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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Not Just Skin Deep: New Concepts & Approaches to Acne & "Actinic Keratosis"


GOAL
To provide dermatologists, residents and dermatology physician assistants with up-to-date information on the treatment and management of patients with acne and actinic keratosis.

TARGET AUDIENCE
This activity is designed for dermatologists, resident and dermatology physician assistants. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Recognize the prevalence and pathogenesis of acne to improve treatment outcomes.
  • Summarize the mechanisms of action and discuss the practical applications of the latest acne treatments.
  • Evaluate various treatment methods, with specific focus on pharmacologic agents to improve patient quality of life for those affected by acne.
  • Discuss the pathogenesis, identification process, and differential diagnoses when diagnosing actinic keratosis (AK). 
  • Describe currently used therapies in the treatment of AK.
  • Analyze the prognosis for the different stages and the efficacy of treatment options.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality and scientific integrity of this CME activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

RELEASE DATE: November 15, 2007. EXPIRATION DATE: November 15, 2009.

After reading this monograph, participants may receive credit by completing the CE test and evaluation, and receiving a score of 70% or higher.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Dermik Laboratories.

FULL DISCLOSURE POLICY AFFECTING CME ACTIVITIES
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Bernard A. Cohen, M.D., F.A.A.P.
Professor, Department of Dermatology and Pediatrics
Johns Hopkins University School of Medicine
Director of Pediatric Dermatology
Johns Hopkins Children’s Center
Baltimore, Maryland
Dr. Cohen reports receiving grants/research support from Astellas and Novartis.

Rachel Nussbaum, M.D.
Instructor of Dermatology
Johns Hopkins University School of Medicine
Director, Dermatology Inpatient Consultation Service
The Johns Hopkins Hospital
Director, Photopheresis Unit, Department of Dermatology
Baltimore, Maryland
Dr. Nussbaum reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Julie C. Harper, M.D.
The Dermatology and Skin Care Center of Birmingham, PC
Clinical Associate Professor
The University of Alabama at Birmingham
Birmingham, Alabama
Dr. Harper reports serving as a consultant for Intendis; receiving honoraria from Allergan Inc, Ranbaxy and Stiefel; and serving on the speakers’ bureaus for Allergan Inc and Stiefel.

Joseph L. Jorizzo, M.D.
Professor and Former (Founding) Chair
Department of Dermatology
Wake Forest University School of Medicine
Winston-Salem, North Carolina
Dr. Jorizzo reports receiving honoraria for speaking for Amgen Inc, Astellas and Sanofi-Aventis.

Susan C. Taylor, M.D.
Former Director
Skin of Color Center
St. Luke’s Roosevelt Hospital Center
Assistant Clinical Professor of Dermatology
College of Physicians and Surgeons
Columbia University
New York, New York
Dr. Taylor reports performing contracted research for Aczone, Amgen Inc, Barrier Therapeutics, Doak, Galderma, Genzyme, Johnson & Johnson, Leo Pharmacy, Medicis, Palomar, Stiefel and Teva; serving as a clinical investigator for Allergan Inc, Barrier Therapeutics, Dermik Laboratories, Galderma, Johnson & Johnson, Medicis, Neutrogena, Novartis, Palomar, Stiefel and Teva; serving on the speakers’ bureaus for Allergan Inc, Barrier Therapeutics, Bradley, Dermik Laboratories, Doak, Galderma, Johnson & Johnson, Medicis, Novartis, Procter & Gamble and Stiefel; and serving on the advisory boards for Astellas, Barrier Therapeutics, Beieresdorf, Connetics, Dermik Laboratories, Duac, Galderma, Johnson & Johnson, Medicis, Procter & Gamble, Skin Medica and Stiefel.

Unapproved/unlabeled drug references: No faculty member has indicated that their article will include information on off-label products.

Not Just Skin Deep: New Concepts & Approaches to Acne & "Actinic Keratosis"
Bernard A. Cohen, M.D., F.A.A.P.,* and Rachel Nussbaum, M.D.

Acne vulgaris and actinic keratosis (AK) are two common skin disorders, which are becoming increasingly prevalent in the United States. As a result, dermatology specialists and patients are becoming more concerned about the sequelae of these conditions and improving patient care.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, nearly 17 million people in the United States have acne.1 Although acne typically presents during puberty and usually resolves by age 30, it can occur well into adulthood.2 While self-limiting at times, acne can lead to scarring and psychological anguish.3 At least four factors are thought to play a role in the pathogenesis of acne, including follicular hyperkeratinization, Propionibacterium acnes, inflammation and sebum production. Successful acne management targets these four pathophysiologic factors and reduces the inflammation caused by acne,4,5 prevents scarring6,7 and reduces the risk of psychosocial comorbidity.8 Topical retinoids and antibacterial agents address the first three factors, and therefore, are often considered the mainstay of acne treatment.4,5,9 Recent studies demonstrate increasing resistance to early antibiotics used for acne, and this should be taken into account when designing a treatment plan.10 Clinical investigators have shown that adding a benzoyl peroxide-containing product to the treatment regimen can minimize antimicrobial resistance and increase efficacy.10-13 Sebum production is addressed topically by choice of vehicle and skin care. Other options include concomitant oral contraceptives, spironolactone or isotretinoin.13 Clinical outcomes may be improved by using combination therapy.5,6,10,11

Skin cancer is the most widespread of all cancers.14 More than 1 million cases of nonmelanoma skin cancer are diagnosed annually in the United States, the majority of which are sun-induced.14 AKs are typically asymptomatic scaly patches and plaques, resulting from chronic ultraviolet exposure and are more prevalent with increasing age.15,16 These premalignant lesions serve as a “reliable marker”15 to identify those individuals at risk for developing squamous cell carcinoma (SCC).15 The ability to identify and treat AKs before progression to invasive SCC is the most important goal of management. Therapeutic options for AKs include cryosurgery, surgical excision with or without curettage or electrodesiccation, topical pharmaceutical agents and photodynamic therapy (PDT). A combination approach can be used to enhance tolerance, compliance and efficacy. Patient education (ie, the importance of sun protection), monthly self skin examinations and routine skin surveillance by a dermatology professional17 are vital in the prevention of AKs and subsequent skin cancer.

This supplement to Skin & Aging includes the proceedings from a Johns Hopkins CME symposium held on August 3, 2007, in New York, NY. The primary objective was to reinforce and enhance the clinician’s knowledge of the pathogenesis and recognition of acne and AKs, while focusing on effective treatment to achieve optimal patient outcomes.

In the opening article, Susan C. Taylor, M.D., from Columbia University, in New York, NY, presents a concise synopsis of the etiology and psychological impact of acne. She then evaluates current management strategies for acne, with an emphasis on reducing the risk of antibiotic resistance and post-inflammatory hyperpigmentation, particularly in patients with skin of color. Next, Joseph L. Jorizzo, M.D., from Wake Forest University School of Medicine in Winston-Salem, NC, provides an overview of AK, focusing on the prevalence and risk factors, evolution to SCC, histology and prevention. Treatment goals and a variety of management options are subsequently reviewed. The supplement concludes with four case studies presented by Julie C. Harper, M.D., from the University of Alabama at Birmingham. She applies the novel information presented by her colleagues to clinical practice by designing treatment plans for different patients.

References

1. National Institute of Arthritis and Musculoskeletal and Skin Disease. What Is Acne? Fast Facts: An Easy-to-Read Series of Publications for the Public.  Available at: http://www.niams.nih.gov/hi/topics/acne/ffacne.htm. Accessed September 7, 2007.

2. American Academy of Dermatology Public Resource Center. Acne. Available at: http://www.aad.org/public/Publications/pamphlets/Acne.htm. Accessed September 2, 2007.

3. Mbuagbaw J, Abongwa C, Ozoh G, Blackett KN. The Prevalence of Acne Vulgaris in Secondary School Students In Yaoundé, Cameroon. The Internet Journal of Dermatology. Available at: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijd/vol5n2/acne.xml. Accessed September 1, 2007.

4. Millikan LE. The rationale for using a topical retinoid for inflammatory acne. Am J Clin Dermatol. 2003;4:75-80.

5. Zaenglein AL, Thiboutot DM. Expert committee recommendations for acne management. Pediatrics. 2006;118:1188-1199.

6. Goodman G. Managing acne vulgaris effectively. Aust Fam Physician. 2006;35:705-709.

7. Cantatore-Francis JL, Glick SA. Childhood acne: evaluation and management. Dermatol Ther. 2006;19:202-208.

8. Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students. J Paediatr Child Health. 2006;42:793-796.

9. Leyden JJ, Shalita A, Thiboutot D, et al. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clinical Therapeutics. 2005;27:216-224.

10. Leyden JJ, Del Rosso JQ, Webster GF. Clinical consideration in the treatment of acne vulgaris and other skin disorders: focus on antibiotic resistance. Cutis. 2007;79:9-25.

11. Leyden JJ. Antibiotic resistance in the topical treatment of acne vulgaris. Cutis. 2004;73:6-10.

12. Del Rosso JQ. Antibiotic resistance: overview and significance in dermatology. Cutis. 2005;76:12-18.

13. Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56:651-663.

14. American Cancer Society. Prevention and early detection. Available at: http://www.cancer.org/docroot/PED/content/ped_7_1_What_You_Need_To_Know_About_Skin_Cancer.asp. Accessed September 1, 2007.

15. Salasche SJ. Epidemiology of actinic keratoses and squamous cell carcinoma. J Am Acad Dermatol. 2000;42:S4-S7.

16. Warino L, Tusa M, Camacho F, et al. Frequency and cost of actinic keratosis treatment. Dermatol Surg. 2006; 32:1045-1049.

17. US Preventive Services Task Force. Screening for skin cancer recommendations and rationale. Am J Prev Med. 2001;20:44-46.

*Dr. Cohen is a Professor in the Departments of Dermatology and Pediatrics at Johns Hopkins University School of Medicine and Director of Pediatric Dermatology at Johns Hopkins Children’s Center in Baltimore, MD.

Dr. Nussbaum is Instructor of Dermatology at Johns Hopkins University School of Medicine, Director of the Dermatology Inpatient Consultation Service at The Johns Hopkins Hospital, and Director of the Photopheresis Unit, Department of Dermatology at Johns Hopkins Medical Institutions in Baltimore, MD.

Address correspondence to: Bernard A. Cohen, M.D., F.A.A.P., Professor, Department of Dermatology and Pediatrics, Johns Hopkins University School of Medicine, Director of Pediatric Dermatology, Johns Hopkins Children’s Center, David M. Rubenstein Child Health Building, Room 2107, Division of Pediatric Dermatology, 200 North Wolfe Street, Baltimore, MD 21287. E-mail: bcohen2@jhmi.edu.





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