Highlights of the 66th Annual Meeting of the American Academy of Dermatology

February 1-5, 2008; San Antonio, Texas

Whitney A. High, MD

Disclosures

August 13, 2008

Introduction

Rather than the familiar locales of San Francisco; Washington, DC; or New Orleans, this year's American Academy of Dermatology Annual Meeting shifted to a special location: San Antonio, Texas. As a practicing academic dermatologist and dermatopathologist with some clinical research interests and teaching responsibilities, my attendance was limited mostly to topics pertaining to general medical dermatology.

Linvingood Lecture

In a widely attended session, Barbara Gilchrest, MD,[1] Professor of Dermatology at Boston University School of Medicine, Boston, Massachusetts, delivered an interesting address on cognitive bias. At the heart of Dr. Gilchrest's talk were errors introduced by various forms of cognitive bias, such as the "herd mentality," the wholesale adoption of the beliefs of a majority under the presumption that so many people must have a rational basis for these beliefs, even when none is readily apparent or understood by the adoptee.

Bringing this talk into the realm of dermatology, Dr. Gilchrest drew comparisons with the ever-increasing number of Mohs dermasurgeons over the last 2 decades, the increasing number of Mohs surgical procedures performed, and what she described as the perceived commonality of the procedure. While certainly not all listeners shared her view, and many continued to speak of the event in the days following, it did provide a certain buzz, particularly as issues of cost-containment and multiprocedure payment reduction are being faced, both by Medicare and by those performing micrographic surgery.

To my mind, the lecture had an even larger applicability to the world of dermatology as a whole, because until recently much of our therapeutic arsenal has been based on anecdotal rather than evidence-based medicine. In that regard, Dr. Gilchrest's speech highlighted the intellectual traps that can permeate much of the field of dermatology.

Warts

In multiple sessions ranging from lectures on sexually transmitted disease to oncogenetics, there was mention of the new preventative vaccine for genital human papilloma virus (HPV) subtypes that was recently approved by the US Food and Drug Administration (FDA).[2] The vaccine, available as Gardasil, affords excellent protection against the 2 HPV subtypes involved in 90% of genital warts (HPV 6,11) and also against the 2 HPV subtypes strongly associated with most cases of cervical cancer (HPV 18, 31).[3] Douglas Lowy, MD, a senior scientist at the National Cancer Institute, Bethesda, Maryland, is the first recipient of the Academy's new J. Van Scott Award for Innovative Therapy of the Skin. The efforts of Dr. Lowy and colleagues resulted in the morphologically correct virus-like particles (VLPs) that make the vaccine functional.[4] Dr. Lowy outlined the goals for the "next generation" of HPV vaccines, including 1) development of a vaccine that is both preventative and therapeutic, and (2) expansion to cover more HPV subtypes, including nongenital forms of disease. Exciting developments such as these would have an enormous impact on the field of dermatology.

Atopic Dermatitis: The Genetics of Skin as a Barrier

Atopic dermatitis is a condition often seen in pediatric and even general dermatology, and an association between atopic dermatitis and ichthyosis vulgaris has been long recognized.[5] Filaggrins are proteins that function to organize keratin filaments within the protective stratum corneum, imparting structural integrity to this skin layer and assisting in the barrier function of
skin.[6] Recently, several teams of investigators have reported on truncating mutations in the FLG (filaggrin) gene that are associated with ichthyosis vulgaris but also atopic dermatitis.[7] These findings may revolutionize our understanding of and treatment options for this condition.

As explained by John McGrath, MBBS, MD, FRCP,[8] St. John's Institute of Dermatology, London, United Kingdom, as part of the Marion Sulzberger lectureship, and echoed by other experts, such as Jon Hanifin, MD, FAAD,[9] of Oregon Health Sciences University, Portland, Oregon, up to 50% of patients with atopic dermatitis have at least one of these mutations in the FLG gene. The fact that several different mutations exist may suggest that the entity we identify clinically as atopic dermatitis is, in actuality, a final common endpoint for a variety of diseases. Of additional clinical utility, Dr. Hanifin observed that this direct etiologic association with a protein involved in the barrier function of skin militates against other causal associations with food allergies -- a point of continued controversy between dermatologists and allergists.

Psoriasis: Biologic Agents

This was the first Academy meeting since adalimumab, a fully human monoclonal antibody that binds TNF-alpha, received FDA approval for the treatment of moderate-to-severe plaque
psoriasis.[10] Adalimumab joins other therapies that interfere with TNF-alpha, specifically etanercept and infliximab, as a highly efficacious therapy specifically approved for this indication. Alice Gottlieb, MD, PhD,[11] Tufts University, Boston, Massachusetts, and Mark Lebwohl, MD,[12] Mount Sinai Medical Center, New York, NY, noted experts in the field of systemic psoriasis management, each alluded separately to a new drug in development, ustekinumab.[13] This new monoclonal antibody, likely to be approved by next year, is a fully human monoclonal antibody targeting the cytokines interleukin 12 (IL-12) and interleukin 23 (IL-23). Dr. Lebwohl remarked that in a recent phase 2 trial, a single injection of ustekinumab led to skin clearance in 63% of patients. If this medication does indeed demonstrate such impressive efficacy, with few side effects, it will be a welcome addition to a growing armamentarium for psoriasis.

Melanoma: Sentinel Lymph Node Biopsy

Several speakers addressed the controversial area of sentinel lymph node biopsy (SLNB) in melanoma management. SLNB is a surgical procedure in which the first lymph node to drain an area of the skin and soft tissue (the "sentinel lymph node") is identified, removed, and examined histologically for involvement with melanoma. The technique is most often used for melanoma of intermediate Breslow depth (typically 1-4 mm), but it has also been used in Merkel cell
carcinoma[14] and even, on occasion, nonmelanoma skin cancer.

Certainly, knowledge of whether a sentinel lymph node is involved with melanoma does shed light on the patient's prognosis; however, the greatest controversy involves any real survival advantage that might be conferred by the procedure.[15,16,17] True to form, various presentations by a variety of surgeons, dermatologists, and dermatopathologists at the meeting offered disparate conclusions. As of 2008, it would seem that SLNB is still not, strictly speaking, the "standard of care."

Even estimates of the cost of SLNB varied widely, with a quoted range of about $7500 to $15,000, according to various talks. In a thoughtful but critical analysis of SLNB, Matthew Kanzler, MD,[18] Stanford University (but unaffiliated with the Stanford Multidisciplinary Melanoma Group), arrived at the following conclusions: (1) at present there is no evidence of an overall survival benefit for SLNB; (2) the prognostic benefit for SLNB is greatest for patients between 20 and 60 years of age and with a depth of involvement from 2 to 4 mm; (3) the cost of acquiring this additional prognostic information is significantly greater than the cost of simple histologic assessment of Breslow depth or ulceration; (4) dermatologists, given that they do not actually perform the procedure, are the specialists best positioned to objectively inform patients of the risks and benefits involved with SLNB. Admittedly, the availability of meaningful treatment based on the results of SLNB, such as biochemotherapy for those with nodal involvement,[19] would have dramatic impact on the course of the debate.

Skin Cancer Prevention: The Risk in Transplant Recipients

Summer Youker, MD,[20] St. Louis University School of Medicine, St. Louis, Missouri, presented an alarming study that showed that most organ transplant patients are unaware of their heightened risk for skin cancer. As of 2006, there are over 220,000 patients living with functioning organ transplants.[21] These transplant recipients have up to a 200-fold increased incidence of certain skin cancers compared with age-matched controls,[22] chiefly due to the complex immunosuppressive regimens required to maintain the graft.

Dr. Youker reported on 298 transplant recipients who attended the outpatient clinics of her university and completed a survey to evaluate their comprehension of their skin cancer risk, compliance with skin cancer preventive measures, and attitudes about sunscreen use and skin screenings. Amazingly, 62% of respondents did not know that they were at risk for skin cancer, and 73% of respondents stated that they were not informed regarding the increased risk for skin cancer following their transplant. Only 21% of responding patients had seen a dermatologist since their transplant, with just 14% receiving annual skin exams. Anecdotally, I am often shocked to find that some of my own university's transplant patients seem unaware of these risks. If this is truly a pattern of ignorance nationwide, it represents an important point for intervention by dermatologists.

Workforce Issues: Pay for Performance

Dirk Elston, MD, Geisinger Clinic, Danville, Pennsylvania, discussed an interesting topic relating to workforce issues and reimbursement: pay-for-performance incentives.[23] In humorous fashion, he pointed out that many large employers, such as American automotive manufactures, spend such large amounts on workforce healthcare that they describe themselves as "healthcare purchasers who also happen to build cars." Because of these large expenditures, these corporations, as well as the federal government through the Centers of Medicare & Medicaid Services (CMS), are now offering voluntary pay-for-performance incentives.[24]

Although a complete discussion of these incentives is beyond the scope of this brief report, an example of the types of incentives being made available is informative. For example (with some simplification), documentation of a personal history of a new or changing mole; performance of a full skin exam; and education regarding performance of a skin self-exam in over 80% of patients with a coded diagnosis of melanoma (172.X) or a history of melanoma (V10.82) will result in an incentive payment of +1.5% on all payments for that period made to the doctor from CMS. Dr. Elston also made the important point that although these incentives did not originate with the physicians, they are firmly entrenched within the administrative agencies involved in Medicare/Medicaid, and they are unlikely to disappear, but do represent an additional revenue stream for dermatologists.

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