INFLAMMATORY BOWEL DISEASE AND SKIN HEALTH KARA N. SHAH, MD, PHD KENWOOD DERMATOLOGY MARCH 4, 2018

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1 INFLAMMATORY BOWEL DISEASE AND SKIN HEALTH KARA N. SHAH, MD, PHD KENWOOD DERMATOLOGY MARCH 4, 2018

2 DISCLOSURES I HAVE NO RELEVANT FINANCIAL DISCLOSURES

3 INTRODUCTION Structure and function of the skin IBD and psoriasis IBD and acne IBD and skin cancer

4 STRUCTURE OF THE SKIN Epidermis Dermis Subcutaneous tissue (fat) Hair follicles Sebaceous glands Sweat glands Nerves Blood vessels

5 FUNCTION OF THE SKIN Barrier that protects against: UV irradiation Mechanical stress Environmental chemicals/toxins Infection Dehydration Thermoregulation Vitamin D synthesis Sensation

6 FUNCTION OF THE SKIN

7 BASIC SKIN CARE RECOMMENDATIONS Use a gentle cleanser when bathing (e.g. Dove, Cetaphil, or Neutrogena ) Try to limit bathing to 10 minutes or less and use warm, not hot, water Apply a moisturizing cream after bathing and as needed during the day (e.g. Cerave, Cetaphil, or Eucerin )

8 IBD AND PSORIASIS

9 PSORIASIS A common, chronic inflammatory skin disease that affects ~ 1% of the population Genetic component, though complex and multi-factorial ~30% of patients report onset during childhood The diagnosis of psoriasis is usually made clinically, skin biopsy only indicated if the diagnosis is in doubt There is no cure for psoriasis, only treatment; however, remissions may occur although recurrences are also common Flares of psoriasis may be associated with illness and stress

10 PSORIASIS AND IBD Associated with IBD and other autoimmune diseases Associated with use of tumor necrosis factor-a inhibitor therapy (e.g/ Remicade /infliximab, Humira /adalimumab, Enbrel /etanercept) Likely as a result of a genetic predisposition to psoriasis Reported in 3.5-5% of adults with IBD on TNF-a inhibitor Psoriasis may be associated with psoriatic arthritis, and therefore recurrent or chronic joint pain should be evaluated promptly as a change in therapy may be needed to prevent permanent joint damage.

11 HOW DO I KNOW IF I HAVE PSORIASIS? Scalp itching, scaling and/or irritation Red, scaling areas on body Elbows, knees Umbilicus Palms, soles Red, rash involving the skin folds (groin, underarm, buttocks) Nail changes

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18 PSORIASIS AND TNF-a INHIBITOR THERAPY TNF-a inhibitor therapy is associated with psoriasis, in particular scalp psoriasis and palmoplantar (hands/feet) psoriasis, but may occur anywhere TNF-a inhibitor therapy does not usually need to discontinued, and discontinuation of the TNF-a inhibitor does not necessarily result in remission of psoriasis. Usually treated with topical medications (e.g. corticosteroids or vitamin D analogs) More severe cases may require phototherapy or systemic therapy (e.g. methotrexate) or discontinuation of TNF-a inhibitor and use of alternate systemic therapy that is effective against both the psoriasis and the IBD (e.g. Stelara /ustekinumab)

19 ADDITIONAL RESOURCES National Psoriasis Foundation (

20 IBD AND ACNE

21 ACNE AND IBD Acne is common in adolescents, and ~25% of adults will have persistent or new-onset acne Moderate-severe inflammatory/cystic acne is noted in ~20% of those with acne Acne is associated with poor self-esteem, depression, and anxiety and deserves appropriate treatment Standard treatment for moderate-severe acne may include oral antibiotics (e.g. doxycycline, minocycline) and isotretinoin, an oral retinoid (form of vitamin A)

22 ACNE AND IBD Use of systemic antibiotics is considered a risk factor for the development of IBD and use of oral antibiotics for the treatment of acne in those with IBD is generally discouraged Use of oral antibiotics has the potential to contribute to antibiotic resistance, obesity, and allergy by disrupting the gut microbiome Recent research concludes that there is no link between isotretinoin use and increased risk or new-onset or worsening IBD Recent research also suggests that changes in mood, including depression, are uncommon with isotretinoin use but more likely to occur in those persons with pre-existing depression or mood disorder

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24 ACNE TREATMENT IN IBD Mild/moderate acne: OTC benzoyl peroxide wash or gel OTC Differin 0.1% gel (topical retinoid) Rx topical antibiotic: erythromycin, clindamycin, dapsone Rx topical retinoid (tretinoin, adapalene, tazarotene) Severe acne: Isotretinoin Photodynamic therapy Hormonal therapy (oral contraceptives, spironolactone) for women

25 ACNE TREATMENT: ADJUNCTS Nicotinamide Low glycemic index diet Limited cows milk intake, including whey protein supplements Fish oil omega-3 fatty acid supplements

26 IBD AND SKIN CANCER

27 SKIN CANCER AND IBD Several studies have reported an increased risk of skin cancer in persons with IBD who are on any immunosuppressive therapy (e.g. azathioprine, 6- mercaptopurine, biologics) Studies highlight an increased risk of non-melanoma skin cancer in patients using anti-metabolite therapy (e.g. 6-MP, azathioprine) At least one study suggests that the risk of non-melanoma skin cancer returns to baseline after discontinuation of antimetabolite therapy Some studies indicate an increased risk for NMSC in IBD patients on antimetabolite therapy in the year age range Studies highlight an increased risk of melanoma in patients on a TNF-a inhibitor

28 SKIN CANCER 1 in 5 Americans will develop skin cancer by age 70 years UV light exposure is the most important risk factor for skin cancer Other risk factors include genetic predisposition in a small number of persons and immunosuppression Melanoma is the most worrisome type of skin cancer, and accounts for about 3% of all skin cancers Non-melanoma skin cancer is much more common than melanoma The overall risk for skin cancer increases with age; skin cancer in very rare in children

29 SKIN CANCER Melanoma Non-melanoma Basal cell carcinoma Squamous cell carcinoma

30 MELANOMA The risk of melanoma doubles if a person has had five or more sunburns Only 20-30% of melanomas occur within an existing mole; most arise spontaneously on normal-appearing skin

31 MELANOMA DETECTION

32 MELANOMA

33 MELANOMA ~50% of melanomas are in-situ and unlikely to cause death; they are easily treated by surgery ~50% of melanomas are invasive and may be lethal The 5-year survival rate for early melanoma is 99%; for melanoma that has metastasized, it is 20% Early detection is therefore crucial to survival!

34 BASAL CELL CARCINOMA The most common skin cancer Low risk for metastasis and death Easily treated

35 BASAL CELL CARCINOMA

36 SQUAMOUS CELL CARCINOMA Second most common skin cancer Intermediate risk for metastasis and death

37 SQUAMOUS CELL CARCINOMA

38 SKIN CANCER PREVENTION UV exposure is classified as a carcinogen by the World Health Organization Use sunscreen every day! Excess sun exposure results not only from intermittent, highintensity sun exposure such as during a summer vacation but also from chronic, lowlevel daily exposure American Academy of Dermatology recommends SPF 30, broad-spectrum, waterresistant Re-apply sunscreen every 1-2 hours Sun avoidance, sun-protective clothing, hats, sunglasses, shade, and limiting time outdoors between 10:00 am and 4:00 pm No tanning bed use!

39 SUNSCREEN AGENTS Physical sunscreen: zinc oxide and titanium dioxide Reflect UV light Protects immediately Excellent broad-spectrum protection Not absorbed into the skin Good for sensitive skin Chemical sunscreen: avobenzone, oxybenzone, other agents Absorb UV light and convert it into heat Should be applied minutes before sun expoure May be irritating or worsen acne

40 SUNSCREEN AND VITAMIN D Vitamin D3 (cholecalciferol) synthesis occurs in the skin Vitamin D deficiency is common in Northern hemisphere and in fairskinned persons Vitamin D deficiency has been suggested to contribute to numerous health concerns, although strong evidence is present for only a limited number of concerns, including osteoporosis

41 SUNSCREEN AND VITAMIN D Given the strong link between UV exposure and skin cancer, oral supplementation is recommended if deficiency exists Fair-skinned person requires about minutes of midday summer sun exposure to generate 10,000 IU of vitamin D3; in the winter, too little UVB reaches the earth Skin type, geographic location, age, and obesity also affect vitamin D synthesis in the skin

42 SUNSCREEN AND VITAMIN D Recommendations for oral vitamin D supplementation vary from 600 IU per day to 2000 IU.per day The Institute of Medicine recommended 600 IU of vitamin D daily for children and adults

43 SKIN CANCER SCREENING AND IBD The American College of Gastroenterology recommends the following:

44 SKIN CANCER SCREENING AND IBD Screening recommendation are most relevant to adults with IBD given the very low incidence of skin cancer in children Skin cancer screening in adults may be performed by the primary care provider if they are comfortable in performing an appropriate evaluation; otherwise, evaluation should be performed by a dermatologist Skin cancer screening in children may be performed by the primary care provider; if any suspicious skin lesions are noted, further evaluation should be performed by a dermatologist

45 SKIN CANCER SCREENING: SELF- EXAMINATION Check you skin every 3 months, more often if you have a history of skin cancer or if recommended by your dermatologist Have a family member or friend help you, if needed Examine all of your skin, including your scalp and feet. Let your primary care provider or dermatologist know if you find anything concerning New or changing mole that looks asymmetric or different than your other moles New lump or bump that doesn t resolve in 1-2 months New red, rough lesion that doesn t resolve in 1-2 months

46 ADDITIONAL RESOURCES Skin Cancer Foundation

47 THANK YOU FOR YOUR ATTENTION!