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


Advances in Dermatological Care: What the Family Physician Needs to Know


GOAL
To provide family physicians with up-to-date information on the treatment of acne and actinic keratosis.

TARGET AUDIENCE
This activity is designed for family physicians. 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 options.
  • 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.

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

CREDIT DESIGNATION STATEMENT
This activity has been reviewed and is acceptable for up to 4 Prescribed credits by the American Academy of Family Physicians. Of these credits, 2 conform(s) to the AAFP criteria for evidence-based (EB) CME clinical content. CME credit has been increased to reflect 2 for 1 credit for only the EB CME portion. AAFP accreditation begins 02/01/08. The term of approval is for two-year(s) from this date, with option for yearly renewal. When reporting AAFP credit, report total Prescribed and Elective credit for this activity. It is not necessary to label credit as EB CME for reporting purposes.

The EB CME credit awarded for this activity was based on practice recommendations that were the most current with the strongest level of evidence available at the time this activity was approved. Since clinical research is ongoing, AAFP recommends that learners verify sources and review these and other recommendations prior to implementation into practice.

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, a business of sanofi-aventis U.S. LLC.

Full Disclosure Policy Affecting CME Activities
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the 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 presenting faculty reported the following:

PROGRAM DIRECTORS

Bernard A. Cohen, MD, FAAP
Director of Pediatric Dermatology
Johns Hopkins Children's Center
Professor, Dermatology and Pediatrics
Johns Hopkins University
School of Medicine
Baltimore, Maryland
• Dr Cohen reports receiving grants/research support from and serving on the speakers' bureau for Astellas and Novartis.

Neil Brooks, MD
Past President
American Academy of Family Physicians
Medical Director
Vernon Manor Health Care Center
Vernon, Connecticut
• Dr Brooks reports having no financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Murad Alam, MD
Associate Professor of Dermatology, Otolaryngology, and Surgery
Chief, Cutaneous and Aesthetic Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois
• Dr Alam reports having no financial or advisory relationships with corporate organizations
related to this activity.

Magdalene Dohil, MD
Assistant Clinical Professor of Pediatrics and Medicine (Dermatology)
University of California, School of Medicine
Rady Children's Hospital
San Diego, California
• Dr Dohil reports having no financial or advisory relationships with corporate organizations related to this activity.

Notice: All faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations.

The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Advances in Dermatological Care: What the Family Physician Needs to Know
Bernard A. Cohen, MD, FAAP,* and Neil Brooks, MD

Dermatologic disorders are among the most common conditions encountered by family physicians.1 Both acne and actinic keratosis (AK) are widely prevalent skin disorders that are important concerns for most family physicians. At a recent satellite symposium at the Annual Meeting of the American Academy of Family Physicians in Chicago, Illinois, experts in the management of acne and AK discussed the epidemiology, diagnosis, and treatment of these common dermatologic disorders in the family practice setting.

Acne is common across a broad age range, from infancy through early childhood, puberty, and into adulthood.2,3 According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, approximately 80% of individuals between the ages of 11 and 30 years experience at least periodic episodes of acne.3 Acne is associated with considerable psychological distress for many patients. As noted by Sulzberger and Zaldems in 1948, "There is no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feelings of inferiority, and greater sums of psychic suffering than does acne vulgaris."4 The clinical presentation of acne includes both inflammatory and noninflammatory features, with lesions that vary across a wide spectrum of severity. A management plan for acne must take into account a number of factors, including the types of lesions, the severity of the disease, and the patient's social circumstances. Regardless of the specific therapeutic strategy, patient education to help dispel acne myths and improve adherence to treatment is an essential part of effective acne management.5

The goals of acne therapy include controlling acne lesions, preventing scarring, and minimizing morbidity. In recent years, experts in the management of acne have increasingly emphasized combination therapy for most patients, even those with relatively mild acne.6 Acne lesions form as the result of complex pathophysiological processes that include abnormal keratinization of hair follicles, infection of follicles by the gram-positive anaerobe Propionibacterium acnes, and inflammation of the surrounding dermis. Combination therapy may help to address these different mechanisms of disease, providing better efficacy than monotherapy. Clinical trials have shown that combination therapy results in significantly faster and greater clearing of acne than antimicrobial therapy alone.7,8

Skin cancer is the most common of human cancers, accounting for more than 1 million new cancer cases per year in the United States.9 More than 33% of all cancers in the United States are attributable to nonmelanoma skin cancers, which include basal cell carcinoma and squamous cell carcinoma (SCC).10 The incidence of SCC increased by approximately 4% to 8% per year from the 1960s through the 1980s, and has continued to increase during the past 2 decades.11,12

Actinic keratosis is the earliest identifiable skin lesion that has the potential to progress to SCC,10 and has therefore been an important focus of skin cancer screening and early treatment efforts. Estimates of the risk of progression to invasive SCC for a patient with AK have varied widely, and it is impossible to predict which AKs will eventually progress. For this reason, professional societies such as the American Academy of Dermatology, the American Cancer Society, and the Skin Cancer Foundation recommend the routine treatment of AKs as an important part of skin cancer prevention.13 A number of very effective treatment options are available to remove AKs and to prevent their recurrence in extensively sun-damaged skin. These treatments include topical application of liquid nitrogen for isolated lesions, pharmacotherapy with topical 5-fluorouracil or imiquimod, photodynamic therapy, and surgical excision. Treatment selection for a particular patient requires consideration of the number of lesions, lesion size and distribution, and patient preferences. Combination therapies are often used to increase treatment effectiveness. Measures to minimize the discomfort of topical therapies can help to improve adherence to treatment, which is important in order to attain complete resolution of AKs.

This issue of Johns Hopkins Advanced Studies in Medicine provides healthcare professionals with an update on the impact, diagnosis, and treatment of these common skin disorders. Magdelene Dohil, MD, reviews the pathogenesis of acne, typical clinical presentations, and acne differential diagnosis. Dr Dohil also describes the use of acne severity and patient characteristics to select an acne management strategy.

Murad Alam, MD, describes the relationship between AK and invasive skin cancer, emphasizes the importance of the early recognition and treatment of AK, and reviews specific management strategies for both isolated AK lesions and the treatment of larger regions of sun-damaged skin.
These reviews are followed by the presentation and discussion of 4 representative case studies. Bernard A. Cohen, MD, presents 2 cases that illustrate the management of acne in special patient populations, including neonatal acne and acne in patients of color. Neil Brooks, MD, describes 2 case studies in the management of AK, using both lesion-directed therapy and therapy directed against a widespread area of affected skin.

At the conclusion of this activity, readers will be able to describe the impact of acne and AK, implement a management plan that is matched to the patient's clinical characteristics and personal situation, and perform appropriate follow-up care. 

REFERENCES

1. Fleischer AB Jr, Herbert CR, Feldman SR, O'Brien F. Diagnosis of skin disease by nondermatologists. Am J Manag Care. 2000;6:1149-1156.
2. Cantatore-Francis JL, Glick SA. Childhood acne: evaluation and management. Dermatol Ther. 2006;19:202-209.
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Acne facts. Available at: http://www.niams.nih.gov/Health_Info/Acne/acne_ff.asp. Accessed November 27, 2007.
4. Roebuck HL. Acne: intervene early. Nurse Pract. 2006;31:24-43.
5. Goodman G. Acne–natural history, facts and myths. Aust Fam Physician. 2006;35:613-616.
6. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49(1 suppl):S1-S37.
7. Zaenglein AL, Thiboutot DM. Expert committee recommendations for acne management. Pediatrics. 2006;118:1188-1199.
8. Goodman G. Managing acne vulgaris effectively. Aust Fam Physician. 2006;35:705-709.
9. McGovern TW, Leffell DJ. American Academy of Dermatology. Actinic keratosis and non-melanoma skin cancer. Available at: http://www.aad.org/professionals/Residents/MedStudCoreCurr/DCActinicKer-NoMelCancer.htm. Accessed November 27, 2007.
10. Lober BA, Lober CW. Actinic keratosis is squamous cell carcinoma. South Med J. 2000;93:650-655.
11. Glass AG, Hoover RN. The emerging epidemic of melanoma and squamous cell skin cancer. JAMA. 1989;262:2097-2100.
12. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294:681-690.
13. Patients urged to seek treatment for actinic keratoses, recommends the American Academy of Dermatology, the American Cancer Society, and the Skin Cancer Foundation. Cutis. 1999;63:348.

*Director of Pediatric Dermatology, Johns Hopkins Children's Center, Professor, Dermatology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Past President, American Academy of Family Physicians, Medical Director, Vernon Manor Health Care Center, Vernon, Connecticut.
Address correspondence to: Bernard A. Cohen, MD, FAAP, Professor, Dermatology and Pediatrics, Johns Hopkins University School of Medicine, East Baltimore Campus, 2105 PMOB, 200 North Wolfe Street, Baltimore, MD 21287. E-mail: bcohena@jhmi.edu.

 The content in this monograph was developed with the assistance of a medical writer. Each author had his/her final approval of his article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.