Transcription
He's going to talk to us a little bit more about dermatology, immunosuppression, and the title "Skin in the Game." Thank you so much, Zan.
Dr. Lambert, you're too kind. Thank you very much. Well, welcome to uh Indianapolis, the crossroads of America. Good morning, everybody. And I do have some disclosures. Uh, the most important one is I grew up in Fort Wayne, Indiana. And that was named the stupidest city in America by Men's Health and USA Today, very meanly twice.
Yes. So, [laughter] but honestly, what do they know? These are some other stories from Men's Health, so just take it with a grain of salt. I don't have any financial disclosures, but I will be talking about some brand-name over-the-counter products. I have no financial interest in these. This is an educational talk. There's not a substitute for seeking out uh dermatologist for personalized recommendations.
So what are we going to talk about today? We're going to talk [clears throat] about some problems that can occur with immunosuppression, including an autoimmune hepatitis. Such things as management of dry skin, itch management that you can do at home, skin cancer protection while you are immunosuppressed and prevention. We want to discuss and then something that some of the patients have given us feedback. They wanted to know what are some available treatments for warts, which can be more common when people are immunosuppressed.
So dry skin is like dry tree bark. Think of it as an analogy this way. The dry skin can flake off. It can break off and then it can let things in because it's not as healthy as something that's sealed, moisturized, and healthy looking. So moisturization will make that skin more healthy. And that's also important because again, with this analogy of the dry tree bark, when that skin breaks off, it acts like little spikes, and those little spikes will then make someone itch, make them more prone to having irritation. So what can we do to keep the skin healthy and moist?
So showers and bathing is one part where we want to try to optimize this. We want to keep the shower water lukewarm, not very hot. So think about as an analogy, when you're washing your dishes, you use hot water to strip off the oils. Well, those oils on our skin, as an analogy, are protective. Turning down the temperature of the water helps reduce the stripping of the oils. So the hot showers, in other words, will dry out the skin. We actually [clears throat] learned this a lot during COVID. Imagine everyone was washing their hands like crazy in the beginning, and then we turned down the temperature. We would advise people, turn down the temperature of the water when they were washing their hands. Make it ice cold. We were able to eliminate a lot of these hand eczema issues related to the heat. I know it feels good, but do something for your skin that can help it out. Keep the shower short. Again, immersion in water will strip some of those oils. Short will be defined as less than 10 to 15 minutes. If you think about it, remember pruned skin fingers in the water. When you keep them in water too much, it's irritating to the skin.
So, people always ask me, "What soap should I use?" And there are some nuances here as well. So, bars [clears throat] are more hydrating than washes. To create a wash, you got to have some alcohols. You have to have some preservatives. It's not, you know, it's a more advanced technology. So, there's more additives. So, we recommend a bar soap. The bars are composed of the fats and the oils, very similar to our skin barrier. Washes, while they may be more convenient, um, if you have an issue with dry skin and irritation, we will ask you to change. So what soaps in specific do we recommend? On the left-hand side, we can see that the Dove unscented bar soap, it actually is the one that has the pH closest to the skin. It's the least irritating. It leaves a moisturizing film. It's very, it's cheap and effective. Also, the Oil of Olay sensitive skin bar. Curél also has a hydrating cleansing bar as well. There are some other soaps that if your skin is able to tolerate it, they're totally fine. But if [clears throat] you do struggle with dry skin or irritated skin, would ask you to avoid things like Ivory, Irish Spring, Dial, Zest, the Axe lines. I think in college I used every single one of these, but [clears throat] I'm older and wiser now. So, in other words, let's do the bar soap. It doesn't need to be antibacterial, something more natural. So, instead of saying "Hello, Kitty" to the Dial soap, you're going to say "No, Kitty."
So, then people will also ask me about moisturization as well. So, I want you to think in terms of these concepts. You [clears throat] want something that is in a jar, usually not in a pump or a lotion or squeeze bottle if you struggle with dry skin. So, ointments, which are thick like Vaseline, they're thicker and more hydrating, which are more hydrating than the white creams, which are more hydrating than the lotions. These moisturizers are more effective when you're sha- after a shower or bathing. We want to say they lock in the moisturize the moisture and they prevent the eruption, the evaporation, excuse me, of moisture off the body immediately after the shower. Moisturization is kind of a misnomer. It it implies like water is being uh put in, but it's actually, again, think about the wax. You're putting a protective layer of oils on the skin when you moisturize. Some areas of the h- like the hands, the feet, the shins, these are hot spots that get dry. They may need moisturization three or four times, three or four times a day. So, often it's not actually the brand you're using. It's this vehicle, whether it's an ointment, a cream, or a lotion, and how often you do it. That's the most important thing. Again, not the brand.
So, itch management. Itch can come with the dry skin. It can come from the disease itself. What are some easy things that you can do at your own home? Well, if there's a rash, then treat it. At [clears throat] your own home, over-the-counter hydrocortisone, 1%, it's safe. You can use it anywhere on the body. The body, the arms, the legs, the face, the groin, sensitive parts included. A dermatologist would tell you that. it. The itch will go away first, and then the rash. The itch will often get better within a couple of couple of days. The rash often will get better, if it's going to get better with this treatment, in a couple of weeks. And if that doesn't work in a couple of weeks, then see your dermatologist. We can help you out. But there's something that we can all do just for purely symptomatic relief, even if there is no rash. Well, first, if the skin is dry, then just moisturize it. It's soothing. [clears throat] It'll help relieve that irritation from the spikes, as we pointed out. Also, a moist compress, just could be a moist compress, just of water. It'll be cooling. If the rash is wet and oozy, then the evaporation will dry it out, and that will be soothing as well. And then beyond that, there are some measures that will calm things. So, people [clears throat] are probably familiar with calamine lotion. It can be soothing, but then the kind of the the bad side is it can be overly drying and it can cake on, and then that can cause some irritation afterwards from that. So, that's actually not what we would recommend. Over-the-counter at your grocery store, you can get something called Sarna Sensitive that has an anesthetic called Pramoxine. It's a topical anesthetic. It's purely symptomatic and it moisturizes. It doesn't cake on. And so you can use this as much or as little as you want to help with your itching for any type of itch. We do this all the time. Another modality would also be camphor and menthol. So these are like cooling. Think like Vicks VapoRub. It'll distract, it'll moisturize, and it'll help soothe the itch as well.
Antihistamines. So, people will call these itch pills. [clears throat] They are best actually for hives. The medical term being urticaria, but they can help itch in general. So, the paragon of this is called diphenhydramine or Benadryl. It it works. It'll make you sleepy. So, you'll be careful with driving heavy machinery, giving talks like this one. So, if you are doing something where you need to be alert and awake, we recommend what are called second-generation antihistamines. These are loratadine or Claritin, fexofenadine or Allegra. Uh, fexofenadine is actually my favorite. It doesn't cross the blood-brain barrier. Cannot make you sleepy. And then cetirizine or Zyrtec. So, what amount of these non-sedating antihistamines can we use? This is this is kind of interesting to me. Um, the box [clears throat] on all of these will tell you to use only one pill once a day. Um, pictured are these guidelines on treatment of hives or urticaria. After studies, like we've determined that they're safe to use even more than that. In the guidelines, you can do two pills twice a day, four times the boxed amount. So, when I was in San Antonio before here, we would treat fighter pilots. They would have hives or allergies. They cannot be sleepy. We would do this for them, and that's how they could still be in the sky and treat their itch.
Sun protection is important in immunosuppression. This is something that everyone should know in this room. [clears throat] And some of the medicines used to treat autoimmune hepatitis can be especially prone to causing skin cancers. So, why is sun protection so important? All [clears throat] immunosuppression, regardless of what it is, h- does increase the risk of skin cancer. And the best comparison we have, the best studies we have, are in transplant patients. So, transplant patients have a 65 times increased risk of squamous cell carcinoma compared to the general population. Basal cell carcinoma, most common skin cancer in the non-immunosuppressed, 10 times more. Melanoma, the most deadly skin cancer, two to five times more. This is what squamous cell carcinoma looks like. It's scaly, it's gritty, it's red. You can look at it, you think it doesn't belong on there. These are often on the head, the neck, the hands, uncommonly on the legs or sun-protected areas, though they can occur there. So, clearly very much has a sun-induced component. If anything is bleeding or painful, that's a warning sign. The basal cell carcinoma, they'll call it a pearly papule. It'll be often this kind of translucent pink to skin-colored. It will have this rolled border. We use this term. It often will have a telangiectasia or a flat, dilated blood vessel that you can see with your naked eye. They often bleed. They're on the head, the neck, the face, the forearms. So, if a bump has been present and it's bleeding and it's been more than six months, in my opinion, this is a basal cell until proven otherwise. So, this is what something that we would like to see in clinic. Melanoma, this is the most feared by patients and doctors. This can occur anywhere, but they're the most common on the upper back in men. Most common on the upper legs and thighs in women. [clears throat] Any changing mole that doesn't look like it should be there should be evaluated. So, as you can see in this picture, this person, this thing stands out, and we're going to come to it, but um, most melanomas are actually caught at home by a partner. So, if someone who loves you and notices something like this, it's always good to get it checked out. We love to give people good news to tell them, "Don't worry about it." But if something isn't fitting and it's changing, please come and see us. And I wanted to go over this an um mnemonic that's an ABCDE F rule for melanomas to go over this. The eye likes something that's healthy. The eye likes to see something that like should be there and it grows very regularly, and something that shouldn't be there. Something that's cancerous. It grows very chaotically, and that's what these rules are for. So, A is for asymmetry. You look at this thing and it's asymmetric in multiple planes. B. The borders are jagged. They're blurred. They're indistinct. They don't look good. C. The colors are multiple. It's not just brown. But I would argue in this picture, we see some reds, some blues, some whites. They're all mixed in. This doesn't look like a regular mole's color. Diameter. This is the weakest criteria, but anything large is going to get your attention compared to something small. 5 millimeters is an arbitrary cut-off, but it's fine. E is evolving. If it's changing, then we want to know about it. And F, it's funny. Not funny, haha. But if you look at all the moles, this one looks funny. I had to have an F in there for the rules.
So, [clears throat] what are the recommendations? General screenings for dermatology. Anyone on immunosuppression should see a dermatologist for a full skin check once a year. We do this with our autoimmune hepatitis patients here at IU. And anyone with immunosuppression and a history of skin cancer should probably be seen every six months. So, how can we prevent this? The Australian guidelines have a nice analogy. They say slip, slap, slap. Slip on protective sun clothing, slap on a wide-brim hat. Ball caps actually let in greater than 50% of UV light. They only have an SPF of one, so they're not sufficient. Slap on some sunscreen. There's actually a UPF rating. [clears throat] It's very similar to the SPF, sun protection factor rating. And you would, similar to the SPF, you want a higher UPF. Fabrics that are less than 15% are not considered UV protective. So, that'd be like a white cotton t-shirt, for example. Something that has a 15, 20 is is good. Then as you get to higher numbers, you obviously will increase the blocking of the sun. So, then what clothing factors will make up this UPF rating? Well, it's construction. If it's dense, it's tight, it's thicker. The color. Darker colors absorb more rays overall, including UV rays. Treatments. Some of these fabrics will have some chemicals and dyes that will enhance the UPF. And fiber types. The synthetic fibers are often a little bit more uh sun protective than the natural fibers. Factors that reduce the ratings: fabric wetness, fabric wear. As it gets older, it will get some more holes in it, let in more more light, and the fabric stretch. Stretched fabrics can lose a significant amount of its UPF. Sun protection factor, it actually is only a rating that applies to UVB radiation, not UVA, which are the main rays responsible for burn. UVA will cause damage to the skin, but this is a longer process. So, we would actually want people to put [clears throat] on the sunscreen. We wanted them to do it every single day. A shot glass amount should be enough to cover the entire body. There's probably no benefit to using a sunscreen stronger than SPF 50. And if you use SPF 30 and apply it after two, reapply it after two hours, you get some of that benefit. We want you to apply the sunscreen 15 minutes before you go outside. Then when you reapply it, the sunscreen after two hours, the reapplication helps cover some of the holes in the first application. It strengthens the blockage. It kind of gives that SPF 30 some superpowers. It's actually been shown that if you reapply the SPF 30 at 2 hours, it makes the protection as strong as SPF 50. So, this is where this recommendation of SPF 30 and reapply after two hours comes in.
You. This was actually like a bigger deal, I think, earlier, but I did get questions about this the last time I presented at um AIH. Um, there are some controversies in using some sunscreen. So, let's address some of that. There's some [clears throat] suns- there's some thought that sunscreens might hurt you or the environment, and I think within good reason. There was an FDA study, I think it's about four or five years old now, that some sunscreen ingredients can enter the bloodstream. It's a matter of debate about how damaging that is or if it is at all a concern. [clears throat] So, I won't discuss the debate here. But you can avoid the controversy. You [clears throat] can choose a physical blocker. These is are considered by the FDA safe and effective. So, zinc oxide sunscreen. It's a naturally broad sunscreen. It'll block the UVA, which was the longer-term damaging, as well as the UVB, the shorter-term damaging, both of which will cause, can cause skin cancer. And these do not get absorbed in the sunscreen, excuse me, in the bloodstream. The technology has advanced that these are no longer that white, cakey stuff that you remember from the '70s or '80s. Now they can have them with tints to match skin of color. Now they blend in more. The technology has advanced that this is an option, and they're becoming much more available now. So, we don't have to worry about looking like this.
There's another question I got the last time I presented. Are [clears throat] there any things that we can do for chemoprevention? Can we take a medicine to help reduce this? There there is now some some evidence about this. Um, this is a New England Journal of Medicine uh study published in 2016. Um, this is now becoming the standard of care across the country, including here at Indiana University. An over-the-counter B vitamin, nicotinamide, also known as niacinamide, is taken taken 500 milligrams twice a day, has been shown to reduce the skin cancer risk over five years. All skin cancers. This is you can buy this at the grocery store. It's non-toxic. Excessive, if you take it too much, it'll just be urinated out. You don't have to worry about if you take a multivitamin or if you did get a lot of B vitamins in your in your diet. This has been shown to be helpful. It is okay to take this if you have autoimmune hepatitis.
Warts. So, [clears throat] the prevalence of warts in transplant patients is proportional to the duration of immunosuppression. So, 50 to 90% of patients after four to five years of transplant will have will have warts. UV light is also considered to be a a important risk factor. So, what can we do for this? Everyone at home can try salicylic acid pads. These are also available at the grocery store. 80% of the warts will go away in two years just using this. Two years is a long time, though. So, your dermatologist can try to freeze these warts. We create a little localized frostbite to not only destroy the wart but to wake up the immune system and attack it. What else can we do that's available at every dermatologist office? This is, I think, kind of cool. It's a the killed yeast Candida. It can be injected into the wart. So, it's killed. It acts like a vaccine in the sense that it stimulates a dormant immune system to attack something that's irritating it, the Candida in this case. And while the immune system is there, it'll actually pick up the wart virus and attack that too. When it works, it works like magic. [clears throat] It just can take care of all the warts on the body. In my experience, it works about for 30 to 40% of a patients. So, we have more stuff beyond this.
What else can you do at an academic laser at an academic medical center? Well, sometimes we'll do laser therapy for warts. Um, this can be added on to the other things that I mentioned. It it's it's smarts. It's like a hot, hot flash, very painful laser that can be done on the warts. It'll bruise, but I have found it helpful for some slow-to-respond warts to move them along. We can also use a chemical peeling agent, trichloroacetic acid at 75%. We can use this with the freezing. We can apply it to the wart and peel off the skin. It's very cheap. I like to do it for multiple warts. It stings and burns and then peels, and it'll be raw. Beyond we can inject a chemotherapy into the wart. We do this at IU. We um will [clears throat] numb this area. We'll inject this chemotherapy agent called bleomycin. And that thing is cytotoxic. It kills all types of cells. It'll leave a blood blister. It may throb. If you have it on the foot, it'll be hard to walk for a couple of days, but it's safe. The chemotherapy just stays in the skin. There's no long-term effect if someone knows how to do it. It's very effective. One or two treatments in my experience. Three treatments very rarely. This is also cheap and covered by insurance in most cases. And finally, this is one of my patients. She had warts in all these areas. [clears throat] We can inject something called cidofovir. This is a direct antiviral. It's being used to treat um a type [clears throat] of virus called CMV, which is a cousin of the herpes virus. You may have heard of Valtrex. This medicine is a cousin of that. We can inject that directly into the wart because it's an antiviral. It's not destructive like the bleomycin. It's relatively painless, just the pain of the injection. It's good to use on sensitive areas if someone has a wart there, the face or the groin. There's very little in the way of scarring. The scars in this picture are from all the other things I tried on this patient. [clears throat] So, but it's expensive and it's difficult for insurance to cover. And so, that's what we've got. Well, I hope you aren't too tired of me. I know we covered a lot in a short period of time, but uh, I always love coming to this conference and I'm happy to discuss more during the Q&A. Thank you very much for your time and attention. [applause]