosuppressed, had previously received vancomycin, and
developed TEN following re-exposure within 3-72 hours.
Vancomycin was discontinued and the patient was started
on IVIG. Three days later the patient developed diffuse firm
flesh-colored, folliculocentric papules, which on biopsy were
consistent with re-epithelialization. On HD 69, with approximately 50% BSA involved with bullae/erosisons (his baseline
RDEB level) he was transferred to a facility in his home city.
While GVHD cannot be fully excluded, severe mucosal
involvement is atypical in GVHD. Further, our patient had no
hepatic abnormalities and minimal diarrhea. Perhaps most
importantly, our patient improved without increasing GVHDtargeting immuno-suppression.
Learning Objective: Wide spread vesiculobullous rash of
the skin and mucosal membranes in the context of HSC transplant has a wide clinical differential diagnosis including TEN,
Graft versus host disease, and Erythema Multiforme among
others. Additionally, given our patients exposure to vancomycin, TEN like linear IgA bullous disease has been described in
patients receiving vancomycin. Detailed clinico-histopathologic
assessment as well are required for establishing the correct
diagnosis and directing appropriate treatment.
Takeaway Message: This article describes the first known
case report of TEN in a patient with EBH. Clinical experience
from our institution has shown lower than expected levels of
severe drug reactions and GVHD among the RDEB population
(14,unpublished data), suggesting that these patients may have
altered immune reactivity. Whether this is simply a reflection
of a low likelihood for intersection of two rare events, or a
true clinical observation remains currently unknown and warrants further study.
P4.07
The treatment of Toxic Epidermal Necrolysis
(TEN) in North America
Roni P. Dodiuk-Gad1, 3, 2 Robert Cartotto4, 2 Marc Jeschke4, 2 Joel
Fish5, 2 Neil H. Shear1, 6, 2
1. Division of Dermatology, Sunnybrook Health Sciences Centre,Toronto, ON;
2. University of Toronto,Toronto, ON; 3. Department of Dermatology, Ha’Emek
Medical Center, Afula, Israel; 4. Ross Tilley Burn Centre, Sunnybrook Health
Sciences Centre,Toronto, ON; 5. Burn Program at The Hospital for Sick Children,
Toronto, ON; 6. Division of Clinical Pharmacology and Toxicology, Department of
Medicine, Sunnybrook Health Sciences Centre,Toronto, ON
Introduction: There is no consensus regarding the optimal management of patients with toxic epidermal necrolysis
(TEN). The most recent treatment protocol recommended by
the American Burn Association was issued in 2008. Since then
new data has accumulated on the lack of survival benefits with
intravenous immunoglobulin (IVIg), and on the effectiveness of
cyclosporine, anti-TNF agents and pulse corticosteroids.
Purpose: To evaluate the different management regimens for
patients with TEN in burn centres and dermatology departments in North America, and to assess the implementation of
the published recommendations and studies.
Methods: Directors of burn centres and dermatology
departments in North America were requested by letter to
complete a questionnaire on their protocol for the management of patients with TEN.
Results: Thirty-seven centres completed the survey (25%
response rate), and 54% of them reported using treatment
guidelines, mostly those of their own centre. IVIg was the
A42
CDA Abstracts
most common systemic treatment for TEN, reported by 81%
of centres. Only 24% reported using systemic corticosteroids
and 11% cyclosporine and anti-TNF agents (etanercept and
infliximab). Sixty-four percent of the centres reported having experience with amniotic membrane transplantation. The
majority of the centres’ directors (70%) thought that there is a
need to formulate international treatment guidelines for TEN.
Conclusions: The failure of physicians to acknowledge the
reported lack of survival benefits with IVIg, and the benefits
of cyclosporine, ant-TNF and pulse corticosteroids in the
treatment of TEN, point to the crucial need to formulate upto-date treatment guidelines for patients with TEN in North
America, a need confirmed by the majority of centres’ directors.
Learning Objective: To present the management of Toxic
Epidermal Necrolysis (TEN) in North America.
Takeaway Message: There is an imperative need to
update the management guidelines for patients with Toxic
Epidermal Necrolysis (TEN) in North America.
P4.08
stage breast cancer. The patient had a fluctuating rash with
early cycles of her FEC-D chemotherapy, which significantly
worsened after her first cycle of docetaxel. Her rash progressed to involve her scalp, cheeks, ears, back, neck, as well as
membranes of the nose and vagina, resulting in epistaxis and
vaginal bleeding. Due to the severity of her presentation, an
urgent dermatology consultation was obtained, with a working diagnosis of Stevens – Johnson syndrome. The diagnosis
was further refined upon pathology, which was consistent with
subacute cutaneous lupus erythematosus, and high titres of
anti-SSA/Ro and anti-SSB/La antibodies were identified. Following chemotherapy discontinuation, the rash fully resolved
after a two-month period, with supportive measures including
topical betamethasone cream. This case serves to highlight the
symptom severity and clinical course of docetaxel-induced
SCLE, and emphasizes the importance of recognizing this uncommon chemotherapy-associated cutaneous reaction.
Learning Objective: This case highlights the symptom
severity and clinical course of docetaxel-induced SCLE, and
emphasizes the importance of recognizing this uncommon but
potentially severe chemotherapy-associated cutaneous reaction.
Takeaway Message:
Drug-induced subacute cutaneous lupus
erythematosus associated with docetaxel
chemotherapy
1) Drug-induced subacute cutaneous lupus erythematosus
(SCLE) associated with docetaxel chemotherapy is an
uncommon but potentially severe disease state.
2) The identification and discontinuation of the offending
agent is essential in the management of drug-induced cutaneous reactions.
Noelle Y. Wong2 Laurie M. Parsons1 Martin J. Trotter3 Roger Y.
Tsang4
1. Department of Dermatology- University of Calgary, Calgary, AB; 2. MD
Candidate 2015 - Undergraduate Medical Education - University of Calgary,
Calgary, AB; 3. Department of Pathology & Oncology - University of Calgary,
Calgary, AB; 4. Department of Oncology, Division of Medical Oncology University of Calgary, Calgary, AB
P4.09
Subacute cutaneous lupus erythematosus (SCLE) is a type of
cutaneous lupus erythematosus most commonly characterized
by photodistributed, non-scarring, papulosquamous or polycyclic annular plaques. SCLE is often associated with high titers
of anti-SSA/Ro antibodies in the serum, and roughly 20% of
newly diagnosed cases of SCLE are due to a drug or another
exacerbating agent. Development of drug-induced SCLE has
been linked to a number of common pharmacological agents
including thiazide diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, and taxane chemotherapy.
Taxanes, such as docetaxel and paclitaxel, are anti-microtubule
chemotherapeutic agents which are widely used in many solid
tumor malignancies including non-small cell lung cancer and
breast cancer. In this case report, we describe a severe case of
docetaxel-induced SCLE in a 60 year old female with Sjogren’s
syndrome receiving adjuvant FEC-D chemotherapy for early
Stevens-Johnson syndrome and toxic
epidermal necrolysis: an analysis of triggers
Monica Miliszewski; Mark Kirchhof; Sheena Sikora; Anthony
Papp; Jan Dutz
University of British Columbia,Vancouver, BC
Introduction: Stevens-Johnson syndrome (SJS) and toxic
epidermal necrolysis (TEN) represent a spectrum of rare,
acute and severe mucocutaneous adverse drug reactions
characterized by extensive epidermal detachment. The mortality rates have been reported to be between 1-5% for SJS and
25-35% for patients with TEN. Early recognition and prompt
withdrawal of the causative agent leads to improved patient
survival rates. The aim of this study was to identify the medications most often implicated in triggering SJS and TEN as well
as to determine the timeline of identification and removal of
these triggers.
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CDA Abstracts
Methods/Results: A retrospective chart review was conducted on 64 patients admitted to Vancouver General Hospital
with a diagnosis of SJS or TEN from 2000 to 2011. In 75% of
cases, a trigger was identified. Allopurinol was the single most
common offending agent, implicated in 20% of cases. Anticonvulsants and antibiotics made up the majority of remaining
triggers. Most often, the offending agent was removed at time
of hospital admission or at time of diagnosis and not at the
onset of symptoms.
Conclusion: Increasing physician awareness of the early
signs and symptoms of SJS and TEN, the triggers that cause it,
and what investigations can be done to prevent it, are key to
improving patient care and outcomes in cases of SJS and TEN.
Learning Objective: To be able to identify the most common medications implicated in triggering Stevens-Johnson
syndrome and toxic epidermal necrolysis
P4.10
Jeff Donovan
University of Toronto,Toronto, ON
Drugs can affect the hair growth cycle by disrupting growing anagen hairs or catapulting hairs prematruely into telogen
phase. The result is anagen effluvium or telogen effluvium.
Other drugs cause acceleration of androgenetic alopecia and
others have the potential to trigger scarring alopecia and possibly alopecia areata. Examples are provided from the University of Toronto Hair Clinic.
Retinoids, lithium and interferon are examples of well recognized contributors of drug-induced telogen effluvium. Chemotherapeutic drugs may cause anagen efflvuium, especially
antimicrotubule agents (docitaxel, paclitaxel) and topoisomerase inhibitors (doxorubicin). It is increasingly being recognized that a proportion of patients fail to completely regrow
hair after chemotherapy, and this is referred to as ‘permanent
chemotherapy induced alopecia’. Common culiprit drugs for
permanent hair loss include docitaxel, busulfan, cyclophosphamide and cisplatin.
We are seeing increasing hair loss in men receiving testosterone therapy for low testosterone. Many of these men experience acceleration of hair loss. An acceleration of androgenetic
EGFR inhibitors may rarely cause scarring and non scarring
hair loss, and TNF inhibitors may cause a variety of hair loss
effects, including precipiation of alopecia areata, lichen planopilaris and folliculitis decalvans.
Treatment for drug induced hair loss may involve consideration of stopping the drug. For cancer treatments, this is not
possible and focus on prevention is more relevant. Scalp cooling has had an interesting history and is currently undergoing
rigorous FDA studies in the USA. Health Canada has approved
one scalp cooling system as a medical device and some hospitals are now using these caps.
Learning Objective:
Takeaway Message: Increasing physician awareness of
the early signs and symptoms of SJS and TEN, the triggers that
cause it, and what investigations can be done to prevent it, are
key to improving patient care and outcomes in cases of SJS
and TEN.
Drug induced hair loss: new additions, new
concepts & new treatments
alopecia may also occur in a proportion of women using
androgenetic oral contraceptives, particularly those with the
progestin component levonorgestrel.
1. To review the common causes of drug-induced hair loss.
2. To review drugs that are implicated in permanent chemotherapy induced alopecia
3. To highlight targetted molecular therapies, including EGFR
inhbitors and TNF inhibitors, that are associated with hair
loss
Takeaway Message:
1. Drugs may cause hair loss through multiple mechanisms
2. Some chemotherapy drugs are associated with a risk for
permanent hair loss
3. Scalp cooling as a means to prevent chemotherapy induced
alopecia is finding increasing acceptance in cancer programs around the world
P5.01
Psoriatic nail changes are associated with
clinical outcomes in psoriatic arthritis
Matthew Sandre5, 1 Sherry Rohekar4, 2 Lyn Guenther3, 2
1. McMaster University, Hamilton, ON; 2. Schulich School of Medicine and
Dentistry, London, ON; 3.The Guenther Dermatology Research Centre, London,
ON; 4. St. Joseph’s Health Care London, London, ON; 5. Michael G. DeGroote
School of Medicine, Hamilton, ON
Introduction: Psoriatic nail changes are common in psoriatic arthritis (PsA). This study aimed to characterize relationships between specific nail changes, psoriasis and joint involvement.
Methods/Results: PsA patients meeting CASPAR criteria had joint counts, axial measurements and physician global
assessment of disease activity (MDGA) recorded by their
rheumatologist. Fingernails were assessed, and hand and
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CDA Abstracts
fingernail photographs taken and reviewed by a dermatologist.
188 patients participated (52.4% male, mean age 53.8 years
[SD 12.5], mean psoriasis and PsA duration 20.4 years and
12.5 years respectively). 85.7% ever had skin disease, 89.9%
peripheral arthritis and 12.7% axial arthritis. The mean tender
joint count was 2.5 (SD 4.8), mean swollen joint count 2.0 (SD
3.7), mean modified Schober’s 4.4 cm (SD 1.5), mean occiputto-wall distance 0.7 cm (SD 2.3), mean chest expansion 4.1
cm (SD 1.5) and mean MDGA 2.3 (SD 2.3). 91.5% had at least
one nail change (matrix in 78.7%, nail bed in 73.9%). The most
common nail matrix changes were pitting (59.0%), leukonychia
(42.0%) and rough onychorrhexis (23.9%). The most common
nail bed changes were splinter hemorrhages (55.9%), onycholysis (51.6%) and oil spots (27.7%). Higher swollen joint counts
were associated with distal interphalangeal/periungual psoriasis
(p=0.001), higher number of splinter hemorrhages (p=0.006)
and any nail bed change (p=0.03). Higher tender joint counts
were associated with rough onychorrhexis (p<0.001), distal/
periungual psoriasis (p=0.03), red spots in the lunula (p=0.001),
nail crumbling (p=0.046), any nail matrix change (p=0.03) and
any nail bed change (p=0.03). Those with any nail change had
a significantly higher mean modified Schober’s measurement
(p=0.01). Mean MDGA was worse in those with any nail matrix (p=0.03) or nail bed change (p=0.002).
Conclusions: Distal interphalangeal/periungual psoriasis,
splinter hemorrhages, rough onychorrhexis and red spots in
the lunula were associated with higher joint counts, and nail
matrix and nail bed changes with higher disease activity.
dermatologic diseases of the nail unit and tumors. Severe cases
may affect the quality of life including physical, social dilemmas
and emotional health.
Multiple reports have been published of successful treatment
of onychomycosis with laser, however none exist to date that
describe the treatment of non-infectious onychodystrophy
with laser modalities.
Methods: We report two case reports where the first patient is a 54-year-old woman who presented with painful noninfectious onychodystrophy of the bilateral thumbs of at least
5-year duration with repeated negative fungal cultures and
clippings, and a 73-year-old woman who presented with persistent painful pincer-nail deformity of the bilateral thumbs after
treated onychomycosis of at least 2-year duration. A 1064
nm neodymium-doped yttrium aluminum garnet (Nd:YAG)
laser was used for the dystrophic thumbnails in both patients.
The laser treatment was targeted at the nail plate, the entire
cuticle and nail folds, in order to target the nail matrix. Laser
settings included a spot size of 5 mm, fluence of 16 Joules/
cm2, and pulse duration of 300 microseconds at a rate of 7
Hz. Between 250 and 450 pulses were administered in total
to both nails at each visit. The patients underwent six to nine
treatments, at 4 to 6 week intervals.
Results: A dramatic improvement was noticed in the appearance of the nails of the bilateral thumbs, in terms of shape and
texture. The patients’ quality of life also improved since the
discomfort and pain around the nails significantly decreased.
Conclusion: Using the 1064 nm Nd:YAG laser is a viable,
noninvasive and novel option for the treatment of non-infectious onychodystrophy. Treatment targeted at the nail plate
itself as well as the nail matrix may lead to significant improvements in nail appearance and patients’ quality of life.
Learning Objective: This study sought to examine the
relationship between psoriatic nail change subtypes with signs
and symptoms of PsA.
Takeaway Message: Nail changes in PsA may be more
common than has been previously noted. Psoriatic nail change
subtypes once thought to be rare, such as rough onychorrhexis, may more frequently occur with PsA. Specific subtypes
of nail changes may be a predictor of PsA disease activity.
Learning Objective: To educate the benefits of using a
300 microsecond 1064 nm Nd:YAG laser for the treatment of
onychodystrophy
P5.02
Takeaway Message: The 300 microsecond 1064 nm
Nd:YAG laser is an effective and novel modality in the treatment of onychodystrophy.
Successful management of onychodystrophy
using a 300 microsecond 1064 nm Nd:YAG
laser
Joseph Doumit2, 1 Omar Ibrahim2 Alexandra Zhang2
1. University of Ottawa, Ottawa, ON; 2. Cleveland Clinic, Cleveland, OH, USA
Completed dermatology residency in 2013.
Background: Onychodystrophy is the dystrophic changes in
the nails occurring as a result of many diseases such as fungal
and nonfungal infections, various noninfectious inflammatory
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CDA Abstracts
P6.01
Diffuse normolipemic plane xanthomas
associated with rectal adenocarcinoma:
report of a case
Learning Objective: Gain an appreciation of diffuse normolipemic plane xanthomas as a rare condition which may be
associated with serious underlying systemic disease.
Takeaway Message:
1) DNPX is characterized clinically by yellow macules and
papules on the face, neck and upper trunk.
2) DNPX most commonly occurs in individuals with multiple
myeloma or other causes of monoclonal gammopathy.
3) In rare cases, other neoplasms including rectal adenocarcinoma may be associated with DNPX.
Ariel Burns1 Noreen Walsh1 John Hickey3 Robert Miller2
1. Dalhousie University, Halifax, NS; 2. Dermatology Associates, Halifax, NS; 3.
Primacy Medical Clinic, Antigonish, NS
A 70 year old man presented with a 5-6 year history of an
asymptomatic eruption on the face and upper trunk. Past
medical history was significant for treated rectal carcinoma
with resected liver metastases, portal hypertension, systemic
hypertension and prostatic hypertrophy. Medications included furosemide, nadolol, spironolactone and zopiclone. On
examination diffuse yellow papules and plaques were seen on
the face with prominent periorbital involvement, and on the
shoulders and upper chest. No flexural or acral involvement
was noted. A biopsy was performed which demonstrated perivascular and interstitial foamy histiocytes in the upper dermis.
The patient was diagnosed with diffuse normolipemic plane
xanthomas. Investigations for underlying hematologic dyscrasias were negative. No treatment was initiated.
P6.02
Subcutaneous panniculitis-like lymphoma
Alice Dahl; Mylène S.Veilleux; Marie-Marthe Thibeault
Université Laval, Québec, QC
Initially described in 1962, the entity termed ‘diffuse normolipemic plane xanthomas’ (DNPX) is rare, presenting with
yellow macules, papules and plaques. Histopathology demonstrates foamy macrophages in the upper dermis sometimes
accompanied by Touton giant cells and perivascular lymphocytes. Plane xanthomas, commonly in flexures or on acral sites,
can occur with familial or cholestasis-related hyperlipidemia. In
normolipemic individuals, lesions on the upper trunk, flexures and periorbital area are often associated with multiple
myeloma or other plasma cell dyscrasias with a monoclonal
gammopathy. Rare associations include leukemia, Castleman’s
disease, Sezary syndrome and photosensitivity. To our knowledge, a link with rectal adenocarcinoma has been reported
only once previously. In some individuals, no underlying disease
is identified, necessitating close follow-up as skin changes
can precede the diagnosis of malignancy. With an underlying monoclonal gammopathy, the pathogenesis may involve
antibody-low-density lipoprotein complex deposition in skin
and subsequent phagocytosis; the pathogenesis is unclear
with other associations. Limited disease may be treated with
excision, resurfacing lasers and dermabrasion; treatment of
diffuse disease is primarily aimed at the underlying condition.
We present our case to raise awareness of this rare condition,
which may have serious systemic associations.
A 71 year old woman, with a pertinent medical history of non
classified arthritis on Plaquenil, presented with numerous nonulcerated subcutaneous erythematous and painful nodules. The
nodules were first localized on the shins on a background of
lipodermatosclerosis.
Initially :
Laboratory :
•
•
•
•
Quantiferon (tuberculosis test) and cultures : negative
Antinuclear antibody (ANA) : 1/160
Remaining auto-immune profile : normal
Non specific histology of a mixed septal-lobular panniculitis
(lower legs)
With this context, lipodermatosclerosis was the main diagnosis, with lupus panniculitis as a differential diagnosis
Partial improvement was obtained with bandage compression
and topical mid-potency corticosteroid
Two years later : The nodules had gradually progressed to the
thighs and forearms
Laboratory :
• Lymphopenia
• ANA 1/360
• Biopsy (forearm) :Clear diagnosis of lymphoma
A few phenotypic and genotypic features oriented towards a
primary cutaneous gamma/delta T-cell lymphoma (PCGD-TCL)
with subcutaneous involvement, but the global portrait tipped
the diagnosis toward SPTCL- αβ
Bone marrow biopsy : normal
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CDA Abstracts
A rapid clinical and paraclinical improvement was obtained
with prednisone 50 mg per day, responding as expected for a
SPTCL- αβ lymphoma
Methotrexate has recently been introduced
Learning Objective: SPTCL are associated to autoimmune diseases in 20% of cases, lupus being the most frequent
association
There can be overlapping features between SPTCL and lupus
panniculitis
Cytopenias can occur in SPTCL, but should alert us of a possible underlying hemophagocytic syndrome, which is present in
~ 15% of SPTCL
The histological profile of SPTCL might have mixed features
of both SPTCL- αβ and PCGD-TCL. In those cases, a closer
follow-up is suggested
Learning Objective:
Takeaway Message: There should be no hesitation in
repeating biopsies in a patient previously diagnosed with lupus
panniculitis, because a SPTCL might be associated
P6.03
An aesthetic procedure that reveals internal
illness
• Recognizing a special manifestation of sarcoidosis.
• Increasing our sensitivity to investigate benign appearing
lesions that are out of the ordinary
Takeaway Message: It is always best to investigate unexplained dermatologic phenomenon to help in the best way we
can our patients.
Steve Mathieu1 Solange Beauregard1 Stéphanie Turmel2
1. Université Laval, Québec, QC; 2. Hôpital Hôtel-Dieu de Québec, CHU,
Québec, QC
A young woman underwent axillary hair electrolysis performed by an esthecian. Following that procedure, she developed brown papules that suggested a Koebner phenomenon.
In order to clarify their nature, a punch biopsy was performed
which revealed naked granulomas, highly suggestive of sarcoidosis. An investigation was performed and revealed pulmonary
sarcoidosis.
P6.04
A new variant of white fibrous papulosis of
the neck in the context of limited systemic
sclerosis
Mohammad A. Almohideb1 Thusanth Thuraisingam 1 Barbara
Miedzybrodzki1 A. Kevin Watters2 Khue Nguyen1
1. McGill University- Dermatology, Montreal, QC; 2. McGill UniversityDepartment of Pathology, Montreal, QC
White fibrous papulosis of the neck (WFPN) is a rare condition initially described by Shimizu et al. in 1985. Although the
pathogenesis still remains unknown, some authors believe
Pseudoxanthoma elasticum–like papillary dermal elastolysis
(PXE-PDE) and WFPN form a continuum of the same disease process having comparable clinical and histopathological
presentations. Herein, we present a 57 year old female with a
recent diagnosis of limited scleroderma and a two year history
of monomorphous, discrete skin colored to yellowish 2-4 mm
papules on both sides of her neck. Histopathologically there
was an increase of collagen and normal elastic fibres. WFPN is
characterised by increased collagen with reduced elastic tissue.
To our knowledge, this is the first case to describe WFPN with
normal elastic fibres and in association with Limited Systemic
Sclerosis.
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CDA Abstracts
Learning Objective: Learn about a new variant of a rare
condition known as white fibrous papulosis of the neck and
its possible association with autoimmune connective tissue
diseases.
Takeaway Message: White fibrous papulosis of the neck
can have different histological variants and can be associated
with autoimmune connective tissue diseases.
P6.05
Iatrogenic kaposi’s sarcoma treated with
doxorubicin in a patient with granulomatosis
with polyangiitis: a case report
Anjali Saxena; Raqiya Al-Rajaibi; Osama A. Roshdy
McGill University, Montréal, QC
Introduction: Iatrogenic Kaposi’s sarcoma (KS) is a vascular neoplasm that develops secondary to immunosuppressive
therapy. Although the majority of these cases are reported in
transplant recipients, there are increasing reports of iatrogenic
KS in patients undergoing treatment for autoimmune disorders. Granulomatosis with polyangiitis (GPA) formerly called
Wegner’s granulomatosis is an autoimmune ANCA associated
vasculitis, classically treated with immunosupressants.
Learning Objective: Management of iatrogenic kaposi’s
sarcoma secondary to treatment of granulomatosis with polyangiitis (GPA).
Takeaway Message: Iatrogenic KS, secondary to GPA
treatment, that has not resolved despite removal of the immunosuppressive agents, can potentially be treated with IV
doxorubicin.
Methods and Results: We present the case of a 66-yearold HIV negative female who developed iatrogenic KS secondary to immunosuppressive treatment for her GPA. Her
treatment consisted of induction with monthly IV cyclophosphamide pulse therapy, one dose of IV methylprednisolone and
daily oral prednisone. Five months after treatment initiation,
the patient developed violaceous maculopapular lesions on her
lower limbs and arms. Biopsy of the leg nodules confirmed KS.
Despite reduction and removal of immunosupressants, which
has been the reported treatment of choice in GPA patients
with iatrogenic KS, her KS rapidly progressed (Figure 1). She
was consequently started on IV doxorubicin, which resulted in
significant improvement of her lesions (Figure 2).
Conclusion: To our knowledge, this is the first case report
of iatrogenic KS secondary to GPA treatment that has not
resolved despite removal of the immunosuppressive agents
and has instead been successfully treated with IV doxorubicin.
Physicians should consider doxorubicin as a possible treatment option in patients with persistent iatrogenic KS.
P6.06
Acquired zinc deficiency secondary to total
parenteral nutrition presenting as a pustular
eruption
Lindsay Eminger; Stacy Cohen; Tammie Ferringer
Geisinger Medical Center, Danville, PA, USA
Introduction: Zinc deficiency may be inherited, known as
acrodermatitis enteropathica, or acquired. Herein, we report a
case of acquired zinc deficiency secondary to total parenteral
nutrition (TPN) presenting as a pustular eruption.
Case presentation: A 55 year old male presented with a
3 week eruption of papules and pustules on his face, neck and
chest. His history was significant for a recent motor vehicle
accident followed by a complicated medical course, including
numerous abdominal surgeries. He had developed an enterocutaneous fistula, and was dependent on TPN. Initially, culture
revealed Staphylococcus aureus. Topical and oral antibiotics
were prescribed but his eruption progressed. His first biopsy
revealed suppurative folliculitis with Pityrosporum yeast, hence
antifungal medications were added. Despite treatment, his
eruption evolved into crusted plaques on the face and scalp
and well-demarcated, scaly, pink plaques in the axillae and
donor graft sites. Dusky erythema was noted in the palmar
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CDA Abstracts
creases. Subsequent biopsies revealed epidermal necrosis and
focal acantholysis, suggestive of nutritional deficiency. Zinc level
was found to be 7 mcg/dL (normal range 60-130 mcg/dL). He
improved rapidly following additional zinc supplementation.
Discussion/Conclusions: Zinc deficiency typically
presents with dermatitis, diarrhea and alopecia. Dermatitis is
characterized by a psoriasiform, eczematous or vesiculobullous eruption predominantly affecting periorificial areas, the
scalp, and acral sites. While our patient eventually developed
dermatitis, his initial presentation was a pustular eruption.
Conclusion: To our knowledge, these two cases are the
first reported in medical literature to illustrate the efficacy of
solifenacin succinate (Vesicare®) in the treatment of primary
focal hyperhydrosis. As it is safe, effective and well tolerated,
we suggest that it should be considered as an alternative treatment option.
Learning Objective: We are the first to describe two
cases of primary focal hyperhidrosis successfully treated with
solifenacin succinate (Vesicare®).
At the time of diagnosis, our patient was receiving 1.3 mg/d of
zinc in his TPN. It is estimated that patients require 3 mg/d in
patients without gastrointestinal losses, and up to 12 mg/d in
patients with diarrhea or fistula losses. Since late 2012, there
has been a limited supply of injectable zinc in the United States
resulting in several cases of zinc deficiency in infants receiving TPN. Our case further emphasizes the need for available
parenteral trace elements to prevent nutritional deficiency.
Learning Objective: Following this presentation, attendees
will be able to describe the clinical and histologic manifestations of zinc deficiency. Nutritional deficiencies commonly associated with total parenteral nutrition will also be discussed.
Takeaway Message: Solifenacin succinate (Vesicare®) has
been demonstrated for the first time, in two isolated cases, as
a safe, effective and well tolerated therapeutical option for the
treatment of primary focal hyperhidrosis.
P6.08
Henoch–Schönlein purpura post-renal
transplantation in a patient with long
standing IgA nephropathy: case report and
literature review
Bahman Sotoodian
University of Alberta, Edmonton, AB
Takeaway Message: In patients receiving total parental
nutrition, a pustular eruption should raise suspicion for zinc
deficiency.
PGY1 Dermatology Resident, University of Alberta
P6.07
Solifenacin Succinate (Vesicare®) in the
treatment of primary focal hyperhidrosis
Hélène Veillette; Anne-Marie Hunt; Pierre-Olivier Grenier
Henoch–Schönlein purpura (HSP) is a type of small vessel
vasculitis that presents as palpable purpura (100%), arthritis
(75%), abdominal pain (65%) and nephritis (40-50%). HSP is
mainly a pediatric disease with 90% of patients <10 years of
age. The presence of IgA in renal mesangium and cutaneous
venules in patients with HSP demonstrates the significance of
IgA in pathogenesis of this disease.
This paper is the second case to describe new diagnosis
of HSP vasculitis in a patient with renal biopsy proven IgA
nephropathy while being treated with immunosuppressive
medications post renal transplant.
Hôpital du St-Sacrement, CHU(Q), Université Laval, Québec, QC
Introduction: Primary focal hyperhidrosis is a common
disorder presenting as excessive symmetrical sweating in
the palms, soles, axilla or the craniofacial region. It frequently
presents a significant therapeutical challenge. As many patients
suffer substantially from the social, occupational and physical
repercussions of this disease, an efficient treatment is in high
demand amongst this population.
Method/Results: We report 2 cases of longstanding primary focal hyperhidrosis. The first, presenting in the cranio-facial
region of a 67 year old woman and the second affecting the
palms and soles of a 21 year old woman. The two were treated
with solifenacin succinate (Vesicare®). Both patients observed
a considerable decrease of sweating episodes and reported
a high level of satisfaction. The treatment was generally well
tolerated and benefits were maintained.
Cutaneous vasculitis post-renal transplantations are mostly
due to secondary infections or drug reactions. The presence
of cutaneous vasculitis subsequent to renal transplant could
also indicate the recurrence of underlying renal disease. Our
patient never experienced cutaneous vasculitis or any clinical
symptoms of HSP prior to his renal transplant. Interestingly,
the HSP vasculitis manifested while the patient was receiving
Tacrolimus, Mycophenolate mofetil and tapering dose of prednisone. The choice of immunosuppressive regimens post renal
transplant does not alter the recurrence likelihood of IgA or
HSP nephropathy. The question remains as to why our patient
developed HSP while receiving immunosuppressive treatments.
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CDA Abstracts
In conclusion, this is the second case of cutaneous HSP after
renal transplant due to isolated IgA nephropathy. Literature
review indicated presence of similar manifestation in a patient
who developed HSP vasculitis post renal transplant when his
prednisone regimen was stopped. Similarly, this patient was
receiving MMF & Tacrolimus immunosuppressive treatments. In
both cases, the patients recovered shortly after re-establishing
their previous prednisone regimens.
Learning Objective: The presence of cutaneous vasculitis
subsequent to renal transplant could indicate the recurrence
of underlying renal disease
Takeaway Message:
1. Patients with IgA nephropathy can present with HSP vasculitis post-renal transplantation
2. Patients can develop cutaneous vasculitis while being
treated with immunosuppressive medications
3. The reduction in dosage of prednisone seems to predispose the occurrence of more systemic vasculitis in patients
with prior history of isolated IgA nephropathy.
P6.09
were normal. Review of symptoms showed only mild fatigue.
History is notable for missionary work abroad and remote
pulmonary tuberculosis. The patient had no history of hepatitis, but had an episode of abdominal pain, nausea and vomiting
in 2007. Upon returning to clinic, the patient was started on
zinc supplementation and referred to the hepatology service
for consideration of systemic treatment of her viral infection.
Conclusion: We report here a case of NAE in an 88-yearold nun, leading to the discovery of previously undiagnosed
hepatitis C. We would like to highlight the unusual morphology
of this case with its nummular eczema-like appearance. Given
that NAE often has non-specific psoriasiform histopathological
findings without necrolytic keratinocytes, a high index of clinical suspicion must be maintained.
Learning Objective: Recognition of the rare entity Necrolytic Acral Erythema based on clinical-pathological correlation
are key, given that both the morphology and the histopathology of this condition can be non-specific.
Takeaway Message: A high index of suspicion must be
maintained in order to diagnose Necrolytic Acral Erythema,
a condition that is pathognomonic for Hepatitis C and which
may lead to early diagnoses of this infection.
Necrolytic acral erythema presenting with
nummular lesions
Carolyn Jack Robin Billick
1
1, 2
P7.01
Khue H. Nguyen
1
Orofacial granulomatosis: case report
1. McGill University, Montreal, QC; 2. Jewish General Hospital, Montreal , QC
Michelle Pratt; Patricia Wadden; Robert Fowler; Wayne
Gulliver
Introduction: Necrolytic acral erythema (NAE) is a rare
but increasingly recognized manifestation of hepatitis C infection and is considered pathognomonic for this condition. It is
characterized by well-circumscribed, dusky, erythematous-toviolaceous plaques with adherent scale and a predominantly
acral distribution.
Memorial University of Newfoundland, St. John’s , NL
Methods/Results: An 88-year-old nun in good health
presented with a seven-month history of multiple well-demarcated, dusky erythematous nummular plaques with adherent,
micaceous scales distributed over her legs, dorsal feet and, to
a lesser degree, arms. High potency topical corticosteroids and
antifungals were ineffective. A previous biopsy in the community was non-specific, with both psoriasiform changes and
spongiosis. Seen in our clinic, we entertained the diagnoses of
nummular eczema, atypical psoriasis or NAE. Repeat biopsy
was performed with screening blood work. The patient was
found to be positive for hepatitis C, confirmed by PCR; importantly, this was previously undiagnosed. Histopathological findings remained non-specific, demonstrating a psoriasiform and
spongiotic lymphocytic dermatitis with overlying parakeratotic
scales containing numerous neutrophils. Stains and culture
results revealed only normal skin flora, and liver function tests
Introduction: Orofacial granulomatosis (OFG) is an uncommon condition that presents as chronic granulomatous
inflammation of the lips, face, and oral cavity, in the absence of
systemic disease. The most common presentation is non-tender, non-pruritic, oral labial swelling. Additional extra and intraoral manifestations may include facial swelling, lip fissuring,
angular cheilitis, perioral erythema, cobblestoning, ulceration,
gingivitis, and lingua plicata. Similar to other granulomatous
diseases, such as Crohn’s disease and sarcoidosis, OFG most
likely has an immunologic etiology. There is debate whether
OFG is in fact a separate entity, or merely an initial and/or
localized form of Crohn’s disease. OFG is a diagnosis of exclusion and therefore requires a systemic workup.
Case Report: The patient, a 37 year old Caucasian male
from Newfoundland, presented with a persistent eruption of
the lower lip, as well as the mid portion of the upper lip. The
mouth appeared normal with no dental or salivary gland lesions. CBC was normal. Serology was negative for ANCAs and
ANA, and positive for rheumatoid factor. Mantoux skin testing
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CDA Abstracts
NO CARCINOMA
was negative. IgE was normal and patch testing was negative.
Biopsy of the lower lip showed non-caseating, granulomatous
inflammation characterized by sarcoidal-like organoid granulomas in perivascular distribution, without mucin deposition or
interface change. Acid-fast staining, fungal staining, and polarization were negative. Full axial CT was unremarkable, but in
particular, negative for pathologic lymph nodes or pulmonary
infiltrate.Visualized portions of the GI tract were normal. Endoscopy was performed from the nasopharynx to the glottis
and was unremarkable.
June 2013: lesion “itchy”
-Rx. Kenaog ‘10’ 0.3mL
September 2013: lesion “not healing”
• Biopsy repeated
• DDx: INFLAMINATORY ACNE PAPULE vs DENTAL SINUS
October 2013: ABSCESSES OF TEETH UNDER PATIENTS
FALSE TEETH.
Discussion: Given the clinical and histologic findings, with a
negative workup for systemic disease, a diagnosis of OFG was
confirmed. Although there is no standardized treatment protocol, corticosteroids are considered the mainstay of therapy,
and have been shown to alleviate swelling. In this case, the
patient has been managed using topical corticosteroid cream,
and occasional intralesional injections. Significant improvement has been noted. There are reports of orofacial symptoms
preceding the onset of systemic Crohn’s disease, and therefore
the patient continues to be followed closely.
• when pressure was applied to the area, allowed pus to exit
from skin of chin
Dx: DENTAL SINUS 2o TO ABSCESSED TEETH
Learning Objective: At the end of this activity the participant should be able to appreciate orofacial granulomatosis as a
diagnosis of exclusion, and as part of the differential diagnosis
for chronic oral labial swelling.
Takeaway Message: Orofacial granulomatosis is an
uncommon disease that presents as chronic oral labial swelling, and its diagnosis requires a systemic workup to exclude
other causes of granulomatous inflammation, such as Crohn’s
disease, sarcoidosis, and tuberculosis.
P7.02
Dental sinus
Andrew A. Simone
Private Practice,Toronto, ON
Patients initials: F.K. Age: 88 Gender: Female
Body region: Left Chin, Left lower Gingiva
History: 88 year old female with a SORE OF THE LEFT CHIN
since November 2012. Unresponsive to antibiotic treatment.
March 2013: Dermatology consult and Dx: BASAL CELL CARCINOMA
• because of “pearly border and ulceration”
• Treated with curettage and electrodesiccation.
• Biopsy report March 2013: MIXED INFLAMMATORY INFILTRATE
DDx: ACNE ACNEIFORM PAPULE vs DENTAL SINUS
References
1. Pasternak-Júnior B., et al. Diagnosis and treatment of odontogenic cutaneous sinus tracts of ondodontic origin: three
case studies. Int Endod J. 2009 Mar;42(3):271-6
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Learning Objective: The objective of this study was to
review the return to work experience of four nurses with
cumulative ICD.
2. Guevara-Gutiérrez E., et al. Odontogenic cutaneous fistulas: clinical and epidemiologic characteristics of 75 cases.
Int J Dermatol. 2013 Oct 18. [Epub ahead of print]
3. Wigler R., et al. Oral cutaneous sinus tract, vertical root
fracture, and bisphosphonate-related osteonecrosis: a case
report. J Endod. 2013 Aug;39(8):1088-90
Many thanks to Dr. Dalal Assaad for DX of this case
Takeaway Message: Altering cumulative exposure to an
allergen is one administrative control that is an important
workplace modification for those with cumulative irritant
contact dermatitis.
Learning Objective: DENTAL SINUS
P8.02
Takeaway Message:
Off-label uses of topical vitamin D in
dermatology: a systematic review
1. DENTAL SINUS (odontogenic cutaneous sinus tracks) is a
difficult clinical diagnosis
2. Presently people with BONE CANCER are being treated
with BIOPHOSPHONATES that cause bone resorption.
There will be an increased incidence of dental sinuses
because of the side effects of these drugs.
3. Sores of the face → think of the diagnosis and check the
teeth
Heidi Wat; Marlene Dytoc
University of Alberta, Edmonton, AB
Background: Topical vitamin D analogues are FDA approved
for the treatment of psoriasis. However, the range of dermatological disease amenable to topical vitamin D therapy is broad
and there is a need for evidence-based guidelines for clinical
decision making.
P8.01
Cumulative irritant contact dermatitis in
nurses
Farheen Mussani1 Sandy Skotnicki1 Pilar Gomez2
1. Division of Dermatology, University of Toronto,Toronto, ON; 2. Department of
Occupational and Environmental Health, St Michael’s Hospital,Toronto, ON
Introduction: Cumulative irritant contact dermatitis (ICD)
is the most common clinical type of contact dermatitis. Common irritants in the health care setting include soaps, disinfectants, alcohol based hand sanitizers and glove wearing, in
addition to wet work.
Objective: The objective of this study was to review the return to work experience of four nurses with cumulative ICD.
Methods and Results: A chart review was conducted to
examine the return to work experience of four nurses.
In addition to ICD, three of the nurses had allergic contact
dermatitis. Removal of the allergen alone did not result in
a successful return to work. In addition to proper skin care
management and monitoring, administrative changes of either
alternating shifts or decreasing consecutive shifts, thereby decreasing the cumulative dose of irritation, resulted in successful return to work.
Conclusions: Administrative controls altering cumulative
exposure are an important workplace modification to accomplish successful return to work.
Methods: A search of the MEDLINE, EMBASE and CENTRAL databases was conducted on May 2013. A total of 165
studies that assessed efficacy and safety of topical vitamin
D analogues were included. Study characteristics analyzed
include: study design, patient characteristics, intervention and
comparison arm, response, adverse effects, and follow-up. The
primary outcome sought was degree of clinical improvement
in skin lesions. Recommendations were established for both
the efficacy and inefficacy of topical vitamin D based on the
highest quality evidence available (Levels A-D, Strong-Weak).
Results: Evidenced-based recommendations was generated for 24 dermatological disorders. A moderate to strong
recommendation was made for use in combination with PUVA
(A), topical corticosteroids (B), and narrow-band UVB (B) for
treatment of vitiligo. In contrast, its role as monotherapy or
in combination with sun exposure was limited. A moderate to
strong recommendation was also given for its use in plaque
type morphea (B), pityriasis alba (A), prurigo nodularis (B) and
polymorphous light eruption (A). There is moderate to strong
evidence showing that topical vitamin D is ineffective for actinic keratoses, seborrheic keratoses, lichen planus, seborrheic
dermatitis, alopecia areata, and hypertrophic scars. Treatment
was well tolerated in all patients.
Conclusion: Topical vitamin D has an important role in the
off-label treatment of dermatological disease, but the therapeutic potential is to be further validated by higher quality
studies. In recalcitrant cases, it may be a worthwhile second
line option for the reviewed disorders.
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Topical vitamin D plus topical corticosteroid
B: Moderate
Learning Objective: The objective of this study is to
provide evidence-based clinical guidelines for the off-label use
of topical vitamin D in dermatological conditions refractory
to conventional therapy, and serve to promote higher quality
future research.
Topical vitamin D plus NB-UVB
B: Moderate
Topical vitamin D plus PUVA
A: Strong
Takeaway Message:
Topical vitamin D plus sun exposure
Ineffective (A: Strong)
Topical vitamin D monotherapy
Ineffective (B: Moderate)
Dermatological Disease
Evidence Based
Recommendation
Vitiligo
Disorders of Keratinization
Congenital ichthyosis, X-linked ichthyosis, lamellar
ichthyosis, epidermolytic ichthyosis
B: Moderate
Confluent and reticulated papillomatosis
D: Weak
Disseminated superficial actinic porokeratosis
D: Weak
Neoplasms and Hamartomas
Inflammatory linear verrucous epidermal nevus
D: Weak
Actinic keratosis
No proven efficacy
(B: Moderate)
Seborrheic keratosis
No proven efficacy
(B: Moderate)
Sclerodermoid Conditions
Morphea (plaque type)
• There is strong evidence suggesting topical vitamin D
analogues can potentiate repigmentation of vitiligo by PUVA
phototherapy, and a moderate level of evidence for combination with NB-UVB and topical corticorticosteroids.
• There is also moderate to strong evidence for its efficacy in
various ichthyoses, morphea, pityriasis alba, prurigo nodularis, and polymorphous light eruption.
• Higher quality studies are still needed to further define its
therapeutic potential in these disorders.
P8.03
Use of facebook as a tool for knowledge
dissemination in dermatology
Whan B. Kim; Ronald B.Vender
Department of Medicine, McMaster University, Hamilton, ON
B: Moderate
Papulosquamous Conditions
Pityriasis alba
A: Strong
Prurigo nodularis
B: Moderate
Granular parakeratosis
D: Weak
Keratosis lichenoides chronicus
D: Weak
Palmoplantar eczema
D: Weak
Pityriasis rubra pilaris
D: Weak
Lichen planus
No proven efficacy
(B: Moderate)
Seborrheic dermatitis
Ineffective (A: Strong)
Hair Disorders
Alopecia areata
Ineffective (A: Strong)
Chemotherapy-induced alopecia
Ineffective (A: Strong)
Other
Verruca vulgaris
C: Fair
Polymorphous light eruption
A: Strong
Trachyonychia
C: Fair
Lichen amyloidosis
C: Fair
Oral leukoplakia
C: Fair
Hypertrophic scars and keloids
Ineffective (A: Strong)
Background: The need to utilize social media as a tool for
knowledge dissemination is fast growing. Out of various available platforms, Facebook remains as the most popular in the
world with 1.26 billion users as of October 2013. Hence, it is
easy to see the potential in utilizing Facebook as an accessible,
interactive, and inexpensive tool for knowledge dissemination
in many fields of medicine, including dermatology.
Methods: Through a search on Facebook, academic journals,
professional societies, and patient-centred groups in dermatology with the highest number of Facebook likes were identified.
Then, the Yearly Page Engagement Rate was calculated (total
number of likes, comments, shares for all Facebook posts
published on the page in 2013/ total number of likes for the
page as of Dec 31, 2013). Engagement Rate is a metric used by
marketers and recently adopted by Facebook to assess how
well a page engages its fans.
Results: As of December 31 2013, the Yearly Page Engagement Rate was 4.332, 0.673, and 0.212 for Journal of the American Academy of Dermatology, Journal of the American Medical
Association Dermatology, and Journal of Investigative Dermatology,
respectively; 2.482, 0.313, and 0.247 for American Academy of
Dermatology, Canadian Dermatology Association, and British
Association of Dermatologists, respectively; and 1.688, 1.563,
and 0.688 for Melanoma Research Foundation, National Psoriasis Foundation, and Skin Cancer Foundation, respectively.
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case was re-submitted. We will examine patient records to see
whether indeed the patient was seen by the recommended
specialist for their condition.
Conclusions: Based on the robust average (i.e. median),
patient-centred groups engaged with their fans significantly
more than academic journals or professional societies did.
Engagement Rate is important because unless the user engages with the Facebook page, the chance that the content of
the page shows up on the fan’s Facebook Newsfeed is slim.
Furthermore, the Engagement Rate provides a valuable gauge
of whether the fans that “liked” the page continue to remain
engaged or not. Thus, as important, if not more than number
of Facebook likes, is the Engagement Rate.
Results: Of 980 consultations, there was a significant female
preponderance 606 (61.8%). Age range of patients included
157 (16.2%) 0-20 years, 167 (17.2%) 20-40 years, 305 (31.4%)
40-60 years, 275 (28.3%) 60-80 years, and 66 (6.8%) 80+ years.
Of the 21 cases that had technical errors with imaging, only 6
(28.5%) were ever re-sent. 51 cases were recommended for
further in-person assessment through the Patch Test Clinic
although only 2 (3.9%) patients ever completed patch testing.
Learning Objective: The Engagement Rate (# of likes,
comments, shares/ total fans) can be used to quantify and objectively evaluate the degree of engagement that dermatologyrelated Facebook pages have with the public.
Conclusions: Otn.TeledermSF is a valuable asset, bringing
access to specialist dermatological assessment to patients
who cannot see a dermatologist in their community. There are
some technical and knowledge-based shortfalls in the the system. Primary provider education and technical improvement is
necessary to optimize the service and ultimately the care for
the patient.
Takeaway Message: Facebook pages devoted to disseminating knowledge in dermatology should first, consider the
Engagement Rate and second, raise the Engagement Rate by
investigating the various factors in play, such as the time of the
day and day of the week that the fans are most engaged or the
types of contents that trigger the most likes, comments, and
shares.
P8.04
Teledermatology: a review of the Ottawa
experience of otn.TeledermSF
Ashley C. O’Toole; Steven Glassman; Loretta Cheung
University of Ottawa, Ottawa, ON
PGY2 Dermatology Resident
Background: The use of communications technology to
facilitate the provision of healthcare for persons is an area of
increasing interest. In Ontario, Otn.teledermSF® is a provincial
government-funded program initiated in 2006 which provides
a free service for doctors to securely send photographs of a
patient’s skin condition and relevant health information to an
Ontario-based dermatologist for consultation.
Objectives: To review the demographics and common
presentations of the patients being referred to otn.TeledermSF
between 2008-2012. We will analyze what percent of cases
have technical submission errors associated with the online
system and whether or not the case is re-sent. We also intend
to study whether consultations suggested for individual patients are being carried out by the referring provider.
Methods: We will examine 980 patient consults collected by
the one Otn.teledermSF dermatologist between 2008-2012.
We will analyze the demographic variables and the dermatological disease classification. We will review the number of
cases that had technical errors and whether or not the same
Learning Objective: We intend to study the demographics
of the initial cohort of patients referred to Otn.TeledermSF.
We will also analyze the technical aspects of the system.
Thirdly, we will evaluate whether in-person consultations suggested for individual patients are being carried out.
Takeaway Message: Otn.TeledermSF is a valuable asset,
bringing access to specialist dermatological assessment and advice to patients who cannot see a dermatologist in their community. However, there are certain technical and knowledgebased shortfalls in the proper use of the system as well as the
fulfillment of the recommendations by the referring provider
that require improvement.
P8.05
Familial Dowling-Degos Disease: case report
and review of the literature
Dominique Fausto de Souza1 Christine Neagoe2 Herbert Srolovitz1 Osama Roshdy1
1. McGill University, Montreal, QC; 2. Sherbrooke University, Sherbrooke, QC
Dowling-Degos disease (DDD) is a rare genodermatosis
that is inherited in autosomal dominant manner, and demonstrates varying degrees of penetrance. It is characterized by
acquired, symmetric, reticular hyperpigmented macules in the
large flexural areas. Associated findings include facial pitted
scars and hyperkeratotic follicular comedo-like papules[1]. We
describe the case of a 66-year-old female that presented with
reticulated, hyperpigmented, confluent macules in the axillae,
inguinal folds, inner thighs, vulva, as well as the inframammary
and intergluteal regions. She was also known for hidradenitis
suppurativa (HS) of the axillae, pitted scars on the nose, and
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comedo-like follicular papules on the face and neck. Histopathological findings from the right axilla showed acanthosis with
elongation of the rete ridges, basilar hyperpigmentation, and
dermal melanosis. On history, her father and grandfather had
similar lesions and her 30-year-old son had recently developed
a similar eruption on the testicles and inguinal folds. Loss-offunction mutations in keratin 5 gene have been described in
DDD[2]. A single defect in epidermal and follicular keratinization may account for the association of DDD with HS and
epidermal cysts[3-4]. To our knowledge, only about 65 cases
have been reported in the literature. We present a classic
case of familial DDD and reviewed the literature of this rare
condition, in order for clinicians to consider this entity in the
differential diagnosis when appropriate.
1 Batycka-Barana A, et al. Dowling-Degos Disease: Case
Report and Review of the Literature. Dermatology
2010;220:254–258.
2 Betz RC, et al. Loss-of-function mutations in the keratin
5 gene lead to Dowling-Degos disease. Am J Hum Genet,
2006. 78(3): p. 510-9.
3 Fenske NA, et al. Dowling- Degos disease, hidradenitis
suppurativa, and multiple keratoacanthomas. A disorder
that may be caused by a single underlying defect in pilosebaceous epithelial proliferation. J Am Acad Dermatol, 1991.
24(5 Pt 2): p. 888-92.
4 Loo WJ, et al. Hidradenitis suppurativa, Dowling-Degos and
multiple epidermal cysts: a new follicular occlusion triad.
Clin Exp Dermatol, 2004. 29(6): p. 622-4.
Learning Objective: To present a classic case of familial
Dowling-Degos disease (DDD) and to review the literature
of this rare condition, in order for clinicians to consider this
entity in the differential diagnosis when appropriate.
Takeaway Message:
• Dowling-Degos disease (DDD) is a rare genodermatosis
characterized by acquired, symmetric, reticular hyperpigmented macules in the large flexural areas.
• It can be associated with hidradenitis suppurativa, facial
pitted scars, comedo-like follicular papules, and epidermal
cysts.
• Loss-of-function mutations in keratin 5 gene have been
described in DDD.
P8.06
Cyclosporine in the management of poststreptococcal pustulosis: a report on two
cases
Patrick Fleming; James Shaw
University of Toronto,Toronto, ON
Introduction: Post-streptococcal pustulosis (a.k.a. pustulosis acuta generalisata) is a rare post-streptococcal disease
characterized by sterile pustules predominantly on the acral
surfaces. It is often associated with fever, leukocytosis, and elevated acute phase reactants. It may present with arthropathy
and/or glomerulonephritis.
Case: A mother and daughter presented together five days
after a culture positive group A streptococcal pharyngitis with
painful, pruritic palmoplantar pustules and leukocytosis. We
used a short course of low-dose cyclosporine as an alternative to prednisone to induce rapid remission of this painful
eruption.
Conclusion: Cyclosporine appeared to have rapid positive
results and was well-tolerated by our two patients. This finding
offers a potential alternative to systemic corticosteroids in the
management of neutrophilic eruptions such as post-streptococcal pustulosis.
Learning Objective:
1) Review clinical features and complications of post-streptococcal skin disease
2) Discuss the use of cyclosporine in post-streptococcal pustulosis
Takeaway Message: Post-streptococcal pustulosis is
characterized by sterile pustules after a group A streptococcal pharyngitis and may be associated with systemic features.
Cyclosporine may be an alternative to prednisone to induce
rapid resolution of his disease.
P8.07
Validating the diagnostic codes for psoriasis
and acne
Aiza Ejaz1 Viba Malaiyandi1 Raed Alhusayen1, 2
1. University of Toronto,Toronto, ON; 2. Sunnybrook Health Sciences Center,
Toronto, ON
The administrative databases serve as reservoirs of extremely
valuable data and are often used to conduct population-based
clinical and epidemiologic studies. However, the accuracy of
diagnostic codes to independently identify patients with a
specific diagnosis is unknown. There have been no studies
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conducted to validate the codes for common dermatological
conditions. The objective of this study was to evaluate the validity of ICD-9-CM codes 696 and 706 for psoriasis and acne,
respectively.
Methods and Results: Questionnaires were sent out to
all orthopedic surgeons involved in the care of all patients who
had been referred to the UBC Contact Dermatitis Clinic to
rule out a metal sensitivity in the perioperative setting. The
questionnaires were designed to assess whether the results
of patch testing changed patient management, whether the
patients had any postoperative complications and if symptoms
improved after adjustments were made in the setting of positive patch test results. The questionnaire response rate was
87% (34/39). Twenty-one out of 34 (62%) returned questionnaires were regarding cases of patch testing in the preoperative setting. In the preoperative setting, 62% of orthopedic
surgeons stated that patch testing results influenced their
management whereas only 46% of orthopaedic surgeons in
the postoperative group stated that patch test results changed
their management. A proposal for a prospective controlled
trial was subsequently created. The data and controlled trial
proposal will be presented at the British Columbia Orthopedic Society 2014 annual general meeting to initiate discussion
about beginning a prospective controlled trial on the role of
patch testing for metal sensitivity in the perioperative setting.
This was a retrospective cohort study that included all
patients seen in general dermatology clinics at Sunnybrook
Health Sciences Centre between March 1 - May 31, 2013.
Billing sheets, collected for each clinic visit during this period were reviewed. The code identified during that visit was
compared to the clinical diagnosis documented in the medical chart corresponding to the same clinical encounter. Using
this data sensitivity, specificity and positive predictive value
(PPV) for the ICD-9-CM 696 (psoriasis) and 706 (acne) were
calculated.
Our preliminary analysis, based on 3,034 patients, showed that
the ICD-9-CM code for acne had a PPV of 83.7% and for psoriasis 90.7%. The sensitivities were 86.6% and 86.1% for acne
and psoriasis respectively. Both ICD-9-CM codes were highly
specific at 99%.
We have demonstrated that in a dermatology setting, ICD9-CM codes 696 and 706 can be used to accurately identify
patients with psoriasis and acne, respectively. This information
can be applied to identify patients with these diseases from
administrative databases for future clinical and epidemiologic
studies.
Conclusions: This data will be used to conduct a prospective trial in conjunction with orthopedic surgeons to investigate the role of patch testing in the perioperative setting.
Learning Objective:
1) To discuss the lack of evidence based guidelines for patch
testing in the perioperative setting.
2) To discuss a proposed prospective trial to look at the role
of patch testing for metal sensitivity in the perioperative
setting.
Takeaway Message: A prospective trial examining the role
of patch testing for metal sensitivity in the perioperative setting is needed. Evidence based guidelines are needed.
Learning Objective: To determine whether ICD-9-CM
codes 696 and 706 for psoriasis and acne, respectively, accurately identify patients with these clinical diagnoses.
Takeaway Message: The ICD-9-CM codes for Psoriasis
(696) and Acne (706), in a dermatology setting, can be used
as tools to identify this group of patients from administrative
databases to conduct future studies in dermatology.
P8.08
A collaborative effort between
dermatologists and orthopedic surgeons to
develop a controlled trial examining the role
of patch testing for metal sensitivity in the
perioperative setting
Kristin L. Noiles1 Gillian de Gannes1, 2
1. University of British Columbia Dermatology,Vancouver, BC; 2. University of
British Columbia Contact Dermatitis Clinic,Vancouver, BC
Introduction: The role of patch testing for metal sensitivity in the perioperative setting is unknown. Evidence based
guidelines are lacking with the majority of current recommendations based on retrospective studies, case reports, and case
series.
P8.09
Erythrokeratodermia variabilis: migratory
skin lesions resolved with acitretin
Ari Juda1 John Kraft2
1. Schulich School of Medicine and Dentistry, University of Western Ontario,
London, ON; 2. Lynde Dermatology, Markham, ON
Introduction: Erythrokeratodermia variabilis (EKV) is
a rare condition characterized by the co-existence of 1)
transient migratory circinate erythematous lesions and 2)
fixed hyperkeratotic plaques, most commonly in the extremities, trunk and buttocks. It typically presents initially at birth
or within the first year of life. EKV is generally inherited in
an autosomal dominant fashion and stems from defects in
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specific connexin genes, GJB3 and GJB4, which each encode
for a different gap junction protein. EKV is a clinical diagnosis
and dermatopathologic features are non-specific, but include
orthokeratotic hyperkeratosis, papillomatosis, acanthosis, and
vascular dilatation.
Mild presentations of EKV often respond well to topical keratolytics and retinoids. Extensive skin involvement is optimally
treated with systemic retinoid therapy, with low doses of
acitretin, a 2nd generation retinoid, often the drug of choice.
Low doses have been found to have success in clearing lesions.
Case: A 48 year old female with a longstanding history of
EKV presented to clinic with characteristic lesions present on
her trunk for over 20 years. She was significantly distressed
by the lesions, attempting to hide them from her husband
over this period. Examination showed figurate erythematous
plaques present on her trunk. Patient was started on a trial
of acitretin, 10 mg/day orally for 2 months, at which time the
lesions had resolved. At 8 month follow-up she remained clear
of all lesions.
Discussion: EKV is a rare dermatogenetic disorder. Our
case demonstrated successful resolution of lesions on a low
dose (10 mg/day) oral trial of acitretin, after 2 months of treatment. Follow-up at 8 months showed no recurrence, while
improving the patient’s quality of life.
Learning Objective: Demonstrate understanding of
proper identification and medical management of EKV.
Takeaway Message: EKV is a rare condition that can
significantly affect quality of life. Low-dose acitretin therapy can
be successful in clearing of lesions.
Methods and Results: A 25-question dermatology handbook was created. These questions were based on concepts
listed in the medical school curriculum objectives. These
handbooks were distributed to third and forth year medical
students at the start of their Ottawa dermatology rotation.
Residents and staff were made available to meet with students
as needed to review the material and a final answer document was distributed. At the end of the rotation, students
were asked to complete a survey regarding how and why the
booklet was used, what aspects they liked about it, and suggestions for improvement. Results were encouraging: 88% of
students used this tool, 62% made use of it one to three times
per week and 79% of students that responded stated that they
would be interested in doing another elective in dermatology.
Conclusions: With limited number of dermatology staff
and clinics combined with a large number of medical students,
creative methods of teaching dermatology to future physicians
are required. Supplemental resources, such as this dermatology handbook, can be used to direct one’s learning while not
in clinic. Future prospects include interactive electronic versions of this handbook – with quizzes, tutorials, and procedural
videos.
Learning Objective:
1. To appreciate the adjuvant teaching tools that can be provided to medical students during a dermatology rotation.
2. How to assess the use and usefulness of a supplemental
resource for medical students during a dermatology rotation.
Takeaway Message: Creative and interactive methods of
teaching dermatology to future physicians are required.
P8.10
P8.11
The implementation of a dermatology
handbook in medical student education at
the University of Ottawa
Intravenous immunoglobulin (IVIG) for the
treatment of recalcitrant atopic dermatitis
Margaret J. Mioduszewski
Monica K. Li; Beata Komierowski; P. Régine Mydlarski
University of Ottawa, Ottawa, ON
Division of Dermatology, University of Calgary, Calgary, AB
Introduction: Medical students receive limited exposure to
dermatology. The amount of time that is devoted to dermatology teaching during medical school can range from zero to ten
hours. Despite this limited amount of teaching, these future
physicians are expected to diagnose and manage patients with
several kinds of skin manifestations. The intent of this study
was to determine if a supplemental dermatology handbook
could help enhance medical knowledge in dermatology, direct
medical students’ learning, and stimulate interest in the discipline.
Background: Atopic dermatitis (AD) is a chronic, relapsing skin disorder affecting between 3.7 and 9.5% of adults.
Although most patients can be effectively treated with topical
agents, there is a subgroup of patients who require systemic
immunosuppression to achieve disease control. Unfortunately,
some patients have recalcitrant disease or develop adverse
events from systemic therapy. Intravenous immunoglobulin
(IVIG) displays various immunomodulatory and anti-inflammatory properties that make it a candidate for the treatment of
AD. Though there are reports on the use of IVIG in adult AD,
the results are inconsistent.
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Objective: To describe our experience and review the literature on use of IVIG in the treatment of adult AD patients with
severe, recalcitrant disease.
Methods: A retrospective chart review was performed
on 11 adult patients with severe, resistant AD. Patients who
were assessed in the Immunodermatology Clinic, University of Calgary between March 2007 and July 2012, received
high-dose IVIG infusions (i.e., 2 g/kg/month). Clinical response
was determined by: (1) change in SCORAD (SCORing Atopic
Dermatitis) skin scores from baseline to cessation of treatment; and (2) serum immunoglobulin E (IgE) levels at baseline
and throughout IVIG therapy.
Results: Adults with recalcitrant AD received IVIG for a
mean of 12.7 months, with initial signs of improvement noted
by three months of therapy. IVIG treatment resulted in significant reductions in both SCORAD skin scores and serum IgE
levels, thereby allowing systemic immunosuppression to be
tapered. Fewer infection-related exacerbations were noted,
and no significant adverse events were attributable to the IVIG
infusions.
Conclusion: In adults with severe, recalcitrant AD, IVIG provides a safe and effective therapeutic option. Larger, randomized controlled trials are required to validate the use of this
promising therapy.
Learning Objective: To review the safety and efficacy of
intravenous immunoglobulin (IVIG) in the treatment of recalcitrant atopic dermatitis in adults.
Takeaway Message: Intravenous immunoglobulin is a safe
and effective treatment option for patients with severe, recalcitrant atopic dermatitis.
Methods, Results: A retrospective review was carried out
on patients with POD seen at Vancouver General Hospital
Skin Care Centre, University of British Columbia, between
June 1, 2003 to June 1, 2013. Charts with an ICD9 diagnostic
code of 695.3 (Rosacea or Perioral Dermatitis) as reported
to the British Columbia Medical Services Plan were selected,
and those with rosacea were excluded. A total of 229 patients,
ranging from 9 to 85 years of age, were included. Eighty-three
percent of patients were female. The average age at presentation was 43. Fifty-one percent of patients presented with
perioral involvement, 10% presented with periocular involvement and 3% presented with perinasal involvement. Thirty-six
percent of patients had POD for greater than 12 months at
presentation. Prior use of topical corticosteroids was reported
in 68% of cases. Systemic minocycline was the most common
effective treatment regimen in 66% of patients.
Conclusions: The retrospective data is consistent with
previous literature on POD. POD affects patients of all ages
although the average age of onset appears to be in the fourth
decade. It occurs more frequently in female patients, generally
involves one area of the face, specifically the perioral area, and
is associated with previous systemic steroid or topical corticosteroid use. Treatment with minocycline is one of the most
common successful therapies for POD.
Learning Objective: To discuss findings from one of the
largest cohorts of patients with POD studied with regards to
epidemiology, etiology, clinical presentation, and effective treatment options.
Takeaway Message: Periorificial dermatitis affects patients
of all ages, occurs more frequently in females, generally involves the perioral area and treatment with minocycline is one
of the most common effective therapies.
P8.12
P8.13
Periorificial dermatitis: a review of 229 cases
Open-label pilot study of acitretin for the
treatment of severe chronic hand dermatitis
Diana Lam1 Kristin Noiles1 Shannon Humphrey1, 2
1. University of British Columbia,Vancouver, BC; 2.Vancouver Coastal Health
Research Institute,Vancouver, BC
Introduction: Periorificial dermatitis (POD), also known
as perioral dermatitis, is a cutaneous inflammatory disorder
with an unknown etiology that commonly presents in children,
young or middle-aged females. Although its pathogenesis is
incompletely understood, it has been associated with the use
of both topical corticosteroids and cosmetics. A large chart
review was completed of patients with POD with the aim of
adding to the current understanding of POD, particularly with
regards to potential etiologic factors, unique demographic
information and effective treatment regimens.
Jerry Tan2 Simon Nigen1 Catherine Maari1 Chantal Bolduc1
Robert Bissonnette1
1. Innovaderm Research Inc., Montreal, QC; 2.Windsor Clinical Research Inc.,
Windsor, ON
Introduction: Chronic hand dermatitis can be a severe and
debilitating condition. A proof of concept study suggested that
acitretin, a systemic retinoid currently approved for the treatment of psoriasis, could improve mild to moderate chronic
hand dermatitis. The objective of this study was to explore the
safety and efficacy of acitretin in patients with severe chronic
hand dermatitis.
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Methods: Open label treatment was initiated with acitretin
10 mg once daily and progressively increased to 30 mg daily
over a period of 4 weeks, as tolerated. Treatment duration was
for up to 24 weeks or until the physician global assessment
(PGA) was clear or almost clear. Hand dermatitis severity was
evaluated using a 5-grade PGA scale and the modified total
lesion symptom score (mTLSS).
gene. The patient’s mother had similar symptoms, but much
milder. She never sought treatment but gets relief with Aveeno
lotion. She was found to carry the same KRT5 mutation. Her
son tried topical retinoids and soriatane with minimal success.
He began using tattoos to camouflage his disease and noticed
an improvement in his symptoms on the tattooed skin. He
reported fewer papules and less pruritis in the tattooed areas.
Results: A total of 9 patients with severe chronic hand dermatitis were enrolled. All patients received acitretin at 20 mg
once a day and it was possible to increase the dose to 30 mg
once daily for 7 patients. The proportion of patients achieving
PGA of clear or almost clear was 33.3% (95% CI: 9-69%) and
the proportion who reached a PGA of clear, almost clear or
mild was 44% (95% CI: 15-77%). The mTLSS was decreased by
45% (-6.3 ±4.7; p=0.02). Three patients did not complete the
study: one withdrew due to lack of efficacy, one because of an
increase in facial dermatitis and one withdrew consent.
Conclusion: We describe two cases of the papular variant
of Dowling-Degos disease in a mother and son. We present
these cases to illustrate the varying severity of Dowling-Degos
disease in two patients with identical genetic mutations. This
suggests that severity is not dictated by the specific keratin
mutation.
We also present the notion of tattooing as an unconventional
coping strategy. Tattoo art has sometimes been used by patients post mastectomy as a way to take creative control over
their post-operative bodies. Although we cannot comment on
whether tattooing actually minimizes the burden of disease, it
is an interesting phenomenon that is gaining popularity among
patients with disfiguring diseases.
Conclusions: This pilot study suggests that acitretin may be
beneficial in severe chronic hand dermatitis. Further studies,
including placebo-controlled studies, are needed to better assess the efficacy and safety of acitretin in patients with severe
chronic hand dermatitis.
Learning Objective: To illustrate two cases of DowlingDegos disease
Learning Objective: To explore the safety and efficacy of
acitretin in the treatment of severe chronic hand dermatitis.
Takeaway Message: There is a spectrum of severity of
Dowling-Degos disease, which is not dictated by the specific
mutation in the KRT5 gene.
Takeaway Message: Acitretin may be beneficial in the
treatment of severe chronic hand dermatitis.
Dowling-Degos disease remains a therapeutic challenge for
dermatologists.
P8.14
P8.15
Two cases of Dowling-Degos disease in a
mother and son
Rachel Vale Lea Velsher
A case of epoxy allergic dermatitis negative
to standardized series
1. University of Toronto,Toronto, ON; 2. North York General Hospital,Toronto, ON
Lin Xing; Melanie D. Pratt
Introduction: Dowling-Degos disease is a rare autosomal
dominant genodermatosis that is caused by a mutation in the
keratin 5 gene (KRT5). Several phenotypic presentations have
been described. Patients may present with reticulate hyperpigmention, comedo-like lesions, pitted acneiform scars or
follicular papules. The lesions may be pruritic and cause emotional distress. Unfortunately, Dowling-Degos disease remains
a therapeutic challenge for dermatologists.
The Ottawa Hospital Division of Dermatology and University of Ottawa, Ottawa,
ON
1
2
Results/Methods: A 31 year-old male was referred to
genetics with a longstanding history of a papular eruption over
his chest and back, and prominent axillary involvement. Histopathologic examination revealed filiform down growth of the
epidermis and multiple small horn cysts, characteristic Dowling-Degos disease. Genetic testing confirmed the diagnosis
and showed a heterozygous p.Gln4Stop mutation in the KRT5
Introduction: Epoxy resins are frequently used chemicals
in industrial adhesives, laminates, electrical equipment, sealants, coating and molds. Sensitization can be seen in workers
who have contact with the uncured material. This is one of the
most common causes of occupational allergic contact dermatitis and carries significant impact on job prospects and quality
of life. Patch testing is the “gold standard” for diagnosis and
standardized screening series of allergens have been developed
for epoxy resins.
Methods: A literature search was performed using Medline
and PubMed with the terms “epoxy”, “resins”, “allergic contact
dermatitis”, “occupational” and “patch test”. Patient record
was reviewed.
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Case: We report a case of 51-year-old female industrial
electronics assembler who presented with a two year history
of pruritic, papulovesicular dermatitis on her fingertips and
nails folds with extension to the hypothenar eminence. She has
been handling circuit boards at work for at least a year. Patch
testing was conducted using The North American Contact
Dermatitis Group Standard Screening Series, Epoxy Series,
Extensive Acrylates Series, Metal Series and additional allergens in the Plastic and Glue Series. Readings were done at 48
and 96 hours. Patient was negative for all series. Further testing was conducted using patient’s workplace materials diluted
to 1% in petrolatum. She was then found to be positive for a
number of epoxy acrylates in those. Arrangements were made
through Worker’s Compensation to transfer her to a different
sector of work and her symptoms resolved within one month.
Conclusions: Previous studies have shown that allergic
contact dermatitis can be missed if the patient is only patch
tested to standardized allergen series. As demonstrated by
our case, we strongly urge including additional patch testing of
suspected sensitizing chemical at the works place.
Learning Objective: To describe a case of epoxy allergic
contact dermatitis negative to standardized epoxy series.
the University of Calgary were randomized into two groups
to receive didactic or group-based education. Dermatology
teaching was provided once monthly for three consecutive months, with pre- and post-tests administered for each
educational intervention. A final test to evaluate long-term
knowledge retention will be administered three months after
the last educational intervention. Only test scores of trainees
who provided consent to the study were analyzed.
Results: Preliminary findings show improvement of scores
from pre- to post-test following dermatology education. Near
significant difference was found in test scores associated
with the first teaching intervention (median pre-test 51% to
post-test 55.2%, p-value 0.11, n=13), and a significant increase
was found in test scores associated with the second teaching intervention (median pre-test 33.4% to post-test 59.6%,
p value 0.03, n=6). No statistical difference in improvement
of test scores were observed between didactic teaching and
group-based learning methods. Further analysis of demographic factors that may affect the acquisition of knowledge, on test
scores for the third teaching intervention, and on knowledge
retention will be performed when the data becomes available.
Conclusion: Preliminary results of our study support the
importance of dermatology education for internal medicine
trainees. Further analysis will provide insights that may contribute to the development of effective dermatology curricula
for this important group of care providers.
Takeaway Message: Apart from the North American
Contact Dermatitis Group Standard Screening Series and
epoxy series, additional patch testing of suspected sensitizing
chemical at the works place is strongly recommended for the
diagnosis of epoxy allergic dermatitis.
P8.16
Teaching dermatology to internal medicine
residents: evaluating the effectiveness of an
educational intervention
Learning Objective: To provide insights on the impact of
a dermatology educational intervention for internal medicine
trainees.
Takeaway Message: Dermatology education has the potential to directly impact the competence of internal medicine
trainees in managing cutaneous problems.
Monica K. Li1 Steve Doucette2 Laurie M. Parsons1
P8.17
1. University of Calgary, Calgary, AB; 2. Research Methods Unit, Capital Health,
Halifax, NS
Background: Internists often encounter dermatologic issues, yet studies have shown that internal medicine trainees
perform poorly at diagnosing skin diseases, and have suboptimal education in dermatology. Specifically, there is no published data comparing different educational interventions in
dermatology and its impact on long-term knowledge retention
in internal medicine residents.
Objective: We aim to evaluate the impact of teaching dermatology to internal medicine trainees, and compare different
educational methods on long-term knowledge retention.
Methods: A prospective, interventional study design was
used. Trainees of the Internal Medicine residency program at
Wait times for routine, urgent and cosmetic
dermatologic care in Ontario
Geeta Yadav1 Jack Resneck, Jr.2 Davina Lau1 Hanna Goldberg3
Chaim Bell1
1. University of Toronto,Toronto, ON; 2. University of California, San Francisco,
San Francisco, CA, USA; 3. University of Western Ontario, London, ON
The field of dermatology is experiencing a physician workforce
shortage, especially in more remote parts of Canada where
patients are waiting longer for routine dermatology appointments. In Ontario, however, there is little empiric data on this
topic. This presentation will give an overview of wait times for
patients seeking medical dermatology services and wait times
for cosmetic procedures. Some have hypothesized that while
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patients with medical dermatology problems face long waits,
those paying cash for cosmetic procedures are seen more
quickly, but this has not been examined in any studies. We will
present data collected through a survey of dermatology practices to discuss the differences between wait times for medical
dermatology (routine and urgent) appointments versus the
wait times for cosmetic procedures. We will be comparing
wait times by region.
Learning Objective: Attendees will learn about the dermatology workforce in Ontario including wait times across the
province and the regional variation for accessibility to routine,
urgent, and cosmetic dermatologic care.
Takeaway Message: This study raises important questions
about workforce adequacy in Ontario and current incentives
for the care of sick patients compared with those who have
cosmetic complaints.
P9-03
Pimples in prepuberty: a five-year-old with
an unusual cause of facial comedones
Learning Objective:
1. Comedones in the pre-pubertal age group are a sign of
early virilization and warrant clinical and laboratory investigations for precocious puberty.
2. 11OHD is an uncommon form of congenital adrenal hyperplasia that can present with early virilization.
3. Early diagnosis of 11OHD is important to prevent virilization, hypertension and short stature in adulthood.
Takeaway Message: Comedones in pre-puberty are never
normal, and should be thoroughly investigated to prevent the
development of serious and permanent sequelae.
P9.01
Neel Malhotra1 Karine Katchadourian2 Daniel Metzger2 Joseph
Lam2
1. University of Alberta, Edmonton, AB; 2. University of British Columbia,
Vancouver, BC
Zinc deficiency and its management in the
pediatric population: A literature review and
proposed etiologic classification
Michael D. Corbo
Introduction: Congenital adrenal hyperplasia (CAH) refers
to a family of inherited disorders caused by a partial or severe
impairment in adrenal steroidogenesis. Over 90% of CAH
cases are caused by a defect in the enzyme 21-hydroxylase and
can present with salt wasting, adrenal crisis and virilization. A
less common cause of CAH is 11β-hydroxylase deficiency
(11OHD).
Methods: We report the case of a 5-year-old boy who
presented with a one-year history of papules over the cheeks,
glabella and ears. His mother noted that he experienced
several episodes of body odor that resolved spontaneously. He
had no history of salt-craving, axillary or pubic hair, or change
in phallus size. Rapid growth was noted in the past six months.
His medical history was otherwise unremarkable. Family history revealed that the paternal grandmother’s first child died
shortly after birth with the cause of death unknown.
Results & Conclusions: Examination revealed multiple
keratotic papules on his cheeks, as well as open comedones
around the inner and outer ears and nose. The facial papules
were initially diagnosed as keratosis pilaris. Facial comedones
may be mistaken for other entities, and the differential diagnosis is large; however, without further investigation, a serious
underlying diagnosis could be overlooked. Testing revealed
a diagnosis of 11OHD. Our patient was treated with hydrocortisone 2.5 mg orally three times per day (8.8 mg/m2/day)
with counseling to double the dose in times of mild illness and
to triple it for moderate-to-severe illness. He appears to be
responding well with the current therapy, but ongoing monitoring is required for central precocious puberty.
University of Toronto,Toronto, ON
Zinc is a trace element essential to the gastrointestinal, immune, integumentary, reproductive, and central nervous systems. Zinc deficiency is prevalent in many areas of the world
and is a diagnostically challenging condition. Cutaneous manifestations typically occur in moderate to severe zinc deficiency
and present as alopecia and dermatitis in the perioral, acral,
and perineal regions. Zinc deficiency is a potentially fatal disease process. The aim of this review is to focus on the cutaneous manifestations, diagnosis, and treatment of zinc deficiency
in children, and to propose an etiologic classification system.
Learning Objective: To review the cutaneous manifestations, diagnostic measures, and treatment options for children
with zinc deficiency.
Takeaway Message: Zinc deficiency can be a diagnostically challenging condition. A proposed etiologic classification
system may help facilitate the diagnosis and management of
zinc deficiency in children.
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CDA Abstracts
P9.02
Rare localized form of infantile Systemic
Hyalinosis in a 45 year old
Methods: A retrospective chart review was performed
from January 2002 to September 2012. Inclusion criteria were
patients under 18 years of age with histopathologic diagnosis
of DFSP. Data on demographics, clinical characteristics, treatments and outcomes were collected.
Jordana Schachter1 Bryan Arthurs2
1. McGill University Department of Dermatology, Montreal, QC; 2. McGill
University Department of Ophthalmology, Montreal, QC
Inherited systemic hyalinosis is a rare inherited disorder
characterized by a broad clinical spectrum encompassing both
infantile systemic hyalinosis and juvenile hyaline fibromatosis.
Clinical features involve multiple subcutaneous nodules composed of hyaline, hyperpigmented skin over bony prominences,
progressive joint contractures, gingival hyperplasia, fleshy perianal lesions, pink pearly papules on the head and neck, bone
lesions and dental abnormalities. In more severe cases there is
involvement of the gastrointestinal system leading to protein
losing enteropathy. Two localized variants have been described
in patients in their 20-30’s with only cutaneous involvement.
We present a case of a 45 year old woman, born to consanguineous parents, diagnosed as juvenile hyaline fibromatosis at
the age of 6 in Syria with a known mutation in ANTXR2 with
localized cutaneous involvement. She has had over 40 surgeries, many with general anesthesia and has had children without
issue. We present this case for interest as she is the oldest
patient described with inherited systemic hyalinosis and has a
localized variant enabling her to have a normal lifespan.
Learning Objective: Review the features of this rare syndrome and the spectrum between infantile systemic hyalinosis
and juvenile hyaline fibromatosis (systemic involvement versus
isolated cutaneous involvement)
The Hospital for Sick Children,Toronto, ON
Introduction: Dermatofibrosarcoma protuberans (DFSP)
is an uncommon low-grade malignant soft tissue tumor. In
children, there are acquired and congenital presentations. Due
to clinical similarities with other conditions, it may associate
with a delayed diagnosis. The objective of this study was to re-
Conclusions: Our study documents the clinical characteristics and treatment of DFSP in pediatric patients. A detailed
medical history and identification of the natural course of
common conditions seen in pediatric patients are important
to identify less common lesions and to suspect DFSP.
Learning Objective: This study documents the clinical
characteristics and treatment of Dermatofibrosarcoma Protuberans in 17 pediatric patients.
Takeaway Message: A detailed medical history and identification of the natural course of common conditions seen
in pediatric patients are important to identify less common
lesions in pediatric dermatology avoiding diagnosis delay.
Evaluation of a triage system based on
the emergency department referrals using
dermatology priority guidelines in a pediatric
dermatology clinic in Toronto, Canada
Claudia J. Posso-De Los Rios; Miriam Weinstein
The Hospital for Sick Children,Toronto, ON
P9.04
Claudia J. Posso-De Los Rios; Irene Lara-Corrales; Nhung Ho
Results: Information was gathered from a total of 17 patients, 9 (53%) were female. Congenital lesions were reported
in 7 patients. The mean delay of diagnosis was 5.7 years; the
most common anatomic location was the trunk in 8/17 (47%)
cases. Treatment options included wide local surgery, Mohs
surgery and imatinib mesylate.
P9.05
Takeaway Message: Inherited systemic hyalinosis is a
disease on a spectrum, encompassing both infantile systemic
hyalinosis and juvenile hyaline fibromatosis. While the disease
may be life threatening for some patients, it is clear that some
will have a mild form which has only cutaneous involvement,
and normal life expectancy.
Dermatofibrosarcoma protuberans in
pediatric patients: a report of 17 cases
view clinical characteristics and treatment of DFSP in pediatric
patients.
Introduction: Triage is used to categorize patients based on
diagnosis and severity to optimize medical attention and patient’s safety. There is lack of information about dermatologic
triage systems in pediatric patients. The objective of this study
was to evaluate the standardized triage system in a dermatology clinic from a tertiary hospital based on the emergency
department referrals.
Methods: A retrospective review of clinical charts from
a tertiary hospital was performed from January 1, 2010 to
March 31, 2010 at the Hospital for Sick Children in Toronto,
Canada. Inclusion criteria included patients evaluated at the
emergency department with a referral to dermatology clinic.
We collected data on the date of the medical evaluations,
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CDA Abstracts
presumptive and final diagnosis. Three evaluations for triage
priority levels were defined: actual, ideal and final. The concordance of priority levels was evaluated.
ing the need of careful follow-up given the broad spectrum of
LCH.
Results: Among total 538 referrals to the dermatology clinic
during the study period, 67 (12%) were cases referred from
the emergency department. The mean waiting time for an
appointment was 83 ± 51 days. Inflammatory diseases were
the most common type of conditions in 32/63 (51%) evaluated cases. Atopic dermatitis (included in the inflammatory
disease category) was the leading cause of referrals. Diagnostic
agreement between the emergency room physician and dermatology clinic physician was 75% based on the final diagnosis.
The concordance of priority level assignments based on final
dermatologic diagnosis varies from 19% to 47.6% for actual or
ideal triage, respectively.
Conclusions: The triage system in our clinic helps to
categorize dermatologic patients based on type and severity of the skin condition in order to prioritize when referred
patients will be seen. A highly accurate diagnosis or assessment
from the emergency department, would allow the best triage
decisions to be made enhancing best care for patients. Our
evaluation shows this accuracy could be improved.
Learning Objective: This study presents new information
about a standardized triage system in a pediatric dermatology
clinic based on the emergency department referrals.
Takeaway Message: A standardized triage system in a pediatric dermatology clinic may help to categorize dermatologic
patients favoring safety and best care for patients.
P9.06
Congenital Self-Healing Reticulohistiocytosis:
cutaneous clinical spectrum
Jérôme Coulombe; Michele Ramien; Afshin Hatami
CHU Ste-Justine, Montreal, QC
Langerhans cell histiocytosis (LCH) is an uncommon disorder
of unknown etiology that may occur at any age. The congenital form is even rarer and have been described as a single or
multi-organ disease with or without organ dysfunction. Skin
manifestations are frequent and critical in accurate diagnosis and management. However, cutaneous presentations of
congenital LCH are variable and can be misleading. Thus, we
present two recent cases of congenital self-healing reticulohistiocytosis (formerly Hashimoto-Pritzker disease) seen in our
pediatric dermatology clinic in CHU Ste-Justine to highlight
and describe it’s polymorphous presentation. We also briefly
review appropriate management of those patients emphasiz-
Learning Objective: To recognize dermatologic presentation of congenital self-healing reticulohistiocytosis.
Takeaway Message:
1. Congenital self-healing reticulohistiocytosis presentation is
variable.
2. Ruling out systemic involvement is imperative.
3. Despite the self-healing clinical course long term follow-up
is indicated.
P9.07
Retrospective review of relapse after
systemic cyclosporine in children with atopic
dermatitis
Cathryn Sibbald1 Nhung Ho1, 2 Elena Pope1, 2 Miriam Weinstein1, 2
1. University of Toronto,Toronto, ON; 2. Hospital for Sick Children,Toronto, ON
Background/Objectives: Cyclosporine is a systemic
therapy used for control of severe atopic dermatitis (AD) in
children. Although traditionally recommended at a dose of
5mg/kg/day for 6 months, longer duration of treatment may
be necessary to bring a child with active and severe disease
into remission. There is little data on the short and long term
effectiveness of longer courses of therapy.
Methods: A retrospective chart review of children treated
with cyclosporine at a Canadian hospital-affiliated clinic between 2000 and 2013.
Results: Fifteen patients were identified with adequate
follow-up. Twelve patients (80%) were male, and the mean age
at initiation of cyclosporine was 11.20 ± 3.41 yrs. The mean
duration of cyclosporine therapy was 10.86 ± 2.70 months
(range 7-15), at a starting dose of 2.83 ± 0.59 mg/kg. Twelve
patients (80%) responded to cyclosporine. Of these, 5 patients
had relapsed (42%) at a follow-up of 22.67 ± 15 months. Duration of therapy was longer in patients who did not relapse
(17.71 ± 10.69 versus 10.2 ± 2.70, 0.06). Adverse events led
to discontinuation in 3 patients (20%) and included infectionrelated complications in 2 patients and reversible renal toxicity
in 1 patient.
Conclusions: These results suggest that a longer duration
of low dose cyclosporine may help decrease risk of relapse in
patients with severe AD who are resistant to topical therapies.
Learning Objective: To report on the relapse rate of
atopic dermatitis and time to relapse after treatment with
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cyclosporine in a pediatric cohort, determine any predictors of
sustained remission, and describe adverse effects
Takeaway Message: A longer duration of low dose cyclosporine may help decrease risk of relapse in patients with
severe AD who are resistant to topical therapies
P9.08
Ataxia-telangiectasia associated with noninfectious granulomas
Learning Objective: Non-infectious cutaneous granulomas
may be associated with primary immunodeficiencies, such as
ataxia-telangiectasia.
Takeaway Message: The presence of multiple noninfectious granulomas in a child may be the initial sign of an
immune deficiency and should alert the astute clinician to
investigate for an underlying primary immunodeficiency.
Ilya Shoimer; Richard M. Haber
University of Calgary, Calgary, AB
Introduction: Ataxia–telangiectasia (A-T) is a rare autosomal recessive disorder that is characterized by cerebellar
ataxia, oculocutaneous telangiectasias, pulmonary infections,
chromosomal instability, immunodeficiency, and malignancy.
Other cutaneous features of A-T include hyper- and hypopigmented macules, vitiligo, café-au-lait macules, seborrheic
dermatitis, premature graying of the hair, and premature aging.
Rarely, primary immunodeficiency disorders, such as A-T, may
also be associated with cutaneous granulomas.
P9.09
An unusual case of congenital blue nevus
Sophie Vadeboncoeur; Julie Powell;Victor Kokta
Université de Montréal, Montréal, QC
Case Report: A three-year-old boy with A-T and an associated immunodeficiency presented to the clinic with a one-year
history of non-resolving erythematous nodules on the right
arm and left thigh. The lesions were thought to be triggered by
mosquito bites. Subsequently, the lesions became pruritic and
crusted. Histopathology revealed a necrotizing granulomatous
dermatitis; however, no organisms were detected with special
stains and cultures. The patient was started on clobetasol
cream under occlusion. Six weeks later, the lesions revealed
marked improvement.
Discussion: There have been nineteen cases reported in
the literature of non-infectious granulomatous inflammation
associated with A-T. Individuals with A-T most often present
in childhood with cutaneous granulomas involving the face
and extremities. The lesions may present as papules, plaques,
or nodules that often become crusted, atrophic, or ulcerated. Histopathology of these lesions is quite variable; the
reported findings include non-necrotizing epithelioid granulomas (sarcoid-like), caseating granulomas (tuberculoid-like), or
necrobiotic granulomas. As such, these presentations may be
misdiagnosed as sarcoidosis or necrobiosis lipoidica. Noninfectious granulomas have also been associated with other
primary immunodeficiencies, including common variable immunodeficiency, chronic granulomatous disease, combined immunodeficiency, X-linked hypogammaglobulinemia, Wiskott-Aldrich syndrome, X-linked hyper-IgM syndrome, and Nijmegen
breakage syndrome. Moreover, granulomatous inflammation
may also involve the joints, lungs, liver, spleen, and conjunctiva.
Conclusion: Non-infectious cutaneous granulomas may
be associated with primary immunodeficiencies, such as A-T.
As such, the presence of multiple non-infectious granulomas
in a child may be the initial sign of an immune deficiency and
should alert the astute clinician to investigate for an underlying
primary immunodeficiency.
Introduction: Blue nevi are present in less than 1/3000
newborns and are generally acquired. Different histopathologic
variants exist including common, plaque-like, cellular, deeppenetrating, epithelioid (associated with the Carney complex),
sclerosing, hypopigmented, compound and atypical blue nevi.
We report a case of an atypical congenital cellular digital blue
nevus.
Methods/Results: A 3 year old male patient was referred
to our dermatology clinic for evaluation of an atypical nodule
on the dorsum of a finger. It was first noticed at birth and
was initially blue in color. It has grown proportionately to the
child’s growth and has slightly faded in color. On examination,
a firm, slightly mobile, skin colored with a blue halo nodule
measuring 1,5 X 1,0 cm was noticed on the dorsum of the
proximal interphalangeal joint of the right index. No limitation
in movement or pain upon palpation was noted. Our initial
differential diagnosis included an infantile localised myofibroma,
an atypical infantile digital fibroma or any other fibrohistiocytic
localised tumor. A punch biopsy was performed and revealed a
dense population of dendritic pigmented dermal melanocytes
compatible with a cellular blue nevus, which is a benign melanocytic tumor. Typical locations are the sacrum, dorsal hand
and dorsal foot, where dermal melanocytes are generally most
numerous. When they are of 1- 3 cm in size, they are classified
as plaque-type. Melanoma may develop in a cellular blue nevus,
although this seems to be rare.
Conclusion: Surgical excision is not always indicated although it should be considered because of its rare malignant
potential. However, a careful clinical follow-up is necessary.
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Learning Objective: Review the clinical and histopathological subtypes of blue nevi, as well as there occasional associated conditions.
the management of AD, and reduce the number of appointments required to manage AD.
Takeaway Message:
1 Blue nevi are generally acquired but may rarely be congenital.
2 Cellular blue nevi have an increased risk of melanoma
development.
3 Surgical excision is not always indicated, although clinical
follow-up is necessary.
P9.10
The Children’s Hospital of Eastern Ontario’s
eczema action plan
Maxwell B. Sauder; Alana C. McEvoy; Nordau Kanigsberg
University of Ottawa, Ottawa, ON
Introduction: Atopic Dermatitis (AD) is a pruritic dermatosis that is chronic and relapsing, making it a complex disease
to manage in the pediatric population. There is a growing
body of literature supporting the use of action plans in the
management of AD. An action plan specifically outlines the
various severities of AD an individual can experience as well
as a therapeutic ladder. In one study, after 3 months of using
an eczema action plan (EAP), 86% of parents found it helpful
with 80% rating their child’s eczema on a lower severity scale.
It is believed that the use of an EAP in the dermatology clinic
at The Children’s Hospital of Eastern Ontario (CHEO) will
improve patient adherence and treatment outcomes in the
pediatric population suffering from this chronic disease.
Learning Objective: To showcase the Children’s Hospital of Eastern Ontario’s Eczema Action Plan currently being
studied.
Methods: The EAP is a single page, carbon copied sheet
that outlines a therapeutic ladder for managing children with
AD. Specifically, it outlines three different treatment scenarios:
under control, eczema flare and eczema out of control. Four
copies of the EAP distributed among the patient, pharmacist,
primary care physician, and health records to ensure continuity of care.
Takeaway Message: Eczema action plans are relatively
simply to create and implement. This project will hopefully
demonstrate the value of this or similar plans with improved
treatment adherence, improved parental comfort and understanding the management of atopic dermatitis, and reduced
number of appointments required to manage atopic dermatitis.
The EAP will be implemented to all patients at the CHEO
dermatology clinic, while subjective and objective data of the
patient experience will be measured using surveys and a threeitem severity scale. This will be compared against current
management of eczema at CHEO.
Conclusion: The abstract will focus on the EAP form and
study design. Once completed, this project will hopefully
demonstrate that an EAP will improve quality of care in the
pediatric population suffering from AD. Specifically, the goals
of this project are to: improve adherence with individualized
treatment plans, improve parental comfort and understanding
P9.11
Linear atrophoderma of moulin: an
underrecognized entity
Omid Zahedi Niaki1 Wendy Sissons2 Van-Hung Nguyen2 Ramin
Zargham1 Fatemeh Jafarian2
1. McGill University, Montreal, QC; 2. Montreal Children’s Hospital - MUHC,
Montreal, QC
Linear atrophoderma of Moulin (LAM) is an acquired skin
condition that manifests in early childhood and adolescence. It
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likely represents a form of cutaneous mosaicism that presents
with linear, hyperpigmented and atrophic lesions appearing
on the trunk and limbs. Its clinical appearance varies and may
closely resemble localized forms of scleroderma. It usually follows a benign course and no effective treatment options exist.
We present a case of a young and healthy patient that developed such lesions on her upper and lower extremities over 5
years. The initial clinical impression of linear scleroderma was
reviewed in favor of LAM following histological examination
of the lesions which revealed no significant inflammatory and
sclerotic changes. LAM remains a rare and possibly underrecognized entity with few reports in the dermatologic literature.
This case highlights the importance of recognizing LAM and
distinguishing it from localized forms of scleroderma given the
significant differences in management options and prognosis.
pairment is an important complication and requires intensive
physical therapy.
SSS is essentially a diagnosis of exclusion in the differential
of sclerodermoid disorders. Clinical evolution (descriptive
and pictorial), investigation, and management of our cases are
discussed to highlight characteristic features of this difficult-todiagnose entity.
Learning Objective: To make the clinician aware of this
condition in the differential diagnosis of pediatric sclerodermoid disorders.
Takeaway Message: Stiff skin syndrome is a rare condition that should be considered in children presenting with skin
hardening and thickening in a limb girdle distribution.
Learning Objective:
P9.13
1. To recognize clinical features of Atrophoderma of Moulin.
2. To discuss the histopathological features’ of Atrophoderma
of Moulin.
3. To discuss the management of this entity.
Takeaway Message: LAM is an underrecognized disease
that can easily be confused with other entities showing similar
patterns of distribution, atrophy, and hyperpigmentation. No
effective treatment options have yet been identified for this
condition.
A case of SCN9A-related inherited
erythromelalgia
Michele Ramien1, 2 Jérôme Coulombe1 Afshin Hatami1
1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of
Dermatology, University of Ottawa, Ottawa, ON
P9.12
Stiff skin syndrome - a case series from CHU
Sainte-Justine
Michele Ramien1, 2 Jérôme Coulombe1 Danielle Marcoux1 Julie
Powell1
Erythromelalgia is characterized by recurrent episodes of
burning pain aggravated by warmth and relieved by cooling,
erythema, warmth and swelling of the extremities. There are
3 major types: associated with thrombocythemia (Type 1),
primary/idiopathic (Type 2), and associated with other underlying diseases (Type 3). Type 2 or inherited erythromelalgia
(IEM) is autosomal dominant and caused by mutations in the
voltage-gated sodium channel subunit Nav1.7 (SCN9A). No
accurate prevalence data is available, but IEM is very rare and
likely underreported.
We present a case of confirmed SCN9A-related inherited
erythromelalgia to detail the clinical presentation and evolution. We review the management approach for erythromelalgia.
Our patient suffers from extreme pain that remains poorly
controlled in spite of the plethora of specific and non-specific
therapies trialed.
1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of
Dermatology, University of Ottawa, Ottawa, ON
Stiff skin syndrome (SSS) is a rare disorder with approximately
40 reported cases in the literature. It classically presents with
stony-hard skin predominantly affecting the hip and pelvic
girdle areas, limited joint mobility, and mild hypertrichosis in
infancy or early childhood. Differential diagnoses include deep
morphea, systemic sclerosis, eosinophilic fasciitis and scleredema but SSS is histopathologically distinct. We present 2 cases
of SSS followed at our institution.
Given IEM’s significant cutaneous manifestations, dermatologists are often implicated early. Heightened awareness of this
condition can promote early diagnosis and appropriate management of these challenging patients. Therapeutic suggestions
are welcomed.
Our patients both presented in early childhood with indurated skin in the hip girdle area that was initially diagnosed
and treated as deep morphea. Imaging and pathology were
consistent with the proposed diagnosis of SSS. Both cases have
remained treatment-refractory, displaying slow progression
despite aggressive immunosuppressive therapy. Functional im-
Learning Objective: To describe the presentation and
evolution of IEM.
Takeaway Message: IEM is a rare condition that presents
with cutaneous manifestations and significant pain that is difficult to manage.
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P9.14
P10.01
Harlequin ichthyosis case report update:
questioning the need for Acitretin
Topical vitamin E in the prevention of visible
light induced pigmentation
Robin Wiviott; Fatemeh Jafarian
Alexandra Mereniuk1 Robert Bissonnette2
McGill University, Montreal, QC
1. Université de Montréal, Montreal, QC; 2. Innovaderm Research Network Inc,
Montreal, QC
Introduction: Harlequin Ichthyosis is a rare congenital
condition in which the baby is born encased in “armour-like”
plates that are separated by deep dermal fissures. Over the
last two decades, treatment with oral retinoids has been associted with dramatically increased survival. We present a case
of a male infant with HI who survived past the neonatal period
after very early cessation of Acitretin. Though Acitretin was
later resumed, it was again discontinued secondary to Pseudotumor Cerebri. Other complications will also be discussed.
Methods: The baby was born with the typical phenotype of
HI. Acitretin was started within the first 24 hours, but after
four doses, it was discontinued in favour of supportive care.
The thick plaques began to shed at nine days of life, and by day
12 the skin was much improved.
The Acitretin was resumed at 1 month of life. At a routine
ophthalmologic exam at 13 months, the baby was found to
have papilledema. Elevated intracranial pressure was confirmed
with MRI. Suspected as the cause, the Acitretin was stopped,
and until now, presently 29 months, the skin has not worsenned. Subsequent examinations revealed normalized cranial
pressure.
To the best of our knowledge, this is the first case of pseudo
tumor cerebri in harlequin ichthyosis treated with Acitretin.
Conclusion: Harlequin Ichthyosis is a rare autosomal recessive condition in which Acitretin has been uesd to improve the
survival. This case, however, questions the need for Acitretin
since early discontinuation was still associated with accelerated shedding of the think plaques, and there was no worsening
of the skin when it was later discontinued for a second time.
Considering the potential side effects associated with long
term usage of oral retinoids, such as pseudotumor cerebri,
this case suggests that the use of Acitretin for HI should be
reexamined.
Learning Objective:
1) Review the pathogenesis and treatment of Harlequin
Ichythyosis.
2) Examine a case of a rare condition with rare complications.
Takeaway Message: This case questions the need for
Acitretin in the treatment of Harlequin Ichtyosis
Visible light has been shown to induce an increase in pigmentation on skin phototypes IV to VI. Studies on human skin
equivalents demonstrated a potential for the use of topical
antioxidants in preventing visible light induced pigmentation. We conducted a double-blind intra-subject randomized
controlled trial to assess the efficacy of topical vitamin E for
the prevention of pigmentation induced by visible light on skin
phototypes IV and V.
Ten healthy adult subjects exhibiting visible light induced
pigmentation were randomized to receive a cream containing 20% vitamin E (Webber First Aid Cream) on one half of
their back and control (Eucerin® Cream) on the other. Areas
of 0.9 cm2 where the creams were applied were exposed
to 40Jcm-2 to 640Jcm-2 of visible light using a filtered quartz
halogen lamp. Study endpoints included the assessment of the
mean lowest fluence inducing pigmentation 7 days after light
exposure, the difference in pigmentation intensity as measured
by chromameter (L*component), and the protection factor of
the vitamin E cream against visible light.Visible light exposure
increased skin pigmentation; the mean difference in pigmentation (L*component of chromameter) between non-exposed
and exposed skin was 3.36 (p<0.005) at 320Jcm-2 and 6.85
(p<0.005) at 640Jcm-2 for skin with antioxidant, and 3.73
(p=0.005) at 320Jcm-2 and 6.23 (p<0.005) at 640Jcm-2 for skin
with control. The mean lowest fluence inducing pigmentation
7 days after visible light exposure was 280Jcm-2 for skin with
vitamin E against 216Jcm-2 for skin with control (p=0.182). The
difference in pigmentation intensity (L*component) between
skin with vitamin E and control were not statistically significant.
There was no statistically significant difference in pigmentation
between skin where vitamin E cream was applied and where
control cream was applied prior to visible light exposure.
Further studies are needed to develop effective methods to
protect against visible light induced pigmentation.
Learning Objective: Could topical vitamin E prevent visible light induced pigmentation in skin phototypes IV and V?
Takeaway Message: The use of a 20% vitamin E cream
alone did not prevent visible light induced pigmentation.
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P10.02
Construction and validation of skin
phantoms for optical modeling
Diana Y. Diao1 Lioudmila Tchvialeva1 Gurbir Dhadwal1 Harvey
Lui1, 2 David McLean1 Tim Lee1, 2, 3
Learning Objective: To become familiar with various types
of skin phantoms and the fabrication and validation processes
of the proposed rough skin phantom for modeling light propagation in skin.
Takeaway Message: Our method of phantom fabrication
creates durable skin phantoms that possess both controllable
surface roughness and bulk optical properties that simulate
human skin, and can be used in studies involving light interactions with surface and volume scattering.
1.Vancouver Coastal Health Research Institute and University of British
Columbia, Department of Dermatology and Skin Science, , Photomedicine
Institute,Vancouver, BC; 2. BC Cancer Agency, Departments of Cancer Control
Research and Integrative Oncology,Vancouver, BC; 3. Simon Fraser University,
School of Computing Science, Burnaby, BC
Introduction: When laser illuminates skin, the remitted light
pattern contains information on the surface and bulk properties of the skin. To study how light interacts with skin, manufactured skin phantoms are often used to model light propagation. However, existing phantoms overlook the important
effect of surface roughness on light propagation patterns. Skin
roughness is an important biophysical feature that is influenced
by various factors, including lesion malignancy. Our team has
been studying laser speckle imaging which analyzes interference patterns from light scattered from rough surfaces. This
technique has shown potential for in vivo lesion differentiation and skin roughness measurement. To further improve the
accuracy of this technique, we aimed to construct and validate
skin phantoms that possess both controllable surface roughness and bulk optical properties suitable for modeling light
interaction with skin.
Methods and Results: We reviewed existing designs of
phantoms and concluded that the solid phantom approach
is the only viable technique for controlling both bulk optical
properties and surface roughness. Silicone and silica microspheres were used to mimic the skin scattering property, while
the surface roughness was created by curing the phantoms
over standardized roughness metal plates. Optical profilometry and unscattering transmission (ballistic photons) were
used to validate the surface and optical attenuation properties
of the phantoms, respectively. Two solid phantoms with seven
rough surfaces each reliably produced the desired surface
roughness values in the range of normal human skin (reported
literature values range between 15 and 50µm), with 10% or
less variability. The measured bulk attenuation coefficients
(62±4 cm-1 and 89±5 cm-1 for phantoms #1 and #2 respectively) fall within the calculated theoretical range and are in
agreement with previously reported values.
Conclusion: We created skin phantoms with surface roughness and bulk optical properties that simulate human skin.
Construction of these phantoms will help further improve our
non-invasive device for skin disease diagnosis. Initially created
to study laser speckle, these phantoms can also be used for
other optical modeling studies of skin.
P10.03
Scleromyxedema initially mimicking diffuse
cutaneous mastocytosis and improving with
phototherapy
Steven J. Glassman
University of Ottawa, Ottawa, ON
Introduction: Diffuse cutaneous mastocytosis and scleromyxedema are rare disorders that have not been reported
together. Diffuse cutaneous mastocytosis represents the most
extreme and rarest form of cutaneous mastocytosis, especially
in adults, and despite its severity is seldom associated with systemic mastocytosis. Itch and blistering occur, with diffuse skin
infiltration, leonine facies and erythroderma. Scleromyxedema
is a recalcitrant disease that represents a generalized form
of primary cutaneous mucinosis, often with serious systemic
symptoms. It presents with myriad waxy papules and increasing skin infiltration and sclerosis mimicking systemic sclerosis.
Leonine facies can be seen in scleromyxedema, which is invariably associated with a monoclonal gammopathy.
Case: a previously healthy 60-year-old man presented with
erythroderma following several months of intense paroxysmal
pruritus, skin thickening and tightening, and occasional blisters.
Examination revealed dull-red exfoliative erythroderma, diffuse skin thickening with leonine facies, leg edema and sparse
bullae. Skin biopsies showed a diffuse dense dermal infiltrate
of mononuclear cells compatible with mast cells (LCA+ and
CD117+). Mucin was not conspicuous. Serum tryptase was
elevated at 20.4ng/ml. Serum protein electrophoresis and
bone marrow biopsy were normal, and c-KIT mutation in the
marrow was negative. A diagnosis of diffuse cutaneous mastocytosis was entertained and he was treated with narrowband
ultraviolet B for the pruritus, with surprising improvement.
Erythema diminished and blistering ceased but there was persistent and increasing skin induration. Oral methotrexate was
added without improvement, and his skin became increasingly
sclerotic with microstomia and sclerodactyly. A papular waxy
element became very prominent on the scalp, arms and legs,
and repeat skin biopsy showed a proliferation of fibroblasts
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with abundant mucin and fibrosis, consistent with scleromyxedema. Repeat serum protein electrophoresis showed a
monoclonal gammopathy, but the bone marrow biopsy was
unaltered. Phototherapy and methotrexate were stopped, and
intravenous immunoglobulin is being considered as the next
line of therapy.
attending more than 10 tanning sessions (OR=1.34 [1.051.71]).
Conclusion: Exposure from over 10 tanning sessions is most
strongly associated with a subsequent melanoma diagnosis
and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning
technology is not safer than older models.
Conclusion: Pruritus and erythema can be prominent early
features of scleromyxedema, possibly a result of mast cell
infiltration. The case also highlights the role for phototherapy
in symptom control.
Learning Objective: To update the dermatologist on the
latest evidence of the association of melanoma and indoor
tanning.
Learning Objective: Examine the overlapping clinical
features and treatment of diffuse cutaneous mastocytosis and
scleromyxedema.
Takeaway Message: Indoor tanning increases melanoma
risk. We performed a meta-analysis of the literature, which
observed increased risk particularly after 10 tanning sessions.
Risk estimates based on number of sessions facilitates patient
risk assessment and patient education.
Takeaway Message: Scleromyxedema can cause severe
pruritus which can be relieved with narrowband ultraviolet B
phototherapy.
P11.01
The association of indoor tanning and
melanoma in adults: systematic review and
meta-analysis
Sophia A. Colantonio1 Jennifer Beecker1 Michael B. Bracken2
P11.02
Analysis of signal transducers and activators
of transcription (STAT) mRNA and protein
expression in Cutaneous T Cell Lymphoma
(CTCL) patients and patient-derived cell lines
Ivan V. Litvinov1 Brendan Cordeiro 1 Hanieh Zargham 1 MarcAndre Doré 2 Martin Gilbert2 Youwen Zhou3 Thomas S. Kupper4 Denis Sasseville 1
1. University of Ottawa, Ottawa, ON; 2. Susan Dwight Bliss Professor of
Epidemiology, New Haven, CT, USA
1. McGill University, Montreal, QC; 2. Laval University, Quebec City, QC; 3.
University of British Columbia,Vancouver, BC; 4. Harvard University, Boston, MA,
USA
Introduction: The purpose of this systematic review and
meta-analysis was to determine the association of melanoma
from the use of indoor tanning beds worldwide in terms of
frequency of use, and use of newer tanning beds.
To date, no meta-analysis had separately examined the association in geographical subgroups and in persons under the age of
25. In addition, a dose-dependent relationship between sunbed
use and the association of melanoma is vaguely defined in the
literature. We quantified this association in metrics that are
more easily understood and personally relevant to patients.
Our analysis is novel in the delineation of use of newer tanning
beds, captured in the subgroup of studies from the year 2000
and onward.
Methods/Results: We searched Scopus, Medline, CINAHL
on August 14, 2013. We included all observational studies with
melanoma patients who had indoor tanned.
Thirty-one studies were included with data available on 14,956
melanoma cases and 233,106 controls. Compared to never
using, the OR for melanoma associated with ever using indoor
tanning beds was 1.16 [95% CI 1.05–1.28]. Similar findings
were identified in recent studies with enrollment occurring in
the year 2000 onwards (OR=1.22 [1.03–1.45]) and in subjects
Many recent studies attempted to elucidate the pathogenesis
of CTCL. Persistent activation of transcription factors of the
signal transducers and activators of transcription (STAT) genes
has been implicated in the pathogenesis of a variety of cancers,
including CTCL. While a number of STAT signaling members
including STAT3, STAT4 and STAT5 have been extensively
studied, the role of other STAT proteins in CTCL remains
only partially understood. Hence, we wanted to investigate
the expression of STAT signaling members in CTCL patients,
normal skin samples, lesional skin from benign inflammatory
dermatoses and in 11 patient-derived CTCL cell lines. Our
findings demonstrate that STAT1, STAT2 and STAT3 were
heterogeneously expressed in CTCL lesional skin and in nonmalignant skin biopsies, STAT4 and STAT5A were preferentially
expressed in CTCL samples, while STAT5B and STAT6 were
primarily expressed in normal skin and in benign inflammatory
dermatoses. We further report the expression of STAT mRNA
and proteins in 11 patient-derived CTCL cell lines and document that such expression is upregulated by T cell stimulation
treatment using PMA (phorbol 12-myristate 13-acetate) and
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patient survival in primary melanoma (HR2.08 overall survival;
HR2.39 disease-specific survival).
ionomycin or magnetic beads coated with anti-CD3 and antiCD28.
Learning Objective: Describe the activity of signal
transducers and activators of transcription (STAT) signaling
pathways in CTCL and compare it to the expression observed
in benign inflammatory dermatoses.
Takeaway Message: A number of STAT signaling members
are preferentially expressed in CTCL, when compared to benign inflammatory dermatoses. Understanding how this cancer
engages STAT signaling may lead to the discovery of novel
therapeutic modalities.
P11.03
Prognostic role of BRAF in melanoma disease
progression and patient survival: protein
expression vs. gene mutation
Gholamreza Safaee Ardekani; Seyed Mehdi Jafarnejad; Shahram
Khosravi; Magdalena Martinka; Li Gang;Vincent Duronio
University of British Columbia,Vancouver, BC
Membership: Other (PhD Candidate), Sponsor: Dr.Vincent
Duronio
Introduction: Alteration in braf expression and activity is
the most prevalent oncogenic event in melanoma development. However, the effect of braf mutation on patient survival,
as the final outcome, and its prognostic value is a matter of
controversy. We investigated the effect of brafV600E mutation
on patient survival and then evaluated the prognostic value of
BRAF protein expression level in different stages of melanoma
and its correlation with brafV600E mutation.
Methods, Results: Using meta-analysis in a pool of 674
patients, we revealed that brafV600E mutation increases the
risk of mortality in melanoma patients by 1.7 times (95%
CI, 1.37-2.12). In addition, our investigation on 370 patient
samples showed a remarkable stepwise increase in BRAF
protein expression level in primary and metastatic melanoma
compare with normal samples (P=1.8×10-11). High BRAF
expression was significantly correlated with thicker tumors,
ulceration and higher American Joint Committee on Cancer
(AJCC) stages (P=1.5×10-7, 1.5×10-5, 3.6×10-13, respectively).
In primary melanoma cases, patients with high BRAF expression had significantly worse overall (P=0.009) and diseasespecific five-year survival (P=0.007). While there was a trend
for higher prevalence of brafV600E mutation in patients with
high BRAF protein expression, no significant correlation was
observed between protein expression and BRAF mutation.
Furthermore, univariate Cox-regression analysis confirmed
high BRAF protein expression as a strong risk factor for poor
Conclusions: We showed that brafV600E mutation is an absolute risk factor for melanoma patients survival. Although, we
revealed a novel prognostic value for BRAF protein expression in primary melanoma there was no significant correlation
between BRAF protein expression and brafV600E mutation in
our samples.
Learning Objective: To get familiar with the criteria of a
melanoma prognostic marker and to learn about expression
pattern and prognostic value of BRAF protein in melanoma.
Takeaway Message: BRAF protein expression could be
used as a feasible and cheap prognostic marker in melanoma
while the exact molecular mechanism behind this observation
needs further investigation.
P11.04
Skin cancer screening after solid organ
transplantation: survey of current practices
in Canada
Eric Coomes1, 2 Kevin Lam1, 2 Melissa Nantel-Battista1, 2 Jessica
Kitchen2 An-Wen Chan1, 2
1. University of Toronto,Toronto, ON; 2.Women’s College Hospital,Toronto, ON
Non-melanoma skin cancer is the most common post-transplant malignancy. Post-transplant screening guidelines thus
recommend annual skin examination. We aimed to determine
current attitudes, practices, and barriers to skin cancer screening after solid organ transplantation in Canada.
From July to December 2013 we performed a cross-sectional
survey of all 479 Canadian post-transplant physicians and
nurses. We tabulated descriptive statistics and performed multivariable logistic regression to identify factors associated with
adherence to annual screening.
The response rate was 48% (230/479); we excluded 46 invalid
responders.
Transplant personnel viewed screening as very important
(median 10/10, IQR 8-10). However, only 57% of respondents
ensured annual screening. Adherence to annual screening
was significantly (p<0.003) associated with having a screening
policy (OR 5.6, 95% CI 2.8-11) and an on-site dermatologist
(OR 3.0, 95% CI 1.5-6.0).
Accessibility to dermatology was moderate (median 7/10,
IQR 4-9). However, 35% rated accessibility as ≤ 5/10. Centres
with an on-site dermatologist had significantly higher accessibility ratings than those without (median 8/10 versus 4.5/10,
p<0.0001). The primary reported barriers to access were wait
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times (48%), excessive distance (26%), and lack of availability of
transplant dermatologists (35%).
Barriers to access (N=176)
Excessive wait time
While post-transplant skin cancer screening is perceived to
be very important, there is a failure to adhere to screening
guidelines. Development and implementation of formal screening policies and improved dermatologist access may improve
adherence to annual screening.
Table 1: Skin Cancer Screening and Access to Dermatology
84
48%
No specialized transplant dermatologist
61
35%
Excessive distance
46
26%
Difficult to routinely refer
26
15%
Lack of priority
44
25%
No barriers
45
26%
Screening policy (N=180)
Learning Objective: To understand current attitudes, practices, and barriers to skin cancer screening after solid organ
transplantation in Canada.
Yes, unwritten policy
76
42%
Yes, written policy
24
13%
109
63%
After 12 months post-transplant
5
3%
Not routinely necessary
39
23%
Not sure
20
12%
Frequency Interval: at least every 12
months
97
57%
Frequency Interval: greater than 12
months
15
9%
Not routinely necessary
44
26%
Retrospective chart review of melanoma
distribution diagnosed over a 5-year period
in a community dermatology clinic
Not sure
15
9%
Daniel Wong2 Priya Maini3 Melinda J. Gooderham1
1. SKiN Centre for Dermatology, Peterborough, ON; 2. University of Western
Ontario, London, ON; 3. McGill University, Montreal, QC
Screening initiation (N=173)
Pre-transplant or within 12 months posttransplant
Screening frequency (N=171)
Type of skin exam in transplant clinic (N=116)
Full
40
34%
Limited
76
66%
Transplant Physician
99
55%
Transplant Nurse
77
43%
Family Physician
74
41%
Dermatologist
128
71%
Patient
63
35%
In our medical centre
101
57%
In another hospital
19
11%
In the community (private clinic)
51
29%
Person(s) responsible for skin exam (N=180)
Most accessible dermatologist (N=176)
Access to dermatologist specializing in transplant (N=178)
Yes (Overall)
105
59%
Yes, in our medical centre
72
40%
Yes, in another hospital
13
7%
Yes, in the community (private clinic)
20
11%
No
63
35%
Takeaway Message:
1. Only 57% of post-transplant physicians and nurses adhere
to guidelines for at least annual skin cancer screening.
2. Development and implementation of formal screening policies and improved accessibility to dermatologists at transplant centres may improve adherence to annual screening.
P11.05
Melanoma is the 8th most common cancer in Canada. It has
commonly been recognized that the most frequent site for
melanoma in men and women are on the back and lower legs,
respectively.
In a 5-year chart review from 2007-2012 of a community
dermatology practice serving Peterborough, Ontario and the
surrounding area, a total of 259 melanomas were diagnosed
histologically via biopsy. Age, gender, site and Clark’s level were
recorded. The most common site for all melanomas was the
head and neck for men (40%) and the upper extremity for
women (35%). However, when looking at melanomas with a
stage of Clark’s level II or higher, the locations of melanoma
were predictably distributed to the back (39%) and lower
extremities (38%) for men and women, respectively. It was
also noteworthy that the second most common site for both
genders was the upper extremity (28% for men and 36% for
women).
From this chart review, it is important to note that a significant
proportion of melanomas, either in situ or with a prognostic level of Clarks II or higher, arise from the head and neck
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region, and the upper extremities in addition to the back and
lower extremities. As a result, a lower threshold for taking a
biopsy of suspicious lesions in any of these areas should be
practiced to help diagnose melanomas earlier. These results
also help reinforce the importance of performing full body skin
exams when searching for potentially fatal skin cancers.
Learning Objective: To review the anatomic distribution
of melanomas in a typical community dermatology practice in
Canada. To make the readers aware that head and neck, and
upper extremity are also significant locations to consider a
low threshold for biopsy of suspicious pigmented lesions.
Takeaway Message: For melanomas of all levels, the most
common location for men was head and neck, and for women
was upper extremities. However, for deeper melanomas
(Clark’s level II or greater) the most common locations are
back for men, and lower extremities for women in agreement
with previous reports.
liferum, trichoblastoma, hidradenoma and numerous seborrheic keratosis. Our patient is offered a close follow-up for
surgical treatment of any further appearing malignancies within
the lesion.
Conclusion: Occurence of multiple secondary tumors
within an epidermal nevus is well known. However, malignant
transformation is extremely rare. Hence, prophylactic excision
is not recommended. When malignancies appear in a small,
localized nevus, it should be completely excised. The extent of
our patient’s nevus is inconsistent with this therapeutic measure. Our patient’s unique presentation highlights the diagnostic and therapeutic challenge associated with such a case.
Learning Objective: The objective of this presentation is
to report a case of multiple tumours arising in an extensive
epidermal nevus and highlight the therapeutic challenge when
dealing which such cases.
P11.06
Takeaway Message: The possibility of a secondary cutaneous malignancy should be suspected when papule, nodule or
ulcer appears within an epidermal nevus.
Development of multiple tumors in an
extensive epidermal nevus : a case report
P11.07
Andréanne Waddell; Janie Bertrand ; Sara-Elizabeth Jean
Université Laval, Québec, QC
Introduction: Extensive verrucous epidermal nevus, also
known as systemized epidermal nevus, is a hamartomatous
proliferation of the cutaneous epithelium. Although rare, several cutaneous malignancies in association with this nevus have
been reported. The malignant transformation tends to occur
most frequently in middle-aged and eldery individuals. Keratoacanthoma, multifocal papillary apocrine adenoma, multiple
malignant eccrine poroma, basal cell carcinoma and squamous
cell carcinoma have all been described but the occurence of
multiple simultaneous lesions is exeedingly uncommun.
Methods and Results: We describe the case of a 55-yearold female with an extensive linear verrucous epidermal nevus
localised on the right side of the body associated with unilateral lower limb hypertrophy and lymphedema. Past evaluation
by an ophthalmologist, a neuropediatrician and a colleague
dermatologist revealed no further associated extracuteanous
manifestations. While the lesion had been stable for a long
time, in the past years the patient noticed multiple suspect
papules and nodules arising within the nevus. Biopsies obtained
from these lesions revealed various benign and malignant
cutaneous tumors within a verrucous epidermal nevus. More
specifically, histopathologic evaluation demonstrated the presence of three basal cell carcinomas as well as a squamous cell
carcinoma, kerathoacanthoma, syringocystadenoma papil-
Predictive value of mitotic rate for
sentinel lymph node positivity in malignant
melanoma: a retrospective seven-year
analysis
Heidi Wat; Thomas G. Salopek
University of Alberta, Edmonton, AB
Background: The utility of sentinel lymph node biopsy
(SLNB) in thin melanomas is controversial given its low
positivity rate (5.6%). In 2010, the AJCC staging classification
of melanoma introduced the concept of mitotic rate (MR)
whereby thin melanomas (≤ 1 mm, non-ulcerated) with a high
mitotic index are upstaged to T1b and are now offered SLNB.
In spite of this recommendation, there is a paucity of studies
to substantiate whether the finding of a single mitosis justifies
this potentially morbid invasive procedure.
Objective: To determine whether MR is predictive of SLNB
status when stratified according to a) tumor thickness, and b)
ulceration.
Methods: All cases of melanoma that had undergone a
SLNB at the University of Alberta between 2007-2013 were
extracted from a provincial-wide surgical database. A total of
556 cases met inclusion criteria. Features that were extracted
included gender, age, tumour thickness, ulceration, and MR.
Variables were analyzed in a binomial logistic regression model
in relation to SLN status.
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CDA Abstracts
Results: The overall SLN positivity rate was 24.5% in all
melanomas regardless of thickness, however, for thin melanomas (≤ 1.0 mm) the rate was only was 4.6% (5/110). In the
five cases of thin melanomas with positive SLNB, all were ≥
0.7 mm in tumour thickness. We found that MR ≥ 1 correlated strongly with SLN positivity when analyzed as a whole
irrespective of thickness (p<0.0001, odds ratio 1.874, CI 1.2102.904). When stratified by tumour thickness, only the 1.01-2.0
mm subgroup featured a significant relationship between MR
and a positive SLNB (p=0.0105). Likewise, there was a significant association between MR ≥ 1 and a positive SLNB only in
the ulcerated subgroup (p=0.0004).
Conclusion: The incorporation of MR in staging was based
on its association with long-term survival in all melanomas and
not on whether it could predict good candidates for SLNB. We
found that MR ≥ 1 is only useful in predicting SLNB status for
patients with either intermediate thickness melanomas (1.012.0 mm) or ulcerated tumours.
confirmed by a pathology report who had a melanoma diagnosis registered in OCR anytime before or up to one year after
the pathological diagnosis date.
Results: Of the 6,044 reports containing “melanoma”, the
majority had a diagnosis of invasive melanoma (N=5,201).
Overall, OCR captured 4,095 (90.5%, 95% C.I. 89.6%-91.3%)
of invasive melanoma pathology reports over the 17-year
period. Annual rates of 95% or higher were found for over
half of the study period. The capture rate in 1993 was 82.5%
and improved in subsequent years (90.9-98.1%), with the
exception of 2004 (71.5%) and 2005 (58.8%). Diagnosis dates
were mostly accurate, with 3,514 (86%) OCR diagnosis dates
matching the pathological diagnosis date.
Conclusions: The OCR capture rate for melanoma was
91% overall. There is a need for ongoing validation to ensure
data remain accurate and complete in order to reliably inform
research, clinical care, and policy.
Year
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Total
Learning Objective: To determine whether MR is predictive of SLNB status when stratified according to a) tumour
thickness, and b) ulceration.
Takeaway Message: Although MR is associated with positive SLNB in all melanomas, it does not appear to be useful
in predicting who should undergo a SLNB particularly if the
melanoma is thin (≤ 1 mm) or thick (>2.0 mm). In the latter
thickness appears to overrides mitotic rate.
P11.08
Validation of melanoma capture by the
Ontario Cancer Registry
Jennifer Tran5 Rodrigo Schwartz3, 4 Kinwah Fung2 Paula Rochon2, 1 An-Wen Chan2, 5
1. University of Toronto,Toronto, ON; 2.Women’s College Research Institute,
Toronto, ON; 3. Dept of Dermatology, Hospital Barros Luco Trudeau, Santiago,
Chile; 4. University of Chile, Santiago, Chile; 5. Division of Dermatology, University
of Toronto,Toronto, ON
Introduction: Monitoring of melanoma incidence over time
requires accurate population-based data. The Ontario Cancer
Registry (OCR) is the primary source of information on melanoma diagnoses in the province. To our knowledge, no study
has directly measured the OCR capture rate of melanoma
diagnoses using external data.
Methods: We examined all pathology reports from a community laboratory that contained the word “melanoma” from
1993-2009. Pathology-confirmed diagnoses were linked to
OCR records using health insurance numbers. Capture rates
were calculated as the proportion of patients with melanoma
Capture Rate
82.5% (85/103)
93.8% (105/112)
93.3% (112/120)
95.6% (153/160)
92.6% (174/188)
95.5% (233/244)
94.8% (274/289)
95.8% (248/259)
97.2% (276/284)
95.9% (234/244)
90.9% (288/317)
71.5% (256/358)
58.8% (207/352)
96.6% (309/320)
96.6% (310/321)
96.2% (378/393)
98.1% (453/462)
90.5% (4095/4526)
Learning Objective: To discuss completeness of melanoma
registration within the Ontario Cancer Registry, a widely-used
database for epidemiological research and cancer surveillance.
Takeaway Message:
• The Ontario Cancer Registry, used widely for populationbased epidemiological research and cancer surveillance, has
achieved high capture rates (up to 98% annually) for invasive
melanoma.
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CDA Abstracts
Takeaway Message:
• There is a need for ongoing validation to ensure data
remain accurate and complete in order to reliably inform
research, clinical care, and policy.
P11.09
One-year review of the “Screen” (skin cancer
post-transplant) clinic: what we have learned
Sarah Baldwin2 Sheila Au1, 2
1) Our clinic identified 123 new non-melanoma skin cancers
in 48 high-risk patients.
2) Caucasian males were most at risk. Squamous cell carcinoma was present in 73% of patients and over 25% of these
were invasive when diagnosed.
3) Despite good awareness of the skin cancer risk, sunscreen
use was poor in this population.
1. St. Paul’s Hospital and Providence Health Care,Vancouver, BC; 2. University of
British Columbia Faculty of Medicine,Vancouver, BC
P11.10
Introduction: The SCREEN Clinic is a new skin-cancer
screening clinic that is fully integrated into the renal transplantation clinic at St. Paul’s Hospital in Vancouver, BC. The purpose
of this review was to determine characteristics of patients
most at risk for skin cancer, to specify types and locations of
skin cancers diagnosed, and to identify areas for patient and
physician education.
Methods/Results: Transplant patients (primarily renal;
some heart) screened by a dermatologist during a 12-month
period were stratified into low, medium and high-risk groups
based on detailed history and skin examination. Of 122 highrisk patients identified and followed, 48(39%) were diagnosed
with new skin cancers. 72% were Caucasian, 2% were Metis
and 2% were Asian. 67% were male, 53% had a previous history of skin cancer, and 85% were aware of their increased skin
cancer risk. 28% reported using only 1-2 bottles of sunscreen
per year. 13% never used sunscreen. Sunscreen was commonly
applied to the face(51%), back(46%) and back of neck(41%),
while the lips(19%) and chest(17%) were areas most neglected.
123 skin cancers were identified. Of these, 33(27%) were basal
cell carcinomas and 90(73%) were squamous cell carcinomas.
27% of the squamous cell carcinomas were invasive. Common
locations included arm(8%), neck(8%), hand(7%) and scalp(7%).
Actinic keratosis occurred in 60%. Strategies undertaken to
prevent further skin cancers included frequent patient education, liquid nitrogen, topical field cancerization therapy, reduction of immunosuppression, sirolimus, and acitretin.
Seasonal and geographic trends in tanning
Bez Toosi; Sunil Kalia
Department of Dermatology and Skin Science, University of British Columbia,
and Photomedicine Institute,Vancouver General Hospital.,Vancouver, BC
Background: The incidence of skin cancer remains high
and continues to rise. Tanning has been linked to causing skin
cancer. Although tanning practices are assumed to be seasonal,
seasonal patterns in tanning have not been systematically
evaluated. This study explores seasonal and geographic trends
in tanning practices in order to better understand tanning behaviors and to design timely intervention and harm reduction
strategies. It utilizes internet search query data from Google
Trends to test the hypothesis that tanning varies by season
and contrary to general understanding peaks before the active
months (June to August) of summer.
Objective: To determine the seasonal and geographic effects
on tanning and tanning salons search queries.
Methods: Internet search query data were obtained from
Google Trends. Monthly normalized search volumes (NSV’s)
were determined for the term “tanning” and “tanning salons”,
from January 2004 to December 2013. Using cosinor analysis,
and Kruskal-Wallis one-way analysis of variance, seasonal and
geographic effects were tested for data from Canada, United
States and Australia.
Conclusion: We have diagnosed 123 skin cancers in over 1/3
of our high-risk population. Caucasian males were found to be
most at risk. As expected, squamous cell carcinoma accounted
for the majority of tumours with over 25% demonstrating
invasion. Although skin cancer awareness was high, sunscreen
use was limited. With this information we have identified a
number of potential target areas for patient and physician
education.
Results: Time series revealed peaks in NSV’s in March-April
and troughs in October-November in Canada and the United
States. The peaks and troughs in NSV’s from Australian data
were out of phase by 6 month as compared to the northern
hemisphere counterparts, consistent with a seasonal pattern. Cosinar analysis revealed statistically significant seasonal
effects on NSV’s in all countries. The magnitude of seasonal
increase in NSV’s was similar between Canada, United States
and Australia. The analysis of variance showed no significant
difference between the three countries.
Learning Objective: To determine patient demographics,
sun protection habits and skin cancer data in post-transplant
patients screened over a 12-month period in Vancouver, BC.
Conclusion: Currently the Canadian educational campaigns
that educate people about the hazards of tanning begin in May
or June. This study suggests interest in tanning practices to be
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CDA Abstracts
highest in the months preceding summer and prior to the onset of these campaigns. Further studies are needed to confirm
these findings, but these results support having educational
campaigns being initiated earlier during the year.
P11.12
Two cases of linear basal cell carcinoma
Jeewanjit Gill; Steven J. Glassman
Learning Objective: Appreciate the seasonality and trends
in tanning.
Takeaway Message:
• Interest in tanning salons is seasonal and is highest in the
months preceding summer.
• The Canadian educational campaigns which attempt to educate people about the hazards of tanning currently start in
May or June after the interest and potential use of tanning
salons have peaked.
• Results support initiation of educational campaigns earlier
during the year.
P11.11
Primary melanoma mimicking cutaneous
metastasis: a potential diagnostic pitfall
following cryotherapy
University of Ottawa, Ottawa, ON
Introduction: Linear forms of basal cell carcinoma (BCC)
are rare, with only 34 cases reported. They have been defined
as straight-edged lesions with a length-to-width ratio of at
least 3:1. Most cases represent nodular BCCs with a predilection for periorbital regions or the neck. Two cases at unusual
locations are presented here.
Case 1: 73-year-old female with incidental finding of a curious
firm 2cm pearly linear lesion in the left cubital fossa, aligned
within skin creases. Dermoscopy revealed arborizing telangiectases and ovoid nests, and pathology showed a pigmented
nodular BCC. The lesion was excised and has not recurred 3
years later.
Case 2: 74-year-old female with the incidental finding of a
reddish linear 4cm lesion in the left axilla, partly aligned within
skin tension lines. Dermoscopy revealed small arborizing
telangiectases, and pathology showed a nodular BCC. She is
awaiting excision.
Conclusion: Linear BCCs can be subtle and missed because
of their unusual morphology, and attributed to benign tumours
or inflammatory conditions. Alignment within skin tension lines
could be due to stromal interactions.
Olivia V. Potok2 Muhammad N. Mahmood1 Thomas G. Salopek2
1. Department of Laboratory Medicine and Pathology, University of Alberta,
Edmonton, AB; 2. Division of Dermatology and Cutaneous Sciences, University of
Alberta, Edmonton, AB
The current gold standard therapy for primary cutaneous
melanoma is surgical excision with appropriate clinical and
histological margins. Aside from very select cases, such as
patients with lentigo maligna who are poor surgical candidates,
cryotherapy is not considered an appropriate therapeutic
modality for primary cutaneous melanoma. In instances where
melanoma has been inadvertently treated with cryotherapy,
the resultant histological changes may prove diagnostically
challenging for the interpreting pathologist. Herein, we report
a case of a primary cutaneous melanoma exposed to cryotherapy, thus resulting in histopathology resembling a cutaneous deposit of metastatic melanoma.
Learning Objective: Antecedent procedures can alter the
histology of melanoma, leading to potential diagnostic pitfalls.
Takeaway Message: Liquid nitrogen cryotherapy may
obliterate the entire intraepidermal component of a primary
cutaneous melanoma, resulting in histology mimicking a cutaneous deposit of metastatic melanoma.
Learning Objective: Recognize unusual linear forms of
basal cell carcinoma.
Takeaway Message: Consider basal cell carcinoma in the
differential of linear lesions.
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CDA Abstracts
P12.01
The Peng flap: a great choice for nasal tip
defects
Emilie G. Bourgeault; Jimmy Alain
Laval University, Québec, QC
Introduction: The Peng flap was first described in 1987 as
a variation of the linear advancement flap. Modifications by
Rowe and colleagues in 1995 and Ahern and Lawrence in 2008
refined the initial design. The flap can be used as an alternative to the paramedian forehead flap in repairing larger distal
nasal tip defects. To date, the technique has been effective in
75 reported cases and no flap failures have been described. We
present 7 new cases of successful repair with the Peng flap and
describe our novel use of Burrow’s triangle as a graft site for
the construction of a new columella.
Methods and Results: In our series of 7 cases, we used
the Peng flap as an alternative to a forehead flap in repairing
distal nasal tip defects ranging from 1.1 cm x 1.1 cm to 2.0 cm
x 1.9 cm. There was no flap necrosis or complications in any
of our cases, nor was there necessity for scar revision with
dermabrasion. The technique allowed us to preserve the nasal
profile, providing excellent cosmetic results. When necessary,
we grafted Burrow’s triangle to build a new columella.
Better cosmesis and minimal patient morbidity make this flap
an excellent choice in the reconstruction of nasal tip defects.
Learning Objective: At the end of this activity, the participant will be able to choose the Peng flap as a reliable alternative approach in repairing defects of the nasal tip and will also
be able to consider grafting Burrow’s triangle for use as a new
columella.
Takeaway Message: Repair of the nasal tip is a difficult
surgical endeavor that can be facilitated by utilizing the Peng
flap.
P12.02
Outcomes of contoured staged excision for
Lentigo Maligna of the face and neck: a pilot
study with survey of current practices
Annie Liu; Alexis Botkin; An-Wen Chan
University of Toronto,Toronto, ON
Introduction: Treatment of lentigo maligna (LM) on the
head and neck remains challenging due to subclinical tumour extension and the potential for adverse functional and
cosmetic outcomes post-operatively. Standard wide excision
with a 0.5cm margin remains the standard of care. However,
no clinical trials exist to guide practice; case series suggest that
most patients require a larger surgical margin for complete
tumour clearance.
Objectives: To determine the current treatment practices
for lentigo maligna of the head and neck in Ontario by practicing physicians who commonly treat LM.
Methods: We conducted a cross-sectional survey of all dermatologists, plastic surgeons, and otolaryngologists practising
in Ontario, examining their current treatment practices for
lentigo maligna of the head and neck.
Conclusion: The incidence of basal cell carcinoma is increasing worldwide, the nose being the most commonly affected
anatomical site. Surgical approaches offer the most effective
way of achieving cure and as such the dermatological surgeon
has a key role in the treatment of this disease. The bilateral
rotation component of the Peng flap allows for defect repair
with minimal advancement, which reduces tension at the nasal
tip and maintains the shape of the nares. The single-stage nature of the flap decreases patient morbidity as opposed to the
complicated two-stage process involved in the forehead flap.
Results: The response rate was 35% (247/710). Treatments
used for lentigo maligna included surgical excision performed
themselves (45%) or by referral to another physician (46%),
topical creams (20%), radiation (4.5%), cryotherapy (3.6%),
and electrodessication & curettage (0.8%). Among the 75% of
responders who treated lentigo maligna with standard wide
excision and immediate reconstruction, 69% of physicians
reported using a 0.5 cm surgical margin, while 27% report a
greater than 0.5 cm margin. We will present full results (overall
and by specialty type) upon completion of the analysis.
Discussion: Although standard wide excision with immediate reconstruction is the most common treatment utilized for
lentigo maligna of the head and neck, surgical practice varies
in terms of excision technique and margin size across Ontario.
Despite consensus guidelines recommending a 0.5 cm mar-
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CDA Abstracts
The majority of patients felt that over the counter antihistamines were useful in disease control although prednisone as
prescribed by emergency room physicians and family practitioners were added in about a fifth of the patients.
gin, there is variability in the margin size used in practice on
the head and neck. Additional evidence from robust studies
is needed to inform optimal treatment for this challenging
tumour.
Learning Objective: To learn of the current treatment
practices for lentigo maligna of the head and neck in Ontario
by practicing physicians who treat it commonly.
Takeaway Message: Standard wide excision with immediate reconstruction is the most common treatment utilized for
lentigo maligna of the head and neck, although surgical practice
varies in terms of excision technique and margin size across
Ontario. Despite consensus guidelines recommending a 0.5 cm
margin, there is variability in the margin size used in practice
on the head and neck.
P13.01
Chronic spontaneous urticaria – the
Saskatchewan experience and questionnaire
survey
Conclusion: In this follow-up questionnaire study, 30% of
patients found antihistamines gave effective control. About 40%
of patients may have chronic spontaneous urticaria caused by
autoimmunity as assessed by the ASST. IVIG was an effective
treatment for this group of patients.
Learning Objective: Upon completion of this session,
participants should be able to:
Be familiar with successful treatments in CSU patients
Be familiar with the symptoms experienced by CSU patients
Takeaway Message:
In approximately 50% of patients, the urticaria had resolved
Quality of life is affected leading to missed work or school
Majority of patients remain frustrated with the lack of efficacy
of treatment
Approximately 30% of participants found that antihistamines
alone gave effective control for hives
Natasha Gattey; Bahar Bahrani; Peter Hull
University of Saskatchewan, Saskatoon, SK
In the ASST (+) patients, IVIG was a highly effective treatment
Background: Chronic spontaneous urticaria (CSU) is
defined as urticaria persisting for more than 6 weeks with
no inducible cause. An autoimmune basis is held responsible
for more than half the cases. Many cases have no identifiable
cause.
Methotrexate was used successfully in 3 patients who did not
respond to IVIG
Approximately 23% of ASST (-) participants still experiencing
hives found no treatment to relieve symptoms
Method: 173 patients with CSU had been seen between
2003 and 2013. There were significantly more females than
males (130:43). The age range was 1 year to 81. The mean age
was 36 years. The average duration was 9.3 years. An autologous serum skin test (ASST) was performed on 138 patients
and was positive in 58 (42.02%).
P13.02
Results: A questionnaire and informed consent, approved by
the Research Ethics Office, was sent to patients and replies
were received from 101 participants. We were unable to contact 25 patients, and 2 patients had died. Of the respondents,
40 were ASST positive and 49 were ASST negative participants.
55.00% of ASST (+) participants and 46.80% of ASST (-) participants no longer had hives. 21 ASST positive patients who
had significant quality of life issues were treated with intravenous immunoglobulin (IVIG), and 85.0% of these patients had
improved quality of life with 13 of these patients now free of
urticaria and no longer receiving IVIG.
Patients were most bothered by pruritus, disturbed sleep, anxiety and their physical appearance including facial swelling. Many
(70.4%) had missed work or school because the urticaria.
Chronic Spontaneous Urticaria – an
evaluation of an indirect immunofluorescence
method for detecting anti-mast cell IgG
antibodies
Bahar Bahrani; Natasha Gattey; Peter Hull
University of Saskatchewan, Saskatoon, SK
An autoimmune basis is believed to be responsible for about
half of all cases of chronic spontaneous urticaria (CSU) with
specific IgG antibodies directed at the high affinity receptor
sites for IgE on the mast cell. The autologous serum skin test
(ASST) is used to identify this autoimmune form of CSU. Currently, basophil histamine release assay and basophil activation
test (BAT) have been used as an alternative to the ASST. We
have developed an indirect immunofluorescence method to
demonstrate the presence of anti-mast cell antibodies using
skin sections from a patient with severe bullous mastocytosis.
Sections from paraffin embedded blocks of skin biopsied infant
with bullous mastocytosis and cord-blood derived mast cells
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CDA Abstracts
were used as substrates. Serum patients with CSU was used,
and fluorescein conjugated human IgG was used to label fixed
antibody. Amongst the bullous mastocytosis slides, positive
indirect immunofluorescence was found in 35 (46.05%) of
the patients (n=76). There was a positive indirect immunofluorescence in 17 (50%) patients who had a positive ASST
(n=34), 49.09% of non-IVIG treated CSU patients (n=55),
and in 61.09% of IVIG treated patients (n=21). Amongst the
cord-blood derived mast cell cytospin slides, positive indirect
immunofluorescence was found in 29 (41.43%) of the patients
(n=70). Positive indirect immunofluorescence was found in
14 (45.16%) patients who had a positive ASST (n=31), 46%
of non-IVIG treated CSU patients (n=50), and in 60% of IVIG
treated patients (n=20). It is possible to detect anti-mast cell
IgG antibodies by indirect immunofluorescence. IgG autoantibodies could be detected in about half of CSU cases examined.
Indirect immunofluorescence should be considered a more
direct and credible indicator of the autoimmune form of CSU.
Learning Objective: An indirect immunofluorescence
method can be used to identify anti-mast cell IgG auto-antibodies.
Takeaway Message: Indirect immunofluorescence should
be considered a more direct and credible indicator of the
autoimmune form of CSU.
P14.01
may be educational - particularly for patients with difficult-tosee wounds. Importantly, this tool may motivate patients to
become more involved in the management of their wounds.
Learning Objective: The objectives of this study are to
provide an assessment of wound photo-documentation from
the patients’ perspective and to evaluate whether this could
improve patients’ understanding and involvement of their
wound care.
Takeaway Message:
• The present study provides the first assessment of the
importance and perceived benefits of wound photography
from the viewpoint of the patient.
• Most patients have difficulty seeing their wounds and few
patients monitor their wounds themselves.
• There is a significant association between the ease with
which a patient is able to see their wound and whether they
reported subsequent memory of how the wound looked.
• Patients’ ability to recall how their wounds looked in a
previous clinical visit declined drastically with the time since
the initial visit to the wound clinic.
• The majority of patients report that taking photos of their
wounds would help them track how their wound is progressing and allow them to be more involved in their own
wound care regardless of whether they have difficult-to-see
wounds.
Patient perception of wound photography
P14.02
Sheila Wang1 John Anderson1 Duncan Jones1 Robyn Evans2
1. University of Toronto,Toronto, ON; 2.Women’s College Hospital,Toronto, ON
The objectives of this study are to provide an assessment of
wound photo-documentation from the patients’ perspective
and to evaluate whether this could improve patients’ understanding and involvement of their wound care. Our results
revealed that most patients attending the wound clinic have
difficult-to-see wounds (86%). Only 20% of patients monitor
their wounds and rely on clinic or nurse visits to track healing
progress. There was a significant association between patient’s
ability to see their wound and subsequent memory for how
the wound looked. This was especially true of patients who
had recently attended the wound clinic. This relationship was
not present in patients who visited the clinic for 3 years or
more. Patients reported that inability to see their wounds
made them feel that they had lost autonomy. The majority of
patients reported that photographing their wounds would help
them to track their wound’s progress (81%) and would afford
them more involvement in their own care (58%). This study
provides a current representation of wound photography from
the patients’ perspective and reveals that wound photography
Treatment of chronic wound staphylococcus
aureus biofilms with staphylococcus
epidermidis Esp protein to promote healing
Christina Scali1 Mark G. Kirchhof1 Adrienne Law2 Dirk Lange2
Brian Kunimoto1
1. Department of Dermatology, University of British Columbia,Vancouver, BC;
2.The Stone Centre at Vancouver General Hospital, Department of Urologic
Sciences, Jack Bell Research Centre,Vancouver, BC
Biofilms are communities of bacteria attached to a surface.
They are commonly found in chronic wounds, where they
lead to a non-healing inflammatory phase and are associated
with persistent infection. Staphylococcus aureus is one of the
most common microorganisms to form biofilms and has been
found to be present in 64-94% of chronic wounds. S. epidermidis strain JK16 cells and its culture supernatants have previously been shown to destroy preexisting S. aureus biofilms
and inhibit the formation of new ones in vitro1. This biofilm
destruction activity was found to be due to the Esp protein
isolated from this S. epidermidis strain1. S. epidermidis JK16
cells as well as purified Esp can also eliminate nasal carriage of
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CDA Abstracts
S. aureus in humans1. This serine protease causes the intercellular matrix to breakdown and changes S. aureus from a sessile
to a planktonic form, making it more susceptible to antibiotics
and the immune system. This makes Esp an attractive candidate to use in anti-biofilm strategies. To date, Esp has not been
studied in relation to chronic wound biofilms or in relation to
wound healing in animals or humans. A pilot study to explore
the biologic activity of S. epidermidis JK16 Esp on biofilms and
healing of chronic wounds is being undertaken. The S. epidermidis JK16 Esp protein has been purified and is currently being
tested in vitro on S. aureus lawns and with a spectrophotometric assay. The purified S. epidermidis Esp protein will then
be compared to standard therapy in 10 patients with chronic
wounds using a cross-over design. This pilot study will allow us
to assess the feasibility of conducting a more definitive trial to
examine the efficacy of the Esp in healing chronic wounds.
1 Iwase T, Uehara Y, Shinji H. et al. Staphylococcus epidermidis
Esp inhibits Staphylococcus aureus biofilm formation and
nasal colonization. Nature 2010; 465: 346-351.
Learning Objective: To introduce the concept of bacterial biofilms and their role in chronic wound nonhealing and
introduce a novel way to combat them.
Takeaway Message:
1) Bacterial biofilms lead to chronic wound nonhealing.
2) Treatment of chronic wounds requires antibiofilm strategies to allow healing.
3) The S. epidermidis JK16 Esp protein is a potential candidate for such an antibiofilm strategy.
P14.03
CD109 regulates macrophage recruitment in
a mouse model of bleomycin-induced skin
fibrosis
Nermin R. Diab1 Anie Philip2
1. McGill University Faculty of Medicine, Montreal, QC; 2. Division of Plastic
Surgery, Department of Surgery, McGill University, Montreal, QC
Background: Fibrotic diseases such as hypertrophic scarring,
scleroderma and keloid formation are pervasive medical problems for which there are no satisfactory treatment strategies.
In addition to excessive ECM production, another hallmark of
these disorders is an association with persistent inflammation.
TGF-β signaling has been shown to play an important role
in the initiation of inflammation in fibrotic diseases. We have
reported that CD109 is an antagonist of TGF-β signaling, and
that it reduces fibrotic processes during bleomycin-induced
skin fibrosis. In this study, we examined whether the mecha-
nism by which CD109 exerts anti-fibrotic effects involves
regulation of inflammatory responses.
Materials/Methods: 6 wild-type and 6 transgenic mice
overexpressing CD109 in their epidermis were used. Mice
were injected with either PBS or bleomycin and sacrificed at
days 14, 21 or 28 post injection. Skin at the site of injection
was harvested at 14, 21 or 28 days and mounted on slides.
Inflammatory cells at the site of injection where quantified at
each time point using immunohistochemical staining with antibodies specific for neutrophils (rat anti-mouse Ly-6G(Gr-1))
at day 14, and macrophages (rat anti-mouse F4/80-mAb) and
T-cells (rat anti-mouse CD3-antibody) at all three time points.
Results: No obvious neutrophil infiltration was evident at
day-14 in transgenic or wild-type mice injected with bleomycin or PBS. CD109 overexpression, on the other hand,
had significant effects on macrophage but not T-cell numbers
as compared to wild-type mice, post-bleomycin injection.
Indeed, overexpression of CD109 in the epidermis reduced
the recruitment of macrophages to the dermis at days 14, 21
and 28, post-bleomycin injection. Interestingly, CD109 overexpression had no effect on T-cell numbers at days 14 and
28, post-bleomycin injection. However, T-cell numbers were
significantly decreased in mice overexpressing CD109 on
day-21 post-bleomycin injection when compared to wild-type
mice(p<0.05).
Conclusion: We conclude that macrophage numbers during
bleomycin-induced skin fibrosis are reduced in CD109 overexpressing transgenic mice. Our results suggest that decreased
macrophage recruitment might contribute to the reduced
fibrotic responses seen in CD109 transgenic mice during
bleomycin-induced skin fibrosis.
Learning Objective: In the current study, we examine
whether the mechanism by which CD109 exerts anti-fibrotic
effects involves regulation of inflammatory responses.
Takeaway Message: We conclude that macrophage
numbers during bleomycin-induced skin fibrosis are reduced
in CD109 overexpressing transgenic mice. Our results suggest
that decreased macrophage recruitment might contribute to
the reduced fibrotic responses seen in CD109 transgenic mice
during bleomycin-induced skin fibrosis.
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P15.01
Figure. ERASURE study design
Secukinumab in subjects with moderateto-severe plaque psoriasis: results from
the efficacy of response and safety of 2
fixed secukinumab regimens in psoriasis
(ERASURE)
Boni E. Elewski1 Mark Lebwohl2 Kim Papp3 Hidemi Nakagawa4
Bardur Sigurgeirsson5 Tsen-Fang Tsai6 Stephen Tyring6 Isabelle
Hampele7 Alexander Karpov7 Silvia Helou8 Charis Papavassilis7
1. Department of Dermatology, University of Alabama at Birmingham School
of Medicine, Birmingham, AL, USA; 2. Department of Dermatology, Mount Sinai
School of Medicine, New York, NY, USA; 3. Probity Medical Research,Waterloo,
ON; 4. Department of Dermatology,The Jikei University School of Medicine,
Tokyo, Japan; 5. Faculty of Medicine, Department of Dermatology, University
of Iceland, Reykjavik, Iceland; 6. Department of Dermatology, National Taiwan
University Hospital and National Taiwan University College of Medicine,Taipei,
Taiwan; 7. Novartis Pharma AG, Basel, Switzerland; 8. Novartis Pharmaceuticals
Corporation, East Hanover, NJ, USA
Learning Objective: To evaluate the efficacy of 2 doses
(150 mg and 300 mg s.c.) of secukinumab (AIN457; a fully
human anti-interleukin 17A monoclonal antibody) at Week
12 and to assess safety, tolerability, and long-term efficacy
(up to 52 weeks) in subjects with moderate-to-severe plaque
psoriasis.
Objectives: To evaluate the efficacy of 2 doses (150 mg and
300 mg s.c.) of secukinumab (AIN457; a fully human anti-interleukin 17A monoclonal antibody) at Week 12 and to assess
safety, tolerability, and long-term efficacy (up to 52 weeks) in
subjects with moderate-to-severe plaque psoriasis.
Methods: The ERASURE study (NCT01365455) was
a double-blind, placebo-controlled, multicenter phase 3
trial . Subjects aged ≥18 years were equally randomized to:
secukinumab 150 mg or secukinumab 300 mg once weekly for
4 weeks, then once every 4 weeks, starting at Week 4 through
Week 48, or matching placebo (Figure). The co-primary objectives were to demonstrate superior efficacy of secukinumab vs
placebo, based on the PASI 75 and investigator’s global assessment (IGA) 0 or 1 response rates at Week 12. Key secondary
endpoints included psoriasis-related itching, pain, and scaling
as measured by psoriasis diary, the PASI 90 response at Week
12, and maintenance of the PASI 75 and IGA 0 or 1 response
at Week 52 in PASI 75 responders at Week 12. Safety and
tolerability of secukinumab were assessed using adverse event
monitoring, vital signs and other standard measures, including
immunogenicity analyses.
Results: 738 subjects with moderate-to-severe plaque psoriasis were randomized. Results up to Week 52 will be provided
in the final presentation.
Takeaway Message: Results from this study will contribute to the understanding of the short- and long-term efficacy
and safety of secukinumab in subjects with moderate-tosevere plaque psoriasis.
P15.02
Secukinumab compared with placebo and
etanercept: the first 52-week head-to-head
comparison of two biologics in a randomized,
double-blind phase 3 study in subjects
with moderate-to-severe plaque psoriasis
(FIXTURE)
Richard G. Langley1 Kristian Reich2 Christopher E. Griffiths3
Lluis Puig4 Lynda Spelman5 Enrique Rivas6 Norman Wasel7
Thomas Salko8 Marianne Notter8 Silvia Helou9 Charis Papavassilis8
1. Dalhousie University, Halifax, NS; 2. Dermatologikum Hamburg and GeorgAugust-Universität, Göttingen, Germany; 3. Dermatology Centre, University of
Manchester, Manchester Academic Health Science Centre, Manchester, United
Kingdom; 4. Hospital de Sant Pau, Barcelona, Spain; 5.Veracity Clinical Research,
Woolloongabba, QLD, Australia; 6. Dermos, Guatemala City, Guatemala; 7.
Stratica Medical, Edmonton, AB; 8. Novartis Pharma AG, Basel, Switzerland; 9.
Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
Objectives: To investigate the efficacy of secukinumab, a fully
human anti-interleukin-17A monoclonal antibody, at Weeks 12
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(compared with placebo and etanercept) and 52 (compared
with etanercept), in subjects with moderate-to-severe plaque
psoriasis.
P15.03
Methods: The FIXTURE (NCT01358578) study was a multicenter, double-blind, double-dummy, parallel-group, active-comparator– and placebo-controlled study consisting of a screening period (1-4 weeks) and 2 treatment periods: induction (12
weeks) and maintenance (40 weeks).
Improvement in psoriasis symptoms and
physical functioning with secukinumab
compared with placebo and etanercept in
subjects with moderate-to-severe plaque
psoriasis and psoriatic arthritis: results of a
subanalysis from the phase 3 fixture study
Patients were randomized 1:1:1:1 to 1 of 4 s.c. treatment
groups:
Alice B. Gottlieb1 Richard G. Langley2 Sandra Philipp3 RLM
Martin4 Charis Papavassilis4 Shephard Mpofu4
1. Secukinumab 150 mg at Baseline and Weeks 1, 2, 3, and 4,
and every 4 weeks thereafter until and including Week 48.
2. Secukinumab 300 mg at Baseline and Weeks 1, 2, 3, and 4,
and every 4 weeks thereafter until Week 48.
3. Placebo from Baseline to Week 11. PASI 75 responders at
Week 12 continued on placebo thereafter. PASI 75 nonresponders were re-randomized 1:1 to secukinumab 150
mg or 300 mg at Weeks 12, 13, 14, 15, and 16, and every 4
weeks thereafter to Week 48.
4. Etanercept 50 mg twice per week from Baseline to Week
12, and once per week thereafter through Week 51, and
secukinumab placebo at the same interval as secukinumab.
The co-primary objectives were the superiority of secukinumab vs placebo in both the PASI 75 and investigator’s global
assessment (IGA) 0 or 1 response at Week 12. Key secondary endpoints included demonstration of the superiority of
secukinumab vs etanercept with respect to the PASI 75 and
IGA 0 or 1 response at Week 12 and maintenance of response
at Week 52. Safety and tolerability of secukinumab were assessed.
1.Tufts Medical Center, Boston, MA, USA; 2. Dalhousie University, Halifax, NS;
3. Charité Universitätsmedizin, Berlin, Germany; 4. Novartis Pharma AG, Basel,
Switzerland
Results: 1,307 subjects with moderate-to-severe plaque
psoriasis were randomized. Short- and long-term efficacy and
safety and 52-week maintenance of response results up to
Week 52 will be provided in the final presentation.
Results: In subjects with concomitant PsA (n=192), significant improvements in PASI75 response rates were observed
with SEC150 mg and 300mg from week 4 and sustained to
week 52. Improvements in physical functioning as measured
by change from baseline in HAQ-DI score were significantly
improved with SEC300mg. HAQ-DI reductions from baseline
at week 12 were SEC300mg, -0.41 (P<0.01 for 300mg vs PBO);
SEC150mg, -0.19; ETN,-0.29; PBO, 0.02. Reductions were
sustained to week 52 and were more pronounced in subjects
with greater disability (baseline scores ≥0.5). Both SEC and
ETN were well tolerated with no unexpected safety findings.
Learning Objective: To investigate the efficacy of
secukinumab, a fully human anti-interleukin-17A monoclonal
antibody, at Weeks 12 (compared with placebo and etanercept) and 52 (compared with etanercept), in subjects with
moderate-to-severe plaque psoriasis.
Takeaway Message: The FIXTURE study investigated
short- and long-term efficacy and safety and 52-week maintenance of response with secukinumab compared with placebo
and etanercept in a large cohort of subjects with moderateto-severe plaque psoriasis.
Background: Secukinumab (SEC;AIN457), a fully human
anti–IL-17A monoclonal antibody, demonstrated efficacy in
phase 3 trials for treatment of plaque psoriasis. We report the
efficacy and safety of secukinumab vs placebo and etanercept
in patients with moderate-to-severe plaque psoriasis and
concomitant PsA.
Methods: Subjects aged ≥18yrs were randomized 1:1:1:1 to
Secukinumab150 or 300mg, PBO, or ETN 50mg. Subjects received treatment at weeks 0,1,2,3, and 4 and Q4W thereafter
until week 48. Subjects in the ETN arm received ETN 50mg
twice per week from baseline to week 12, and 50mg weekly
thereafter through week 51. The co-primary objectives were
to show superiority of SEC vs PBO for PASI75 and investigator’s global assessment (IGA) 0/1 response at week 12. A
pre-specified sub-analysis of PASI responses and changes from
baseline in the Health Assessment Questionnaire–Disability
Index (HAQ-DI) up to week 52 in subjects with concomitant
PsA is reported here.
Conclusion: In patients with psoriasis and concomitant PsA,
Secukinumab improved skin symptoms and physical functioning
vs placebo, with benefits evident from week 4 and sustained to
week 52. SEC300 mg demonstrated significantly improved PASI
75/90 responses and greater reductions in HAQ-DI compared
with ETN. These data strongly support continued evaluation of
Secukinumab in patients with PsA.
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Learning Objective: Secukinumab (SEC;AIN457), a fully
human anti–IL-17A monoclonal antibody, demonstrated efficacy in phase 3 trials for treatment of plaque psoriasis. We
report the efficacy and safety of secukinumab vs placebo and
etanercept in patients with moderate-to-severe plaque psoriasis and concomitant PsA
spectively). Patients with moderate to severe plaque psoriasis
(28%) were more likely to visit their family physician than
the control group (9 vs 3 visits per year, respectively). These
patients missed more days of work than the control (11 vs 4,
respectively) and recorded more work absences (2 vs 0.03
absence notes per year).
Takeaway Message: In patients with psoriasis and concomitant PsA, Secukinumab improved skin symptoms and
physical functioning vs placebo, with benefits evident from
week 4 and sustained to week 52. SEC300 mg demonstrated
significantly improved PASI 75/90 responses and greater reductions in HAQ-DI compared with ETN. These data strongly
support continued evaluation of Secukinumab in patients with
PsA.
Conclusion: Chronic plaque psoriasis is a significant health
condition and is associated with higher rates of comorbidity
and use of health services in Canada, especially in patients with
a moderate-severe condition.
Learning Objective: To compare the comorbidities and
healthcare resource utilization of chronic plaque psoriasis
compared to a matched control cohort in a large, Canadian,
real-world dataset.
P15.04
Comorbidities and health resource use of
chronic plaque psoriasis patients in Canada: a
matched-cohort study
Valerie Gregory1 Laura Luciani2 Martin Barbeau1 Robert J.
Petrella3, 4, 5
Takeaway Message: Chronic plaque psoriasis is a significant health condition and is associated with higher rates of
comorbidity and use of health services in Canada, especially in
patients with a moderate-severe condition.
P15.05
Characteristics of chronic plaque psoriasis in
Canada: a retrospective database study
1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2. Université de Montréal,
Montréal, QC; 3.Western University, London, ON; 4. Lawson Health Research
Institute, London, ON; 5. Indivisual Clinical Outcomes, London, ON
Introduction: Compare the comorbidities and healthcare
resource utilization of chronic plaque psoriasis compared to
a matched control cohort in a large, Canadian, real-world dataset.
Methods and Results: This was an observational, retrospective study of patients ≥ 18 years who, between 2008 and
2012 received a diagnosis of psoriasis and at least 1 treatment.
Data were retrieved from the Southwestern Ontario (SWO)
database, which is a representative primary care database of
over 325,000 unique patient records in Ontario, Canada. Comorbidities and health resource utilization were recorded in
the patient chart as per their healthcare provider. A matched
control cohort was constructed based on age, gender and
ethnicity. Differences between psoriasis and control groups
were compared using paired and independent samples t-tests.
A total of 7,776 patients in the SWO database (n=325,618)
had a diagnosis of psoriasis and received at least 1 treatment
between January 1, 2008 and December 31, 2012. Of these,
85% had chronic plaque psoriasis. Over half of patients with
chronic plaque psoriasis were diagnosed with hypertension
(61%, similar in the control group), 11% had diabetes (vs 7%
in control group), 4% had depression and/or anxiety disorders
(vs 1%), 6% had insomnia (vs 1%). Thirty-two percent (32%)
were overweight and 24% were obese (vs 27% and 19%, re-
Robert J. Petrella2, 3, 4 Valerie Gregory1 Laura Luciani5 Martin
Barbeau1
1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2.Western University,
London, ON; 3. Lawson Health Research Institute, London, ON; 4. Indivisual
Clinical Outcomes, London, ON; 5. Université de Montréal, Montréal, QC
Introduction: The objective of this study was to describe
the epidemiological characteristics and treatments for chronic
plaque psoriasis in a large, Canadian, real-world dataset.
Methods/Results: This was an observational, retrospective cohort of patients ≥ 18 years who, between 2008 and
2012 received a diagnosis of psoriasis (overall, scalp, nail,
chronic plaque, pustular, palmoplantar pustulosis and guttate psoriasis) identified by ICD9-10 or text coding, and who
were prescribed at least 1 treatment. Data were retrieved
from the Southwestern Ontario (SWO) database, which is a
representative primary care, researchable database of over
325,000 unique patient records in Ontario, Canada. Among
325,618 patients in the SWO database, 7,935 patients had a
diagnosis of psoriasis between January 1, 2008 and December
31, 2012 (prevalence 2.44%). Of these, 98% (n=7,776) were
treated. Chronic plaque psoriasis was the most common
subtype of psoriasis (85%, n=6610), followed by scalp psoriasis
(50%, n=3888) in patients receiving treatment. Among chronic
plaque psoriasis patients, duration of disease ranged from 1 to
23 years. Mean age at diagnosis was 31 (sd=12) years. Patients
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with mild disease were generally treated with topicals, most
commonly corticosteroids (65%), salicylic acid (28%) and/or
coal tar (19%). Phototherapy (NB-UVB, psoralen+UVA) and
oral systemic agents (acitretin, cyclosporine, methotrexate)
were also prescribed. Twenty eight percent (28%) of chronic
plaque psoriasis patients had a moderate to severe condition.
About 60% of moderate to severe patients were treated with
phototherapy, whereas 33% were prescribed biologics (adalimumab, etanercept, infliximab, ustekinumab).
the same productivity losses as the general population due to
illness or disability, as reported by Statistics Canada. The mean
number of days lost from work per year per subject owing
to psoriasis-related events was 7.7 days for people with mild
psoriasis and 16.3 days for those with moderate to severe
psoriasis. The average annual cost per subject was CAD$1,495
for patients with mild psoriasis and CAD$3,171 for patients
with moderate to severe psoriasis. Overall, the estimated total
annual cost of productivity losses attributable to psoriasis in
Canada reached approximately CAD$800 million, when extrapolating the cost per patient to the afflicted population.
Conclusion: Psoriasis is a significant problem in primary
care, affecting over 2% of the population. Of these, 85% have
chronic plaque psoriasis and 28% are considered moderate to
severe. These results confirm those observed in the literature. This real-world database may be used as a resource for
further examination of the effectiveness of psoriasis treatment
and health resource use.
Conclusion: Work absenteeism attributable to psoriasis
represents an important component of the burden of psoriasis in Canada. Nonetheless, there are limited data and further
studies assessing productivity loss in psoriasis are required to
better inform health care professionals in Canada.
Learning Objective: To describe the epidemiological
characteristics and treatments for chronic plaque psoriasis in a
large, Canadian, real-world dataset.
Learning Objective: To explore the existing evidence
regarding the work productivity losses related to psoriasis, and
to estimate the cost of these productivity losses in Canada.
Takeaway Message: Psoriasis is a significant problem in
primary care, affecting over 2% of the population. Results from
this real-world database study are consistent with the existing literature, such that 85% of psoriasis patients have chronic
plaque psoriasis and 28% are considered moderate to severe.
Takeaway Message: Work absenteeism attributable to
psoriasis represents an important component of the burden of
psoriasis in Canada.
P15.07
P15.06
Productivity losses related to psoriasis in
Canada: a literature review
Valerie Gregory1 Laura Luciani2 Martin Barbeau1
Malignancy events in the psoriasis
longitudinal assessment and registry
(PSOLAR) study: current status of
observations
Richard Langley1 Mark Lebwohl2 David Fiorentino3 Vincent
Ho4 Steve Fakharzadeh5 Steve Calabro5 Wayne Langholff5 Marc
Chevrier5
1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2. Université de Montréal,
Montréal, QC
Introduction: Psoriasis has a significant impact on patients’
quality of life, resulting in important losses in productivity. The
objective of this study was to explore the existing evidence
regarding the work productivity losses related to psoriasis, and
to estimate the cost of these productivity losses in Canada.
1. Dalhousie University, Halifax, NS; 2. Mount Sinai Medical Center, New
York, NY, USA; 3. Stanford University, Stanford, CA, USA; 4. University of British
Columbia,Vancouver, BC; 5. Janssen Scientific Affairs, LLC, Horsham, PA, USA
Methods and results: A literature search was conducted
in PubMed using combinations of keywords relating to psoriasis and productivity for articles published between 2000 and
2013. Twelve relevant articles identified costs or productivity
losses related to psoriasis. Among these, only two articles reported work absenteeism results in the Canadian population.
The number of days lost from work as a consequence of psoriasis was extracted from these two articles. Lost productivity,
including only work absenteeism, was calculated based on an
8-hour work day and the Canadian mean hourly wage for full
time employees. Mild psoriasis patients were estimated to have
Methods/Results: PSOLAR is a multicenter, longitudinal,
observational study evaluating long-term safety and clinical
outcomes for patients receiving (or eligible to receive) treatment for psoriasis with biologics and/or conventional systemic
agents.The accrual of malignancies excluding NMSC (ie, basal/
squamous cell carcinomas) in PSOLAR overall and by exposure sub-groups is reported. Rates of malignancy are assessed
using a definition of exposure based on whether patients had
ever been exposed to a given therapy at any time prior to the
event. In cases of exposure to multiple therapies, malignancies
are attributed to treatment groups in the order of ustekinum-
Introduction: To report the accrual of malignancies excluding non-melanoma skin cancers(NMSC) in PSOLAR.
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ab first, infliximab/golimumab second, other biologics third,
and non-biologic therapy last. As of the August 23,2012 data
cut, 11,900/12,000 patients had enrolled in PSOLAR (22,918
cumulative patient-years of follow up). Unadjusted rates of
malignancy, excluding NMSC, across treatment groups were:
ustekinumab 0.53 events per 100 patient years of observation
(PYO) [95%CI:0.35, 0.76; 28/5332 PYO], infliximab/golimumab
0.70 per 100 PYO [95% CI:0.44, 1.06; 22/3136],other biologics (almost exclusively etanercept/adalimumab) 0.68 per 100
PYO[95% CI: 0.53, 0.87; 69/10093], non-biologic therapy 0.83
per 100 PYO[95%CI:0.58,1.14;36/4357], and overall 0.68 per
100 PYO[95%CI:0.57,0.79; 55/22918]. Limitations: Due to
channeling of therapy, there may be differences in subgroup
characteristics. Formal comparison will require statistical modeling to adjust for patient characteristics and risks, including
consideration of multiple treatments.
Conclusions: Although many patients exposed to biologics have been exposed to multiple prior immunosuppressive
therapies, rates of malignancy appear limited overall. Unadjusted rates show a trend towards lower rates in ustekinumab-treated patients, despite the rules of event attribution,
compared to other treatment groups. These are preliminary
results;PSOLAR will follow patients for up to 8years, providing additional data over time. PSOLAR is a powerful resource
for tracking safety events of interest among patients eligible to
receive systemic therapies.
Learning Objective: To report the accrual of malignancies
excluding non-melanoma skin cancers(NMSC) in PSOLAR.
Methods/Results: PSOLAR is a multicenter, prospective,
longitudinal, observational study that will follow patients for
at least 8 years in academic and community-based settings.
Eligible patients are aged ≥18 years, have a diagnosis of psoriasis and are currently receiving or are candidates to receive
systemic therapies for psoriasis. Demographics and medical/
family history are collected at enrollment. Collections at 6
month intervals include: adverse events, disease activity, quality of life, economic status, healthcare utilization and interval
therapies. International sites in North America, Latin America,
and Europe had recruited 11,900 of a target of 12,000 patients
as of 23 August 2012. Baseline characteristics were as follows:
median age: 49.0 years (range 12-100 years), with 61.4% of
patients ≥ 45 years; 54.7% male; 83.1% white; mean body mass
index (BMI) 30.9 (SD 7.2); and mean disease duration of 17.5
years (SD 13.5 years) since diagnosis. Medical history includes:
38.2% of patients with cardiovascular disorders; 14.4% with
pulmonary disorders; 20.7% with psychiatric disorders; 18.8%
with endocrine disorders; and 6.2% with skin cancer. Infections requiring treatment in the 3 years preceding enrollment
occurred in 24.6% of patients, of which 21.6% were bacterial
infections. Mean body surface area (BSA) coverage at enrollment was 12.1% (SD 17.5%), mean physicians’ global assessment (PGA) score was 2 (SD 1.2); 96.9% of patients presented
with plaque type psoriasis. Psoriasis medications (current and
historical) included topicals (96.9%), phototherapy (54.6%),
systemic steroids (23.4%), immunomodulators (47.6%), and
biologics (72.1%).
Conclusions: As a disease directed registry, PSOLAR offers
the ability to collect disease activity and outcomes associated
with many therapies in actual clinical practice.
Takeaway Message: Although many patients exposed to
biologics have been exposed to multiple prior immunosuppressive therapies, rates of malignancy appear limited overall.
P15.08
Psoriasis longitudinal assessment and
registry (PSOLAR): global update of a
multicentre, open registry of psoriasis
patients
Learning Objective: To report the baseline demographics and characteristics of participants enrolled in the PSOLAR
study.
Takeaway Message: As a disease directed registry, PSOLAR offers the ability to collect disease activity and outcomes
associated with many therapies in actual clinical practice.
Kim Papp1 Matthias Augustin2 Vincent Ho3 Craig Leonardi4
Alan Menter5 Bruce Strober6 Steve Calabro7 Wayne Langholff7
Steve Fakharzadeh7 Marc Chevrier7
1. Probity Research,Waterloo, ON; 2. University Clinics of Hamburg, Hamburg,
Germany; 3. University of British Columbia,Vancouver, BC; 4. Central
Dermatology, St. Louis, MO, USA; 5. Baylor Research Institute, Dallas,TX, USA; 6.
University of Connecticut, Farmington, CT, USA; 7. Janssen Scientific Affairs, LLC,
Horsham, PA, USA
Introduction: The objective of this analysis is to report
the baseline demographics and characteristics of participants
enrolled in the PSOLAR study.
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P15.09
Major adverse cardiovascular events in
the psoriasis longitudinal assessment and
registry (PSOLAR) study: current status of
observations
Robert Bissonnette Alice B. Gottlieb Francisco Kerdel Luigi
Naldi4 Kim Papp5 Steve Fakharzadeh6 Steve Calabro6 Wayne
Langholff6 Marc Chevrier6
1
2
3
1. Innovaderm Research, Inc, Montreal, QC; 2.Tufts Medical Center, Boston, MA,
USA; 3. University of Miami, Miami, FL, USA; 4. Centro Studi GISED, Ospendali
Riuniti, Bergamo, Italy; 5. Probity Research,Waterloo, ON; 6. Janssen Scientific
Affairs, LLC, Horsham, PA, USA
Introduction: The objective of this analysis is to report
the accrual of major adverse cardiovascular events(MACE) in
PSOLAR.
Methods/Results: PSOLAR is a multicenter, longitudinal,
observational study evaluating long-term safety and clinical outcomes for patients receiving (or eligible to receive)
treatment for psoriasis with biologics and/or conventional
systemic agents. The accrual of MACE in PSOLAR overall and
by exposure sub-groups is reported. MACE are defined as
cardiovascular death, non-fatal stroke, and confirmed non-fatal
myocardial infarction. MACE rates are assessed using definitions of exposure based on treatment at any time or treatment within 91 days preceding the reported event. In cases of
exposure to multiple therapies, MACE are attributed to treatment groups in the order of ustekinumab first, infliximab/golimumab second, other biologics third, and non-biologic therapy
last. As of the August 23,2012 data cut,11,900/12,000 patients
had enrolled in PSOLAR(22,918 cumulative patient-years of
follow-up). Unadjusted MACE rates, based on exposure at any
time, were:ustekinumab 0.28 events per 100 years of patient
observation(PYO) [95%CI:0.16,0.46;15/5332 PYO]; infliximab/
golimumab 0.32 per 100 PYO [95%CI:0.15,0.59;10/3136 PYO];
other biologics (almost exclusively etanercept and adalimumab) 0.34 per 100 PYO[95%CI: 0.23,0.47;34/10093 PYO]; nonbiologic therapy 0.55 per 100 PYO[95%CI:0.35, 0.82; 24/4357
PYO]; overall 0.36 per 100 PYO[95% CI: 0.29,0.45;83/22918
PYO]. Similar rates of MACE per 100 PYO were observed in
the analysis of exposure based on treatment received within
91 days of an event. Limitations: Due to channeling of therapy,
there may be differences in subgroup characteristics. Formal
comparison will require statistical modeling to adjust for
patient characteristics and risks,including consideration of
multiple treatments.
Conclusions: Although the numbers of MACE are
limited,unadjusted MACE rates are generally similar across
biologic treatment groups and trended higher in the no biologic group. These are preliminary results; PSOLAR will follow
patients for up to 8years,providing additional data over time.
PSOLAR represents a powerful resource for tracking safety
events of interest,such as MACE,among patients receiving
treatment for moderate to severe psoriasis.
Learning Objective: To report the accrual of major adverse cardiovascular events(MACE) in PSOLAR.
Takeaway Message: Although the numbers of MACE are
limited,unadjusted MACE rates are generally similar across
biologic treatment groups and trended higher in the no biologic group.
P15.10
Major adverse cardiovascular events among
initiators of biologic therapies in the
psoriasis longitudinal assessment and registry
(PSOLAR) study
Robert Bissonnette1 Alice B. Gottlieb2 Francisco Kerdel3
Luigi Naldi4 Kim Papp5 Steve Calabro6 Wayne Langholff6 Marc
Chevrier6
1. Innovaderm Research, Inc, Montreal, QC; 2.Tufts Medical Center, Boston, MA,
USA; 3. University of Miami, Miami, FL, USA; 4. Centro Studi GISED, Ospendali
Riuniti, Bergamo, Italy; 5. Probity Research,Waterloo, ON; 6. Janssen Scientific
Affairs, LLC, Horsham, PA, USA
Introduction: The objective of this analysis is to assess
rates of major adverse CV events(MACE) among patients who
initiated a new biologic during PSOLAR.
Methods/Results: PSOLAR is a multicenter,longitudinal
,observational study evaluating long-term safety and clinical
outcomes for patients receiving(or eligible to receive) treatment for psoriasis with biologics and/or conventional systemic
agents. Rates of MACE(CV death,non-fatal stroke,and non-fatal
myocardial infarction) among initiators of biologics in PSOLAR
are summarized.
As of the August 23,2012 data cut,11,900/12,000 patients
enrolled in PSOLAR. 57 MACE occurred across biologic treatment groups;of these 20 MACE were reported among patients
who initiated a new biologic. The proportions of patients who
initiated a new biologic and had a MACE at any time after
starting treatment were:adalimumab (ADA) 10/1121(0.89%,
95%CI 0.49%-1.63%), etanercept(ETA) 3/468(0.64%,95%CI
0.22%-1.87%), infliximab (IFX) 3/250(1.20%,95% CI 0.41%3.47%) and ustekinumab( UST) 4/1576(0.25%,95%CI 0.10%0.65%). Of patients with MACE, 3/1121(0.27%,95% CI 0.09%0.78%) in ADA group, 1/468(0.21%,95%CI 0.04%-1.2%) in ETA
group, 0/250(0%) in IFX group and 0/1576(0%) in UST group
had their MACE within 91 days of starting treatment. Baseline demographics and features were generally similar across
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CDA Abstracts
groups with some exceptions (eg.higher body mass index, and
proportions of patients with psoriatic arthritis and CV disease
for IFX patients).Onset of MACE after starting treatment
ranged from 16-789 days for TNF-alpha inhibitor initiators and
204-814 days for UST initiators. Among the subsets of bionaïve
new users,8/698 (1.15%,95%CI 0.58%-2.25%) in TNF-alpha
inhibitor group and 0/352(0%) in UST group had a MACE
after starting treatment. Of those in the bionaïve TNF-alpha
inhibitor new user group,4 occurred within 91 days of starting
treatment. Limitations:MACE among biologic initiators were
limited in number and rates were not adjusted for differences
among groups.CV events were confirmed by registry personnel but have not been externally adjudicated.
receptor (FcERI) on the cell surface. Recently, phase 3 studies
have demonstrated the safety and efficacy of omalizumab in
the treatment of CSU. In these studies, treatment with 150mg
and 300mg omalizumab every 4 weeks was shown to improve
significantly the symptoms of the patients (itching and wheals
number) in a dose dependent manner. Following this phase
3 program, a phase 3b study, OPTIMA, has been designed in
order to understand further the response of CSU patients
to omalizumab. The main two objectives of the study are to
gather data on the impact of withdrawl and retreatment with
omalizumab in CSU patients initially responding to treatment
and efficacy of optimizing the dose from 150mg to 300mg in
patients not achieving a UAS7<6 after 6 months of treatment.
Conclusions: At this time,no distinct patterns of MACE
have been observed after initiation of biologic therapies among
PSOLAR patients.Further analyses adjusting for demographic
features,CV risk factors and biologic exposure are planned.
Methods/Results: This study will be a: 320 patients, international, multi-center, randomized, open labeled trial. Efficacy
of omalizumab 150mg or 300mg doses administered every 4
weeks will be monitored by using the UAS7 score and quality
of life questionnaires. The study design will be presented here.
Learning Objective: To assess rates of major adverse CV
events(MACE) among patients who initiated a new biologic
during PSOLAR.
Takeaway Message: At this time,no distinct patterns of
MACE have been observed after initiation of biologic therapies
among PSOLAR patients.
P15.11
Optima: an ongoing phase 3b study to
evaluate the efficacy of optimized retreatment and step-up therapy with
omalizumab in patients with chronic
spontaneous urticaria refractory to standard
of care
Charles Lynde2 Gordon Sussman4 Wayne Gulliver3 William
Yang6 Jacques Hébert5 Sam Khalil1 Olivier Chambenoit1
1. Novartis Pharma Canada, Dorval, QC; 2. Mediprobe Research, London, ON; 3.
Memorial University of Newfoundland/NewLab Clinical Research Inc, St John’s,
NL; 4.The university of Toronto,Toronto, ON; 5. Centre de Recherche Appliquée
en Allergie de Québec, Québec, Québec, QC; 6. Ottawa Allergy Research
Corporation, Ottawa, ON
Introduction: Chronic spontaneous urticaria (CSU), also
called chronic idiopathic urticaria (CIU), is a condition where
patients experience frequent pruritic hives with associated
erythema and/or episodes of angioedema that have no apparent external trigger and which last for at least 6 weeks. Mast
cells are a key effector cells in this condition. Omalizumab is
a humanized neutralizing anti-IgE indicated for moderate to
severe persistent asthma in Canada. Omalizumab has a direct
impact on mast cells by reducing the density IgE high affinity
Conclusion: This will be the first phase IIIb study worldwide
to evaluate the efficacy of optimized re-treatment and step-up
Therapy with Omalizumab in patients with Chronic Spontaneous Urticaria.
Learning Objective: Chronic spontaneous urticaria (CSU),
also called chronic idiopathic urticaria (CIU), is a condition
where patients experience frequent pruritic hives with associated erythema and/or episodes of angioedema that have no
apparent external trigger and which last for at least 6 weeks.
Mast cells are a key effector cells in this condition. Omalizumab is a humanized neutralizing anti-IgE indicated for moderate
to severe persistent asthma in Canada. Omalizumab has a
direct impact on mast cells by reducing the density IgE high
affinity receptor (FcERI) on the cell surface. Recently, phase
3 studies have demonstrated the safety and efficacy of omalizumab in the treatment of CSU. In these studies, treatment
with 150mg and 300mg omalizumab every 4 weeks was shown
to improve significantly the symptoms of the patients (itching
and wheals number) in a dose dependent manner. Following
this phase 3 program, a phase 3b study, OPTIMA, has been
designed in order to understand further the response of CSU
patients to omalizumab. The main two objectives of the study
are to gather data on the impact of withdrawl and retreatment with omalizumab in CSU patients initially responding to
treatment and efficacy of optimizing the dose from 150mg to
300mg in patients not achieving a UAS7<6 after 6 months of
treatment.
Takeaway Message: This will be the first phase IIIb study
worldwide to evaluate the efficacy of optimized re-treatment
and step-up Therapy with Omalizumab in patients with
Chronic Spontaneous Urticaria.
A86
CDA Abstracts
P16.01
Allergic contact dermatitis to black rubber
milking equipment in a dairy farmer
P16.02
The most common co/cross reactants in
p-phenylenediamine allergic patients and the
impact on available alternative hair dyes
Tiffany Chen2 Melanie D. Pratt1
Gurbir Dhadwal; Gillian de Gannes
1. Division of Dermatology, University of Ottawa, Ottawa, ON; 2. University of
Toronto,Toronto, ON
Introduction: Paraphenylenediamine (PPD) is a colouring
agent known to cause severe allergic contact dermatitis. Traditionally, hair dye has been the primary route of exposure to
PPD; however, new patterns of occupational exposure to PPD
and cross-reacting substances are emerging. Black rubber mix
is used to colour rubber black or grey and is found in several
common industrial and household products. It contains isopropyl paraphenylenediamine, a chemical that has been associated
with cross-reactivity to PPD.
Methods and Results: We describe the case of a 33 yearold dairy farmer who presented with a severe allergic contact
dermatitis on the dorsal aspects of his hands and forearms.
The patient stated that he often employed a black rubber
milking device when milking cows that would directly contact
his dorsal thumb and forearm. Additional history revealed that
many years earlier, the patient had developed a severe allergic
contact dermatitis several days after receiving a temporary
henna tattoo. The patient was patch-tested with the North
American Contact Dermatitis Group series, the rubber series,
and various other rubber accelerators. Patch testing results
revealed strong positive reactions to PPD, black rubber mix,
and mecaptobenzothiazol.
Department of Dermatology and Skin Science, University of British Columbia,
Vancouver, BC
Background: P-phenylenediamine (PPD) is a common component of hair dyes and is also a common contact sensitizer.
Rates of sensitization to PPD, amongst patients presenting for
patch testing, range between 2%-12%. Given the rates of sensitization, hair dyes containing alternatives to PPD have been
developed. Here we attempt to determine if contact sensitization to the co/cross reactants found in these alternative hair
dyes limit their use by PPD allergic patients.
Methods/Results: We retrospectively reviewed all patch
test results of patients presenting to the UBC Contact
Dermatitis Clinic between January 2008 and June 2013. All
patients were patch tested with a screening series of 65-80 allergens as well as supplemental allergens as clinically indicated.
The American Contact Dermatitis Society Contact Allergen
Management Program (CAMP) database was queried for hair
dyes without PPD and each of the most common co/cross
reactants. Of the 95 patients found to be patch test positive
to PPD, 74(78%) had at least one other positive reaction. The
most common co/cross reactants, constituting statistically
significantly greater than 1% of PPD positive patients, were
nickel(24%), ammonium persulfate(18%), cobalt (16%), p-toluenediamine sulfate(15%), 4-aminophenol(14%), fragrance mix
I(12%), toluenediamine base(9%), fragrance mix II(7%), myroxylon pereirae resin(7%), glyceryl thioglycolate(7%), 3-aminophenol(6%), black rubber mix(6%), thiuram mix(6%) and carba
mix(6%). The CAMP database contained 17 PPD free dyes. Co/
cross reacting to nickel, cobalt, ammonium persulfate, glyceryl
thioglycolate, p-toluenediamine sulfate/base, black rubber mix,
thiuram mix or carba mix did not further restrict the number
of dyes. Cross reacting to 4-aminophenol restricted available dyes to 16. Positivity to any of the fragrances restricted
patients to 1 non-permanent dye.
Conclusions: This case highlights an uncommon yet important source of exposure to a substance known to crossreact with PPD in the occupational setting. Our patient likely
became sensitized to PPD at the time of his prior henna
tattoo. Subsequent exposure to the black rubber milking
device resulted in his current presentation. Given the increasing number of products containing PPD and related chemicals
found in the workplace, an awareness of such products and
the occupational implications of reactions to these products is
warranted.
Learning Objective: To highlight the cross-reactions that
can occur with PPD and related chemicals. To describe the occupational implications of a PPD allergy.
Takeaway Message: Given the increasing number of
products containing PPD and related chemicals found in the
workplace, an awareness of such products and the occupational implications of reactions to these products is warranted.
Conclusions: Patients who are allergic to PPD are commonly allergic to other chemicals found in hair dyes. Patients
that are PPD allergic and also react to fragrances are severely
restricted in their choices of hair dye.
Learning Objective: To understand if chemicals, that PPD
sensitized patients commonly co/cross react to, restrict their
choice of hair dyes.
A87
CDA Abstracts
Takeaway Message: Patients that are PPD allergic and
also react to fragrances are severely restricted in their choices
of hair dye.
Takeaway Message: Lauryl glucoside is an important
marker for allergenicity and serves as a marker for cross-reactions to a wide group of compounds found in many products.
P16.03
P16.05
Lauryl glucoside - a valuable marker of cross
reactions during patch testing
Lessons learned in occupational dermatology
from Australia
Jeewanjit S. Gill1 Laurie M. Parsons2
Tiffany Kwok1 Rosemary Nixon2
1. University of Ottawa, Ottawa, ON; 2. University of Calgary, Calgary, AB
1. Division of Dermatology & Cutaneous Sciences, University of Alberta,
Edmonton, AB; 2. Skin and Cancer Foundation, Melbourne,VIC, Australia
Background: Lauryl glucoside is a common compound
found in a variety of products that include shampoos, soaps,
deodarants, toilet wipes, baby wipes, and cosmetics. It often
functions as a surfactant and/or emulsion stabilizer. Cross
reactivity of this compound during patch testing has been
reported but a comprehensive search has not been conducted
to date.
Objective: To discuss emerging trends and lessons learned
during an occupational contact dermatitis mentorship elective
in Australia.
Methods: Three case vignettes of cutaneous allergy seen in
the Occupational Dermatology Clinic at the Skin and Cancer
Foundation in Melbourne, Australia will be presented.
Methods: A comprehensive literature search was conducted
using Medline, Scopus, Google Scholar, and individual dermatology journals. Key words included “lauryl glucoside”, “contact
dermatitis”, and “patch testing”. An analysis of similar glucoside
compounds was also done.
Results: A total of 12 articles were found. Even though lauryl
glucosides have been suggested to cross react with alkyl glucosides, the specificity and range of these moieties is immense.
They can include hydrocarbon chains (C10-C22), cyclical rings,
as well as aromatic groups. The list of compounds commonly
encountered include arachidyl glucoside, butyl glucoside,
caprylyl/capryl glucoside, cetearyl glucoside, coco glucoside,
ethyl glucoside, hexadecyl glucoside, isostearyl glucoside,
myristyl glucoside, octadecyl glucoside, octyldodecyl glucoside,
undecyl glucoside, glucose homopolymers, dodecylether, and
glucopyranose. Interestingly, the glucoside base is a hexose
structure and diastereomers may also be implicated in cross
reactivity.
Conclusion: Lauryl glucoside is an important marker for
allergenicity and serves as a marker for cross-reactions to a
wide group of compounds found in many products.
Learning Objective: To demonstrate the importance of
lauryl glucoside as a marker for patch testing.
Results: A 47-year old automotive emissions worker with
hand dermatitis was patch test positive to methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI), found in a hand cleaner at work as well as
in numerous personal care products. A 46 year-old endoscopy
technician developed respiratory symptoms as well as an
eruption on the hands within minutes of entering the endoscopy suite, and was found to be prick test (but not patch
test) positive to chlorhexidine. A 31 year-old nuclear medicine
technologist had severe atopic dermatitis on her body which
cleared with conventional treatment, but her hand dermatitis
persisted. Patch testing was positive for coconut diethanolamide in her hand cleanser at work.
Conclusions:
1) Contact dermatitis to MCI/MI and MI alone is found in numerous occupational and non-occupational exposures and
has become increasingly relevant in Australia. The Australian Baseline Series has expanded to include methylisothiazolinone as an allergen on its own.
2) It is important to delineate between immediate and delayed hypersensitivity reactions, based on patient history.
3) Consider patch testing all atopics recalcitrant to treatment.
Acknowledgements: American Contact Dermatitis
Society Mentoring Award, Canadian Dermatology Foundation
Frederick Kalz Bursary
Learning Objective: To discuss emerging trends and
lessons learned during an occupational contact dermatitis
mentorship elective in Australia.
A88
CDA Abstracts
Takeaway Message:
1) Contact dermatitis to MCI/MI and MI alone is found in numerous occupational and non-occupational exposures and
has become increasingly relevant in Australia. The Australian Baseline Series has expanded to include methylisothiazolinone as an allergen on its own.
2) It is important to delineate between immediate and delayed hypersensitivity reactions, based on patient history.
3) Consider patch testing all atopics recalcitrant to treatment.
contact dermatitis with re-exposure to unpolymerized acrylates.
P16.06
Acrylate systemic contact dermatitis
Maxwell B. Sauder1 Melanie D. Pratt1, 2
1. University of Ottawa, Ottawa, ON; 2. North American Contact Dermatitis
Group, Ottawa, ON
Background: Acrylates, the 2012 American Contact Dermatitis Society allergen of the year, are found in a range of
industries and products including the absorbent materials contained within feminine pads. When fully polymerized, acrylates
are non-immunogenic; however, if not completely cured the
monomers can be potent allergens resulting in delayed-type
hypersensitivity reactions (type IV allergic reaction).
Objective: A 28 year old female is presented that had her
teeth varnished with Septodont’s Isodan that contains 2-hydroxyethyl methacrylate (HEMA) with no initial reaction.
Approximately 1 month later, the patient developed a genital
dermatitis secondary to her feminine pads. The initial reaction
resolved but 5 month’s later the patient developed a systemic
contact dermatitis after receiving a second varnishing.
Methods: The patient was patch tested to the North
American Contact Dermatitis standard screening series, select
acrylates, select vehicles and preservatives, sunscreen series,
flavours and fragrances series and the patient’s own pads both
wet and dry pieces from various layers. Patch test readings
were performed at 48 and 96 hours.
Results: The patient was dramatically patch test positive to
many acrylates: methylmethacrylate, hydroxyethyl methacrylate, butyl methacrylate, hydroxypropyl methacrylate, ethylene
glycol dimethacrylate, triethylene glycol dimethacrylate, butanediol dimethacrylate, urethane dimethacrylate, hexanediol
diacrylate, tetrahydrofurfuryl methacrylate, triethylene glycol
dimethacrylate, dimethyl ethyl methacrylate, tripropylene glycol diacrylate and trimethylolpropane triacrylate.
Learning Objective: To present a case demonstrating:
1. Allergic contact dermatitis to unpolymerized acrylates
2. Cross sensitization to various other acrylates
3. Systemic contact dermatitis from acrylates
Takeaway Message: This case demonstrates a reaction
to unpolymerized acrylates within a feminine pad as well as
broad cross sensitization to acrylates and the potential for
systemic contact dermatitis with re-exposure to unpolymerized acrylates.
Conclusion: This case demonstrates a reaction to unpolymerized acrylates within a feminine pad as well as broad
cross sensitization to acrylates and the potential for systemic
A89
CDA Abstracts
P17.01
An array of mobile apps in dermatological
surgery
Joshua M. Mercer
University of Alberta, Edmonton, AB
As of June 2013, there were 19619 and 8,209 medical applications (apps) available for the Apple and Android platforms,
respectively. Hence, finding useful dermatology apps by physicians, residents and medical students can be overwhelming.
Therefore, I decided to methodically review hundreds of apps
obtained by using the following keywords: dermatology, medications, skin cancer, skin surgery and melanoma; in an attempt
to create a short list of credible apps, organized into functional
categories, that would be clinically relevant for dermatological
surgeons or their patients.
Learning Objective: To create a short list of credible apps,
organized into functional categories, that would be clinically
relevant for dermatological surgeons or their patients.
Takeaway Message:
• Recent developments in technology, including mobile apps
and teledermatology, are shaping the way in which the practice of Dermatology is being conducted.
• Currently there are hundreds of Dermatology apps and
counting, some of which can be useful in your daily practice
or for your patients.
• Caution must be used regarding patient confidentiality, data
storage and the accountability of some apps.
P18.01
Hot-spots of CTCL cases in Houston and
Texas: a comparison of the MD Anderson and
Texas Cancer Registries
Ivan V. Litvinov1 Michael T. Tetzlaff2 Elham Rahme1 Pamela
Gangar2 Michelle A. Jennings2 Kevin Pehr1 Denis Sasseville1
Madeleine Duvic2
1. McGill University, Montreal, QC; 2.The University of Texas MD Anderson
Cancer Center, Houston,TX, USA
Background: Cutaneous T-Cell Lymphomas (Mycosis Fungoides and the leukemic variant, Sézary Syndrome) are rare
cancers with a documented incidence of ~4-8 cases per million individuals per year. Currently, the pathogenesis of CTCL
remains only partially understood. Reports of incidence of
Mycosis Fungoides in married couples and families raise a possibility that there might be an important environmental trigger
for this disease. However, to date no unequivocal geographic
hotspots have been documented for this cancer.
Methods: We analyzed by region, zip code, age and ethnicity
the demographic data of 1047 patients from Texas, who were
seen in a CTCL clinic at the MD Anderson Cancer Center
(MDACC) during 2000-2012 using the MDACC database. In
addition de-identified data on CTCL incidence was requested
from the Texas Cancer Registry (TCR) database and similar
analyses were performed on 1970 patients with MF and SS
that were registered in that database between 1995-2010. Subsequently both data sets were cross analyzed and compared.
Results: Our findings, based on the MDACC database
results, document geographic clustering of patients in three
communities within the Houston metropolitan area, in which
the CTCL incidence rates were 10-50 times higher than the
expected population rate. Moreover, analysis of incidence rates
in these communities over time suggests a significant increase
in the disease after ~2006. The data results from the TCR
database defined the CTCL population rate for the state to be
5.57 [CI 5.34; 5.83] cases per million per year. Furthermore,
the TCR database confirmed the above findings and further
highlighted 4 additional putative geographic hotspots for
CTCL within the state of Texas, but outside the Houston metropolitan area. In addition, in this work we summarize disease
incidence patterns based on sex, age and race across the state
of Texas using both databases.
Learning Objective: Describe clustering of CTCL cases in
the state of Texas using the MD Anderson and Texas Cancer
Registry databases.
Takeaway Message: Identification of geographic clustering for CTCL argues for existence of yet unknown external
causes in triggering this rare cancer. Identification of additional
CTCL hotspots around the world will potentially help identify
these triggers and will bring us closer to preventing this disease.
P18.02
Investigating the role of CD133 in melanoma
stem cell niche morphogenesis
Anthony B. Mak1, 2 Caroline Schnegg1 Chiou-Yan Lai3 Jason
Moffat2 Mei-Yu Hsu1, 3
1. Department of Dermatology, Boston University Medical Centre, Boston,
MA, USA; 2. Banting and Best Department of Medical Research, University
of Toronto,Toronto, ON; 3. Department of Pathology, Brigham and Women’s
Hospital, Boston, MA, USA
Our battle with melanoma continues to be complicated by frequent metastasis, therapeutic resistances and clinical relapse.
A90
CDA Abstracts
These complications may be explained by the cancer stem cell
(CSC) model, which has revolutionized the strategic considerations for modern melanoma treatment. However, melanoma
stem cell (MSC) targeted therapy may be non-efficacious due
to an increase in tumor plasticity (i.e. the ability to induce
MSCs from differentiated melanoma cells through environmental cues in the niche) relative to certain other cancers.
Thus, MSC targeting requires multipronged approaches that
are not only directed to the MSCs themselves but also to
their niche. We previously demonstrated that MSCs expressing
the pentaspan transmembrane glycoprotein CD133 reside in a
complex vascular niche comprising of authentic endotheliumlined blood vessels, tumour-derived vasculogenic mimicry (VM)
channels, and mosaic vessels. Importantly, silencing of the CSC
marker CD133 in melanoma cells results in reduced tumorigenicity and depletion of MSCs, as well as the inhibition of VM
and niche morphogenesis in vivo.
To elucidate the molecular mechanisms responsible for
CD133-dependent MSC niche morphogenesis, we performed
gene expression profiling using PCR-based pathway-specific
arrays on a melanoma cell line and melanoma tumour xenografts transduced with lentiviral short-hairpin RNA (shRNA)
interference vectors targeting either CD133 or a control
transcript. A validated gene hit termed brain angiogenesis
inhibitor 1 (BAI1) is significantly downregulated in CD133expressing melanoma cells and xenografts transduced with the
control shRNA, suggesting it has a role as a negative regulator
for MSC niche establishment and maintenance. Studies are
underway to evaluate the potential of targeting CD133 and/
or upregulating BAI1 as novel niche-targeting strategies for
therapy in melanoma.
Learning Objective: CD133+ melanoma stem cells reside
and depend on a complex vascular niche in tumours.
Takeaway Message: Inhibiting CD133 to target melanoma
stem cells and their niche is a promising approach for melanoma treatment.
18.03
Evaluating morbidity and association with
autoimmune thyroiditis of chronic urticaria
in children
50 % of spontaneous CU cases. The pathogenesis of CU and
its effect on quality of life (QoL) are not well established in
children. We aimed to establish a registry of CU in children to
assess autoimmunity, QoL and factors affecting QoL. Between
January 2013 and 2014, we recruited 35 children. Participants
were queried on demographics, clinical history and QoL (CUQ2oL) through a validated questionnaire. In addition, participants filled the urticaria activity score (UAS). Blood tests were
drawn to assess basophile activation, thyroid autoimmunity
and confirmatory tests were performed when applicable to diagnose inducible forms. The Wilcoxon Rank Sum test and multivariate regression analysis were used to assess autoimmunity
and factors associated with impaired QoL respectively. Our
findings reveal that the majority of children were males (57%)
presenting at a median age of 8 years (IQR: 3.75-12.0). Thyroiditis was reported in 17.1% of family members, but TSH and
anti-thyroid peroxidase were normal in all patients. Physical
forms occurred in 17.1 % of patients. Mean CD63 expression
was 5.3% and was comparable to CD63 levels in controls. The
mean weekly quality of life (UAS) score over 3 months was
6.5 on a scale of 42, which indicates a mild disease. Increased
age at onset (OR=2.2, 95%CI) was associated with decreased
QoL in the functionality domain and higher UAS (OR=2.16)
with worse sleep domain. In conclusion, CU in children was
not associated with thyroiditis or autoimmunity. Older age of
onset and higher UAS may affect the quality of life in pediatric
population. Our cohort will be followed for 10 years to study
the natural history of CU.
Learning Objective:
• To understand the role of autoimmunity in the pathogenesis
of chronic urticaria in children.
• To determine the impact of CU on the quality of life in
pediatric population.
• To assess factors affecting the quality of life in children.
Takeaway Message:
• Compared to adults, the implication of autoimmunity and
thyroiditis seems to be less important in pediatric CU.
• Most children have a mild disease and good control with
anti-histamines only.
• Older age of onset and higher urticarial activity score may
affect the quality of life in pediatric population.
Elena Netchiporouk
McGill University, Montreal, QC
Chronic urticaria (CU) is defined when hives occur for at least
6 weeks. Recent studies suggest that autoimmunity including
targeting either the mast cell IgE receptor, the IgE molecule
or auto-antigens (i.g. thyroid antigens) may account for almost
A91
CDA Abstracts
P19.01
Effective management of eccrine
angiomatous hamartoma using pulsed dye
laser
Joseph Doumit; Allison Vidimos
Cleveland Clinic, Cleveland, OH, USA
Eccrine angiomatous hamartoma (EAH) is a rare condition
which presents itself as a benign tumor known to typically
affect the pediatric population but may infrequently be seen in
adulthood. Defining features of the condition include increased
eccrine and vascular glands. Albeit clinical manifestations are
variable, true diagnosis is confirmed by histological examination. There have been reports of associated hyperhidrosis and
pain although the condition tends to be asymptomatic. No
systemic conditions have yet been associated with EAH but in
our experience we have noted concomitant onset of diabetes
mellitus with our adult patients. There is no gold standard
treatment for EAH but current literature has reported the
following treatment options: surgical excision, pulsed-dye laser,
Nd:YAG laser, botulinum toxin, and certain sclerosing agents
depending on the size and symptoms of the condition. In our
experience, pulsed-dye laser has provided effective treatment
amongst current options. We present a case series where
pulsed-dye laser proved to be a successful approach in this
condition.
Learning Objective: To educate the benefits of using a
pulsed-dye laser for the treatment of Eccrine angiomatous
hamartoma.
Takeaway Message: The pulsed-dye laser is an effective
modality in the treatment of Eccrine angiomatous hamartoma
P20.01
Drup price listing as a requirement for
meeting speakers and drug marketing
displays
Robert N. Richards
North York General Hospital, University of Toronto,Toronto, ON
Results: The media, insurance companies, governments , and
the public express concerns about prescription costs. Drug
company marketers recognize the physicians’ prescribing role
and they collectively spend billions of dollars on physician persuasion. Marketers are full time experts. Physicians may not be
fully prepared to deal with their persuasive expertise. A CBC
report noted (too strongly?):-- “Doctors, who are bombarded
with marketing materials promoting brand names, simply do
not consider the cost burden---when they write prescriptions.” Physicians often believe that they know drug prices
but, unfortunately, observational studies indicate otherwise.
However, numerous studies demonstrate that physician knowledge of drug costs leads to more economical prescribing. An
ideal venue to educate physicians about costs is at scientific
meetings.
If all educational presentations and marketing displays were
required to provide drug costs at all meetings;---then physicians would be more aware of drug costs. This innovative educational practice would help dispel the common perception
that there is too close a relationship between physicians and
‘big pharma’ . Some universities recommend this educational
practise, but we could not identify any that required it.
Conclusions: Physician knowledge of drug costs leads to
more economical prescribing. The requirement to list drug
prices in educational presentations and marketing displays
would assist in educating physicians about drug costs. The
CDA, if it decided to mandate drug price listings, would be in
the forefront of drug cost education;-- as well as sending a
message to the public that our first responsibility is patients.
Learning Objective: Learning objective: To demonstrate
that the compulsory listing of drug prices in all scientific meeting presentations, posters, and marketing displays would result
in better physician education about drugs and would lead to
more cost efficient prescribing.
Takeaway Message: Takeaway message: Physician knowledge about drug costs results in more cost efficient prescriptions. Mandating the listing of drug prices in all scientific
meeting presentations, posters, and marketing displays would
be an ideal and innovative way to educate physicians about
drug costs.
Introduction: Drug prices are a major determinant in total
health care costs. Increased physician awareness of drug costs
would assist in cost efficient prescribing. Physician knowledge
about drug costs would be increased if all meeting presentations and marketing displays were required to give the prices
of all drugs discussed.
Methods: Medline search, media review. Colleague and
patient discussions.
A92
CDA Abstracts
P20.02
Dermatolgy drug sampling: educational and
other considerations
Robert N. Richards
Takeaway Message: Physicians receiving drug samples
should remember that everyone is affected by marketing and
that sampling often leads to higher costs for patients. When
possible, physician education should be received from independent sources and not from samples.
North York General Hospital, University of Toronto,Toronto, ON
Introduction: Product sampling is a well entrenched marketing tool. Educators and ethicists often disapprove, but physicians often approve. Educational aspects and pros and cons
reviewed.
Methods: Medline search. Observation of samples in our
group office and hospital clinics. Colleague discussions.
Results: Physicians receiving samples may feel obligated to a
company and grant their representative preferential access;-resulting in greater biased prescribing of their product.
Particularly true if the samples are for self or family use. Dispensed samples which are expired can reflect adversely upon
the physician. Samples may benefit the patient short- term but
usually cost them more later, because ordinarily, only expensive products are sampled. Samples are often of the ‘me too’
type and price is rarely given. ie: Olux-E foam: $168 whereas
generic clobetasol: $20.35. Companies ONLY give samples
because they are proven to increase physician prescribing. Physician education obtained from drug samples is biased. Drug
education is better obtained from independent educational
sources:---professional meetings, colleagues, journals, and ‘Medical Letter” type reviews. Physicians requiring topical testers to
determine patient tolerance can buy them, or without obligation, contact the company for a sample without representative marketing. Expensive office and hospital space is better
used for requisitions and patient educational materials than
for storing overflowing samples, drug literature and discount
coupons. Expensive staff and physician time is required to
store and monitor samples. Abundant ‘me-too’ samples can be
confusing. Educators state: “Know a few drugs and know them
well.” Observational studies show that resident access to drug
samples influences them to use more expensive advertised
products.
Conclusions: Drug sampling marketing is designed to influence physician prescribing and often leads to product bias and
higher drug costs. Samples can be useful for patient testing,
physician education, and occasionally for patients without
funds. However independent options are usually available and
should be pursued.
Learning Objective: Learning objectives: Physicians accepting drug samples have a significant risk of receiving a
biased drug education and of being persuaded to prescribe
higher cost drugs.
A93
CDA Abstracts
Author Index
Abbas, Mariam........................................................................................... A41
Afifi, Tarek.................................................................................................. A35
Ahluwalia, Renita...................................................................................... A37
Al-Rajaibi, Raqiya...................................................................................... A48
Alain, Jimmy............................................................................................... A76
Alavi, Afsaneh............................................................A9, A10, A12, A21, A34
Albrecht, Lorne......................................................................................... A27
Alhusayen, Raed............................................................................... A10, A55
Almohideb, Mohammad A....................................................................... A47
Anderson, John......................................................................................... A78
Anooshirvani, Niloofar..................................................................... A9, A10
Arbour, N................................................................................................... A13
Arthurs, Bryan.......................................................................................... A62
Asai,Yuka ................................................................................................ AA1
Au, Sheila........................................................................................... A24, A74
Augustin, Matthias.................................................................................... A84
Bahrani, Bahar .......................................................................................... A77
Baibergenova, Akerke.................................................................... AA1, A10
Bailey, Kristy.............................................................................................. A34
Baldwin, Sarah........................................................................................... A74
Barbeau, Martin............................................................................... A82, A83
Barber, Duane........................................................................................... A39
Barber, Kirk................................................................................................ A26
Beauregard, Solange................................................................................. A47
Beecker, Jennifer.............................................................................. A38, A69
Bélisle, Annie....................................................................................... A4, A21
Bell, Chaim................................................................................................. A60
Benohanian, Antranik................................................................................. A8
Bertrand, Janie ......................................................................................... A72
Bhogal, Meetu............................................................................................ A20
Billick, Robin.............................................................................................. A50
Bissonnette, Robert............................................. A13, A26, A58, A67, A85
Bocz, Heather........................................................................................... A31
Boggild, Andrea................................................................................ A34, A35
Bolduc, Chantal......................................................................................... A58
Botkin, Alexis A.................................................................................. A9, A76
Boull, Christina ........................................................................................ A42
Bourcier, Marc........................................................................................... A26
Bourgeault, Emilie G................................................................................ A76
Bracken, Michael B.................................................................................. A69
Brassard, Alain........................................................................... A5, A11, A12
Burns, Ariel................................................................................................ A46
Calabro, Steve......................................................................... A83, A84, A85
Cartotto, Robert...................................................................................... A42
Chalabi,Youb............................................................................................. A26
Chambenoit, Olivier................................................................................ A86
Champagne, Trevor ................................................................................. A37
Chan, An-Wen...................................................................A9, A70, A73, A76
Chandrakumar, Shivani F.......................................................................... A41
Chandran,Vinod......................................................................................... A3
Chaplin, Anna C........................................................................................ A38
Chen, Tiffany.............................................................................................. A87
Cheung, Loretta........................................................................................ A54
Chevrier, Marc......................................................................... A83, A84, A85
Chia, Justin................................................................................................. A25
Chimenti, Sergio.............................................................................. A22, A27
Cohen, Stacy ............................................................................................ A48
Colantonio, Sophia A................................................................................ A69
Coomes, Eric............................................................................................. A70
Corbo, Michael D...................................................................................... A61
Cordeiro , Brendan.................................................................. A7, A14, A69
Côté, Benoît....................................................................................... A4, A21
Coulombe, Jérôme................................................................... A3, A63, A66
Cowger, Jeffery ........................................................................................ A16
Crawford, Richard I.................................................................................... A6
Dahl, Alice.................................................................................................. A46
Danylo, Alexis............................................................................................ A34
Day, Robert M................................................................................ A22, A27
de Gannes, Gillian.................................................................. A11, A56, A87
Denburg, Judah A...................................................................................... A31
Desjardins, Danielle................................................................................. A41
Dhadwal, Gurbir.............................................................................. A68, A87
Diab, Nermin R......................................................................................... A79
Diao, Diana Y.............................................................................................. A68
Dodiuk-Gad, Roni P.................................................................................. A42
Donovan, Jeff............................................................................................. A44
Doré, Marc-Andre ........................................................................... A7, A69
Doucette, Steve............................................................................... A17, A60
Doumit, Joseph....................................................................... A36, A45, A92
Doumit, Marc............................................................................................ A19
Duronio,Vincent....................................................................................... A70
Dutil, M...................................................................................................... AA1
Dutz, Jan..................................................................................................... A43
Duvic, Madeleine............................................................................. A15, A90
Dytoc, Marlene......................................................................................... A52
Eder, Lihi....................................................................................................... A3
Ejaz, Aiza..................................................................................................... A55
El-Hadi, Hadal.............................................................................................. A2
Elewski, Boni E........................................................................................... A80
Eminger, Lindsay........................................................................................ A48
Erickson , Janelle ...................................................................................... A26
Evans, Robyn.............................................................................................. A78
Fakharzadeh, Steve................................................................. A83, A84, A85
Fausto de Souza, Dominique................................................................. A54
Ferringer, Tammie..................................................................................... A48
Fiorentino, David...................................................................................... A83
Fish, Joel...................................................................................................... A42
Fitzpatrick, Richard E............................................................................... A19
Fleming, Patrick......................................................................................... A55
Foley, Peter ...................................................................................... A22, A27
Fowler, Robert ......................................................................................... A50
A94
CDA Abstracts
Fredholm, Simon....................................................................................... A14
Fung, Kinwah............................................................................................. A73
Gang, Li....................................................................................................... A70
Gangar, Pamela................................................................................. A15, A90
Gattey, Natasha......................................................................................... A77
Geduld, Jennifer........................................................................................ A35
Ghassemi, Farhad..................................................................................... A10
Ghesquiere, Wayne.................................................................................. A35
Ghiasi, Nazli................................................................................................. A7
Gilbert, Martin................................................................................... A7, A69
Gill, Jeewanjit S........................................................................ A36, A75, A88
Gill, Pavandeep.......................................................................................... A13
Gladman, Dafna D....................................................................................... A3
Glassman, Steven J.................................................................. A54, A68, A75
Goldberg, Hanna...................................................................................... A60
Gomez, Pilar.............................................................................................. A52
Gooderham, Melinda J............................................................................. A71
Gottlieb, Alice B............................................................................... A81, A85
Greenspoon, Jill........................................................................................ A40
Gregory,Valerie...................................................................... A23, A82, A83
Grenier, Pierre-Olivier............................................................................ A49
Griffiths, Christopher E......................................................... A22, A27, A80
Grobler, Andre............................................................................................ A2
Groff, William............................................................................................ A19
Guenther, Lyn................................................................................... A24, A44
Gulliver, Wayne.......................... A23, A29, A30, A31, A32, A33, A50, A86
Gupta, Ambika............................................................................................. A2
Habel,Youssef............................................................................................ A15
Haber, Richard M...................................................................................... A64
Haddad, Amir............................................................................................... A3
Hajek, Jan.................................................................................................... A35
Halton, Jacqueline .................................................................................... A16
Hampele, Isabelle...................................................................................... A80
Harris-Janz, Sydney................................................................................... A16
Hatami, Afshin........................................................................... A3, A63, A66
Hébert, Jacques......................................................................................... A86
Heffernan , Michael ................................................................................. A26
Helou, Silvia............................................................................................... A80
Hickey, John............................................................................................... A46
Ho, Nhung......................................................................................... A62, A63
Ho,Vincent........................................... A29, A30, A31, A32, A33, A83, A84
Holfeld, Karen.................................................................................... A2, A41
Hook, Kristen............................................................................................ A42
Hsu, Mei-Yu................................................................................................ A90
Hu, ChiaChi...................................................................................... A22, A27
Huang,Yuanshen................................................................................ A7, A14
Hull, Peter........................................................................................ AA1, A77
Humphrey, Shannon.................................................................AA1, A6, A58
Hunt, Anne-Marie..................................................................................... A49
Hylwa, Sara ............................................................................................... A42
Ibrahim, Omar........................................................................................... A45
Jack, Carolyn..................................................................................... A13, A50
Jafarian, Fatemeh.............................................................................. A65, A67
Jafarnejad, Seyed Mehdi........................................................................... A70
Jean, Sara-Elizabeth................................................................................... A72
Jennings, Michelle A......................................................................... A15, A90
Jeschke, Marc............................................................................................. A42
Johnston, Donna ...................................................................................... A16
Jones, Duncan............................................................................................ A78
Juda, Ari....................................................................................................... A56
Kain, Kevin C............................................................................................. A35
Kalia, Sunil ........................................................................................ A13, A74
Kanigsberg, Nordau........................................................................ A16, A65
Karpov, Alexander ................................................................................... A80
Katchadourian, Karine............................................................................. A61
Kerdel, Francisco...................................................................................... A85
Keystone, Jay S........................................................................................... A34
Khalil, Sam......................................................................................... A23, A86
Khosravi, Shahram.................................................................................... A70
Kim, Whan B.................................................................................... A21, A53
Kirchhof, Mark........................................................................ A11, A43, A78
Kircik, Leon ..................................................................................... A22, A27
Kirshen, Carly........................................................................................... A16
Kitchen, Jessica.......................................................................................... A70
Klekotka, Paul................................................................................... A27, A28
Kokta,Victor.............................................................................................. A64
Komierowski, Beata................................................................................. A57
Kraft, John.................................................................................................. A56
Kraft, John N................................................................................................ A2
Kricorian, Greg......................................................................................... A28
Kuhn, Susan................................................................................................ A35
Kunimoto, Brian........................................................................................ A78
Kupper, Thomas S..................................................................... A7, A14, A69
Kurian, Anil................................................................................................. A19
Kuzel, Paul.................................................................................................. A12
Kwok, Tiffany............................................................................................. A88
Lacroix, Julie............................................................................................... A38
Lai, Chiou-Yan........................................................................................... A90
Lam, Diana................................................................................................. A58
Lam, Joseph................................................................................................ A61
Lam, Kevin.................................................................................................. A70
Lam, Lauren............................................................................................... A39
Lange, Dirk................................................................................................. A78
Langholff, Wayne..................................................................... A83, A84, A85
Langley, Richard G.................................................................. A80, A81, A83
Lara-Corrales, Irene........................................................................ A33, A62
Lau, Davina................................................................................................. A60
Law, Adrienne............................................................................................ A78
Lebwohl, Mark.................................................................................. A80, A83
Lee, Tim...................................................................................................... A68
Leonardi, Craig............................................................... A22, A26, A27, A84
Leung, Jordan............................................................................................. A12
Levy, Jonathan............................................................................................ A11
Li, Monica K............................................................................. A17, A57, A60
A95
CDA Abstracts
Libman, Michael........................................................................................ A35
Lima, Hermenio C........................................................................... A16, A31
Litvinov, Ivan V..........................................................A7, A14, A15, A69, A90
Liu, Annie............................................................................................. A9, A76
Lovegrove, Fiona....................................................................................... A18
Luciani, Laura.................................................................................... A82, A83
Lui, Harvey................................................................................................. A68
Lynde, Charles W...............................................................A1, A2, A26, A86
Maari, Catherine....................................................................................... A58
Mahmood, Muhammad..................................................................... A5, A75
Maibach, Howard...................................................................................... A12
Maini, Priya................................................................................................. A71
Mak, Anthony B......................................................................................... A90
Malaiyandi,Viba......................................................................................... A55
Malhotra, Neel.......................................................................................... A61
Mallya, Usha............................................................................................... A23
Marcil, Isabelle ............................................................................................ A8
Marcoux, Danielle.................................................................................... A66
Marinas, Joseph E...................................................................................... A16
Martin, RLM............................................................................................... A81
Martinka, Michal................................................................................. A6, A70
Mashiko, S................................................................................................... A13
Mathieu, Steve........................................................................................... A47
McCarthy, Anne........................................................................................ A35
McCourt, Collette.................................................................................... A24
McEvoy, Alana C........................................................................................ A65
McLean, David........................................................................................... A68
Menter, Alan............................................................................. A27, A28, A84
Mercer, Joshua M....................................................................................... A90
Mereniuk, Alexandra................................................................................ A67
Metzger, Daniel......................................................................................... A61
Miedzybrodzki, Barbara........................................................................... A47
Miliszewski, Monica.................................................................................. A43
Miller-Monthrope,Yvette........................................................................ A38
Miller, Robert................................................................................... A20, A46
Milmont, Cassandra E..................................................................... A27, A28
Mioduszewski, Margaret J....................................................................... A57
Mistry, Nisha.............................................................................................. A21
Moffat, Jason.............................................................................................. A90
Mpofu, Shephard....................................................................................... A81
Murray, Christian........................................................................................ A9
Mussani, Farheen............................................................................. A33, A52
Mydlarski, P. Régine ........................................................................ A25, A57
Nakagawa, Hidemi .................................................................................. A80
Naldi, Luigi................................................................................................. A85
Nantel-Battista, Mélissa.................................................................... A8, A70
Neagoe, Christine ................................................................................... A54
Netchiporouk, Elena....................................................................... A15, A91
Nguyen, Khue................................................................................... A47, A50
Nguyen,Van-Hung.................................................................................... A65
Nigen, Simon............................................................................................. A58
Nirula, Ajay........................................................................................ A27, A28
Nixon, Rosemary..................................................................................... A88
Noiles, Kristin L.............................................................................. A56, A58
Notter, Marianne...................................................................................... A80
O’Toole, Ashley C............................................................................ A38, A54
Odum, Niels.............................................................................................. A14
Olynych, Tim.............................................................................................. A31
Ortonne, Jean-Paul.......................................................................... A27, A28
Pannu, Mohammad................................................................................... A35
Papavassilis, Charis.......................................................................... A80, A81
Papp, Anthony............................................................................................ A43
Papp, Kim....................................................... A22, A26, A27, A28, A29, A30
........................................................................ A31, A32, A33, A80, A84, A85
Parsons, Laurie M.......................................................... A17, A43, A60, A88
Pehr, Kevin.................................................................................. A7, A15, A90
Petrella, Robert J....................................................................................... A82
Philip, Anie.................................................................................................. A79
Philipp, Sandra........................................................................................... A81
Poelman, Susan.......................................................................................... A39
Polcari, Ingrid............................................................................................. A42
Pope, Elena................................................................................................. A63
Posso-De Los Rios, Claudia J................................................................. A62
Potok, Olivia V............................................................................................ A75
Poulin-Costello, Melanie......................................................................... A26
Poulin,Yves..........................................AA1, A26, A29, A30, A31, A32, A33
Powell, Julie................................................................................ A3, A64, A66
Pratt, Melanie D.............................................................. A38, A59, A87, A89
Pratt, Michelle .......................................................................................... A50
Prieto,Victor G......................................................................................... A15
Puig, Lluis ................................................................................................... A80
Rahme, Elham................................................................................... A15, A90
Ramien, Michele........................................................................ A3, A63, A66
Reich, Kristian ........................................................................ A22, A27, A80
Resneck, Jr., Jack........................................................................................ A60
Richards, Robert N......................................................................... A92, A93
Richer,Vincent.................................................................................... A8, A21
Risser, David R........................................................................................... A15
Rivas, Enrique............................................................................................ A80
Rochon, Paula............................................................................................ A73
Rockwell, Gloria....................................................................................... A19
Rohekar, Sherry........................................................................................ A44
Rosen, Cheryl F.....................................................................................A1, A3
Roshdy, Osama A............................................................................. A48, A54
Roszell, Eric E............................................................................................ A24
Safaee Ardekani, Gholamreza................................................................ A70
Sajic, Dusan ............................................................................................... A42
Salko, Thomas............................................................................................ A80
Salopek, Thomas G.......................................................................... A72, A75
Samycia, Michael ...................................................................................... A24
Sandre, Matthew....................................................................................... A44
Sapra, Priya................................................................................................... A1
Sarfati, M..................................................................................................... A13
Sasseville , Denis......................................................A7, A14, A15, A69, A90
A96
CDA Abstracts
Sauder, Maxwell B............................................................................ A65, A89
Saxena, Anjali............................................................................................. A48
Scali, Christina........................................................................................... A78
Schachter, Jordana.................................................................................... A62
Schnegg, Caroline..................................................................................... A90
Schwartz, Rodrigo.................................................................................... A73
Shah, Kamal................................................................................................ A27
Shaw, James................................................................................................ A55
Shear, Neil H........................................AA1, A29, A30, A31, A32, A33, A42
Shelton, Jennifer........................................................................................ A26
Shoimer, Ilya............................................................................................... A64
Shojania, Kam............................................................................................ A24
Sibbald, Cathryn...................................................................... A21, A34, A63
Sibbald, R Gary.................................................................A9, A12, A21, A34
Siddha, Sanjay.........................................................................................A1, A2
Sigurgeirsson, Bardur............................................................................... A80
Sikora, Sheena........................................................................................... A43
Silver, Shane...................................................................................... A22, A35
Simone, Andrew A........................................................................... A36, A51
Sissons, Wendy.......................................................................................... A65
Skotnicki, Sandy............................................................................... A12, A52
Solish, Nowell.............................................................................................. A9
Sotoodian, Bahman........................................................................... A6, A49
Spelman, Lynda.......................................................................................... A80
Srolovitz, Herbert.................................................................................... A54
Stevens, Michael S..................................................................................... A35
Stevens, Randall M.......................................................................... A22, A27
Strober, Bruce........................................................................................... A84
Strober, Bruce........................................................................................... A28
Sussman, Gordon..................................................................................... A86
Szakacs, Tom.............................................................................................. A40
Tan, Jerry.......................................................................................... AA1, A58
Tchvialeva, Lioudmila............................................................................... A68
Tetzlaff, Michael T............................................................................. A15, A90
Thavaneswaran, Arane............................................................................... A3
Thibeault, Marie-Marthe......................................................................... A46
Thompson, Elizabeth H.................................................................. A27, A28
Thuraisingam , Thusanth......................................................................... A47
Tolar, Jakub................................................................................................. A42
Toole, Jack........................................................................................ AA1, A26
Toosi, Bez................................................................................................... A74
Tran, Jennifer.............................................................................................. A73
Trentin, Grace........................................................................................... A20
Trotter, Martin J......................................................................................... A43
Tsai, Tsen-Fang.......................................................................................... A80
Tsang, Roger Y............................................................................................ A43
Turmel, Stéphanie..................................................................................... A47
Tyring, Stephen ........................................................................................ A80
Vadeboncoeur, Sophie...................................................................... A4, A64
Vale, Rachel ............................................................................................... A59
Van De Velde, Rochelle............................................................................ A35
Veillette, Hélène ...................................................................................... A49
Veilleux, Mylène S..................................................................................... A46
Velsher, Lea................................................................................................ A59
Vender, Ronald B....................................................................................... A53
Vidimos, Allison......................................................................................... A92
Vieira, Andrew........................................................................................... A26
Villeneuve-Tang, Catherine..................................................................... A21
Vincelette, Jean.......................................................................................... A35
Vo, Anthony................................................................................................ A19
Waddell, Andréanne................................................................................. A72
Wadden, Patricia....................................................................................... A50
Wagner, John............................................................................................. A42
Walsh, Noreen.......................................................................................... A46
Walsh, Scott........................................................................................ A7, A18
Wang, Sheila............................................................................................... A78
Ward, Brian .............................................................................................. A35
Wasel, Norman......................................................................................... A80
Wat, Heidi.................................................................................. A5, A52, A72
Watters, A. Kevin...................................................................................... A47
Weinstein, Miriam........................................................................... A62, A63
Wiviott, Robin........................................................................................... A67
Woetmann, Anders.................................................................................. A14
Wong, Daniel............................................................................................. A71
Wong, Noelle Y.......................................................................................... A43
Wu, Douglas....................................................................................... A5, A19
Wu, Jane............................................................................................ A18, A37
Xing, Lin...................................................................................................... A59
Yadav, Geeta.............................................................................................. A60
Yang, William.............................................................................................. A86
Yeung, Jensen............................................................................................. A41
Zahedi Niaki, Omid................................................................................. A65
Zargham, Hanieh............................................................................... A7, A69
Zargham, Ramin........................................................................................ A65
Zhang, Alexandra............................................................................. A36, A45
Zhou,Youwen............................................................................ A7, A14, A69
Zimmer, June............................................................................................. A41
Zip, C......................................................................................................... AA1
A97