Journal Review Series: January-March 2019

Next Steps in Derm author, Dr. Anna Chacon, searched the journals so that you don’t have to! She reports on important take-aways from different dermatology journals for the months of January, February, and March of 2019.

It is key to keep in mind that “important” is subjective and what is contained in this review is one person’s view of what should be remembered from these months of the literature.

January 2019

Current controversies in early-stage melanoma: Questions on incidence, screening, and histologic regression

Is there a melanoma epidemic?

    • Melanoma incidence is increasing
    • Melanoma mortality rates are not increasing as fast as incidence rates
    • Increased incidence of thick as well as thin lesions
    • Basis for increasing incidence is unclear
    • Roles of ultraviolet light exposure, aging, and socioeconomic status
    • Pathologic overdiagnosis may be a factor
    • Role of increased awareness and screening

Does melanoma screening improve outcomes?

    • Population-based skin screening is not recommended by the USPSTF
    • Inconsistent screening/survival results have been reported from Germany
    • Screening may enable diagnosis at an earlier stage or identify low-grade lesions that are unlikely to metastasize
    • There may be significant costs of screening
    • Recommending skin screening for high-risk groups

How should histologic regression in primary melanoma be interpreted?

    • Lack of pathologic reporting consistency
    • Regression may indicate an antitumor immune response
    • Conflicting studies on prognostic importance of regression
    • Histologic regression is not an indication for SLNB in thin melanoma

Current controversies in early-stage melanoma: Questions on management and surveillance

What are the consequences of transecting a melanoma?

    • Transection prevents precise depth determination
    • Transection is usually associated with the shave biopsy technique
    • Transection does not affect survival
    • May be an indication for SLNB
    • Considering extent of deep margin involvement and repeat biopsy procedure may be useful

What is the impact of more extensive histologic sectioning on staging accuracy and prognosis?

    • No standards exist for sectioning technique of suspected melanoma biopsy specimens
    • Upstaging could potentially affect treatment and prognosis
    • Invasive melanoma: may change Breslow depth
    • Melanoma in situ: may detect occult invasion
    • Extensive sectioning may increase staging accuracy, but is unlikely to affect outcome

What is the role of the 31-gene prognostic test?

    • Limitations of SLNB as a prognostic test in patients with thin melanoma
    • Gene expression panel segregates lesions into 2 classes to predict metastatic risk
    • Not a substitute for SLNB
    • Resolution: more data needed to incorporate into staging schemes

How (and how often) should patients with early-stage melanoma be screened?

    • Lack of controlled studies on the frequency of complete skin examination
    • No imaging indications for stage 0 or I disease
    • Imaging can detect recurrence in patients with stage II disease, but is unlikely to affect survival
    • Some imaging may be indicated in stage IIB and IIC disease, but only for several years after diagnosis

Psoriasis: Which therapy for which patient: Psoriasis comorbidities and preferred systemic agents

    • Currently, 5 TNF-α inhibitors (etanercept, infliximab, adalimumab, certolizumab, and golimumab), 2 interleukin-17 (IL-17) blockers (secukinumab and ixekizumab), methotrexate, apremilast, tofacitinib, and abatacept are approved by the US Food and Drug Administration for the treatment of psoriatic arthritis.
    • While ustekinumab demonstrates good efficacy in psoriatic arthritis, its impact on skin disease is much more impressive than on joint disease.
    • Apremilast is effective in treating psoriatic arthritis, but prevention of radiologic progression has not been demonstrated.
    • Novel IL-23 inhibitors are currently under investigation for the treatment of psoriatic arthritis.
    • Methotrexate improves symptoms of joint disease but does not alter radiographic progression of disease.
    • Cyclosporine and acitretin have modest efficacy but are almost never used as monotherapy for psoriatic arthritis.
    • Infliximab, adalimumab, certolizumab, and ustekinumab are approved for the treatment of patients with CD. Golimumab is approved for UC but not for CD.
    • Etanercept is not as effective as other TNF-α inhibitors for CD.
    • A direct causal relationship between IL-17 inhibitors and CD has not been established but some clinicians avoid them in patients with a diagnosis or history suggestive of IBD.
    • IL-23 inhibitor use in CD has promising results in preliminary studies, but more data are needed to draw definite conclusions.
    • Methotrexate and cyclosporine can be used. There is no proven association between retinoids and CD, but some clinicians avoid acitretin in patients with a diagnosis or history suggestive of IBD.
    • TNF-α inhibitors may increase the risk of NMSC, namely SCCs, but they do not increase the overall risk of cancers. It is best to avoid anti–TNF-α agents in patients with concurrent malignancy or a history of malignancy, especially multiple cutaneous SCCs.
    • The clinical data for ustekinumab look promising, but caution needs to be exercised because it has demonstrated carcinogenic potential in animal models.
    • Data is limited for apremilast and IL-17 and IL-23 inhibitors, and more long-term studies are needed to assess their carcinogenic potential.
    • Acitretin has preventative effects on NMSCs and therefore is the preferred agent in patients with a high risk of skin cancers. Methotrexate and cyclosporine should be avoided in this setting.
    • Infliximab and ustekinumab are dosed based on weight and are ideal drugs to treat psoriasis in obese patients.
    • IL-17 inhibitors are highly effective regardless of a patient’s weight but are shown to have even better clearance rates in nonobese patients. There are not enough weight data on IL-23 inhibitors, but they are highly efficacious agents nonetheless.
    • Apremilast can be used favorably in obese patients because weight loss is a noted side effect of this drug.
    • Methotrexate carries a higher risk of fatty liver and hepatic fibrosis in obese patients and therefore should be avoided. Acitretin and cyclosporine need to be used in higher doses in obese patients, leading to a higher incidence of side effects and potential for toxicity.
    • TNF-α inhibitors are preferred systemic agents for treatment of psoriasis in patients with coexisting cardiovascular risk factors.
    • Ustekinumab has some potential cardioprotective benefit, but more long-term data are needed.
    • More data is needed for the use of apremilast, IL-17, and IL-23 inhibitors
    • Methotrexate has proven cardioprotective benefits but may cause end organ toxicity with long-term use. Cyclosporine and acitretin should be avoided because of concerns of hyperlipidemia and hypertension.
    • Although controversial, the New York Heart Association recommendations for anti–TNF-α agents in patients with CHF are as follows:
        • TNF-α inhibitors are contraindicated in class 3 or 4 CHF
        • Echocardiogram should be done before treatment initiation in class 1 or 2 CHF and TNF-α inhibitors should be avoided in patients with ejection fraction <50%
        • TNF-α inhibitors should be discontinued in patients with new onset CHF
    • Ustekinumab, apremilast, IL-17, and IL-23 inhibitors appear to be safe to use in CHF patients.
    • Methotrexate, cyclosporine, and acitretin can be used in patients with psoriasis who have CHF.
    • TNF-α inhibitors are contraindicated in patients with MS and other neurologic disorders. Regular evaluation of neurologic signs and symptoms should be performed during treatment with this class of drugs.
    • Ustekinumab can be used in patients with MS as it does not improve or worsen MS.
    • IL-17 inhibitors can be used with some benefit in MS symptoms.
    • Data are limited for the traditional agents, apremilast and IL-23 inhibitors, but there are no reports of MS worsening with these drugs.
    • Anti–TNF-α agents can be used watching out for lupus inductions and flare-up.
    • Ustekinumab emerges as the safest treatment option for concomitant lupus and psoriasis.
    • Data are limited for apremilast, IL-17, and IL-23 inhibitors, but there have been no reports of lupus induction or flare-ups.
    • Methotrexate and acitretin are good treatment options. Cyclosporine should be used only in severe or treatment refractory cases, as it is usually used with systemic corticosteroids.

Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections

    • Currently, 5 TNF-α inhibitors (etanercept, infliximab, adalimumab, certolizumab, and golimumab), 2 interleukin-17 (IL-17) blockers (secukinumab and ixekizumab), methotrexate, apremilast, tofacitinib, and abatacept are approved by the US Food and Drug Administration for the treatment of psoriatic arthritis.
    • While ustekinumab demonstrates good efficacy in psoriatic arthritis, its impact on skin disease is much more impressive than on joint disease.
    • Apremilast is effective in treating psoriatic arthritis, but prevention of radiologic progression has not been demonstrated.
    • Novel IL-23 inhibitors are currently under investigation for the treatment of psoriatic arthritis.
    • Methotrexate improves symptoms of joint disease but does not alter radiographic progression of disease.
    • Cyclosporine and acitretin have modest efficacy but are almost never used as monotherapy for psoriatic arthritis.
    • Infliximab, adalimumab, certolizumab, and ustekinumab are approved for the treatment of patients with CD. Golimumab is approved for UC but not for CD.
    • Etanercept is not as effective as other TNF-α inhibitors for CD.
    • A direct causal relationship between IL-17 inhibitors and CD has not been established but some clinicians avoid them in patients with a diagnosis or history suggestive of IBD.
    • IL-23 inhibitor use in CD has promising results in preliminary studies, but more data are needed to draw definite conclusions.
    • Methotrexate and cyclosporine can be used. There is no proven association between retinoids and CD, but some clinicians avoid acitretin in patients with a diagnosis or history suggestive of IBD.
    • TNF-α inhibitors may increase the risk of NMSC, namely SCCs, but they do not increase the overall risk of cancers. It is best to avoid anti–TNF-α agents in patients with concurrent malignancy or a history of malignancy, especially multiple cutaneous SCCs.
    • The clinical data for ustekinumab look promising, but caution needs to be exercised because it has demonstrated carcinogenic potential in animal models.
    • Data are limited for apremilast and IL-17 and IL-23 inhibitors, and more long-term studies are needed to assess their carcinogenic potential.
    • Acitretin has preventative effects on NMSCs and therefore is the preferred agent in patients with a high risk of skin cancers. Methotrexate and cyclosporine should be avoided in this setting.
    • Infliximab and ustekinumab are dosed based on weight and are ideal drugs to treat psoriasis in obese patients.
    • IL-17 inhibitors are highly effective regardless of a patient’s weight but are shown to have even better clearance rates in nonobese patients. There are not enough weight data on IL-23 inhibitors, but they are highly efficacious agents nonetheless.
    • Apremilast can be used favorably in obese patients because weight loss is a noted side effect of this drug.
    • Methotrexate carries a higher risk of fatty liver and hepatic fibrosis in obese patients and therefore should be avoided. Acitretin and cyclosporine need to be used in higher doses in obese patients, leading to a higher incidence of side effects and potential for toxicity.
    • TNF-α inhibitors are preferred systemic agents for treatment of psoriasis in patients with coexisting cardiovascular risk factors.
    • Ustekinumab has some potential cardioprotective benefit, but more long-term data are needed.
    • More data are needed for the use of apremilast, IL-17, and IL-23 inhibitors
    • Methotrexate has proven cardioprotective benefits but may cause end organ toxicity with long-term use. Cyclosporine and acitretin should be avoided because of concerns of hyperlipidemia and hypertension.
    • Although controversial, the New York Heart Association recommendations for anti–TNF-α agents in patients with CHF are as follows149, 150:
    • TNF-α inhibitors are contraindicated in class 3 or 4 CHF
    • Echocardiogram should be done before treatment initiation in class 1 or 2 CHF and TNF-α inhibitors should be avoided in patients with ejection fraction <50%
    • TNF-α inhibitors should be discontinued in patients with new onset CHF
    •  Ustekinumab, apremilast, IL-17, and IL-23 inhibitors appear to be safe to use in CHF patients.
    • Methotrexate, cyclosporine, and acitretin can be used in patients with psoriasis who have CHF.
    • TNF-α inhibitors are contraindicated in patients with MS and other neurologic disorders. Regular evaluation of neurologic signs and symptoms should be performed during treatment with this class of drugs.
    • Ustekinumab can be used in patients with MS as it does not improve or worsen MS.
    • IL-17 inhibitors can be used with some benefit in MS symptoms.
    • Data are limited for the traditional agents, apremilast and IL-23 inhibitors, but there are no reports of MS worsening with these drugs.
    • Anti–TNF-α agents can be used watching out for lupus inductions and flare-up.
    • Ustekinumab emerges as the safest treatment option for concomitant lupus and psoriasis.
    • Data are limited for apremilast, IL-17, and IL-23 inhibitors, but there have been no reports of lupus induction or flare-ups.
    • Methotrexate and acitretin are good treatment options. Cyclosporine should be used only in severe or treatment refractory cases, as it is usually used with systemic corticosteroids.

Oral Collagen Supplementation: A Systematic Review of Dermatological Applications

Preliminary results are promising for the short and long-term use of oral collagen supplements for wound healing and skin aging. Oral collagen supplements also increase skin elasticity, hydration, and dermal collagen density. Collagen supplementation is generally safe with no reported adverse events. Further studies are needed to elucidate medical use in skin barrier diseases such as atopic dermatitis and to determine optimal dosing regimens. 

Update in Herpes Zoster Prevention and the Role of Dermatologists

Widespread encouragement of dermatologists to recommend vaccination against HZ is crucial, and dermatologists are in a prime position to make the vaccine more accessible to their patient population.

Seborrheic Dermatitis in Skin of Color: Clinical Considerations

Skin of color patients may require a modified treatment approach which takes into account differences in hair texture and hair washing frequency.

Final Data from the Condition of Submental Fullness and Treatment Outcomes Registry (CONTOUR)

Data from CONTOUR indicate that cost is the most important factor in a patient’s decision to undergo treatment, that choice of treatment method is most influenced by SMF severity and preference for nonsurgical versus surgical intervention, and that the availability of noninvasive/minimally invasive options has made SMF treatment an attractive first procedure for patients who have not undergone previous facial aesthetic treatments.

IncobotulinumtoxinA: A Highly Purified and Precisely Manufactured Botulinum Neurotoxin Type A

IncobotulinumtoxinA is manufactured using advanced technology to precisely isolate the pure BoNT without unnecessary clostridial proteins, and with low immunogenicity and high specific activity. In incobotulinumtoxinA clinical studies, no previously BoNT-naïve subjects developed neutralizing a antibodies, and there was no secondary non-response to incobotulinumtoxinA treatment.

Cutaneous Sensitization to Peanut in Children With Atopic DermatitisA Window to Prevention of Peanut Allergy

Atopic dermatitis affects approximately 20% of children internationally and is commonly associated with the development of other allergic conditions, such as peanut allergy. With an increase in peanut allergy, especially in children at high risk, such as those with atopic dermatitis, focus has shifted from treatment to prevention, in part through determining the mechanism of peanut sensitization. Dermatologic interventions might modify the development of peanut allergy.

Benefits and Harms of Omalizumab Treatment in Adolescent and Adult Patients With Chronic Idiopathic (Spontaneous) Urticaria. A Meta-analysis of “Real-world” Evidence.

In a meta-analysis of 67 published reports, benefits and safety of omalizumab in the real-world treatment of chronic idiopathic urticaria meet or exceed the results gleaned from clinical trials. Benefits and safety of omalizumab in the real-world treatment of CIU meet or exceed results gleaned from clinical trials. These real-world data on omalizumab in CIU may help inform both clinical treatment expectations and policy decision making.

Economic Evaluation of Talimogene Laherparepvec Plus Ipilimumab Combination Therapy vs Ipilimumab Monotherapy in Patients With Advanced Unresectable Melanoma

Patients with advanced unresectable melanoma treated with talimogene laherparepvec plus ipilimumab achieve objective response, but this comes at an additional cost that is well above what payers typically are willing to pay. The cost to gain 1 additional progression-free quality-adjusted life-year, 1 additional progression-free life-year, or to have 1 additional patient attain objective response is about $1.6 million. This amount may be beyond what payers typically are willing to pay. Combination therapy of talimogene laherparepvec plus ipilimumab does not offer an economically beneficial treatment option relative to ipilimumab monotherapy at the population level. This should not preclude treatment for individual patients for whom this regimen may be indicated. 

February 2019

Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations

Epidemiology and cost

    • Basal cell carcinoma and squamous cell carcinoma comprise the keratinocyte carcinomas, which are the most common malignancies worldwide and are increasing in incidence
    • The lifetime risk of developing basal cell carcinoma in the United States is estimated to be ≥20% and ≥30% for whites
    • Male sex and age are independent basal cell carcinoma risk factors
    • The basal cell carcinoma cost burden continues to increase with rising incidence
    • Physician office–based basal cell carcinoma management is less costly compared to ambulatory surgery or inpatient settings

Clinical presentation and associated histologic findings

    • Patients with BCC often report an enlarging, nonhealing lesion that may sometimes bleed; they may also describe pruritus or deny any symptoms
    • Many lesions exhibit >1 histopathologic pattern, most commonly nodular-micronodular
    • Morpheaform (sclerosing, desmoplastic) and infiltrative, as well as lesions with micronodular or basosquamous histopathologic changes, are more aggressive variants
    • Although rare, perineural invasion indicates an aggressive variant with increased rates of metastasis and locoregional recurrence

Carcinogenesis and natural history

    • Predominantly through ultraviolet B light–driven mutagenesis, keratinocyte progenitor cells develop into BCCs
    • Constitutive activation of the Hedgehog signaling pathway is responsible and alone sufficient for BCC carcinogenesis
    • BCCs have the greatest mutational burden in coding DNA of any human cancer, perhaps allowing for greater antigenicity and contributing to indolence via heightened immunosurveillance
    • While BCCs grow indolently with local invasion, a small portion progress to locally advanced and metastatic tumors, usually as a result of neglect

Environmental, disease, and treatment associations

    • Intermittent intense sun exposure is significantly associated with BCC development via UV-driven mutagenesis and is exacerbated by fair skin, red or blond hair, light eye color, and an inability to tan
    • Nevoid basal cell carcinoma, multiple hereditary infundibulocystic, Dupre–Christol, Rombo, and xeroderma pigmentosum syndromes are characterized by increased BCC risk
    • Some autoimmune conditions (ie, rheumatoid arthritis) may be independently associated with increased risk, while evidence exists that others (ie, vitiligo and alopecia areata) may be BCC protective
    • BCC risk increases secondary to a variety of therapies, including psoralen plus ultraviolet A light phototherapy, immunosuppression in organ transplant patients, and ionizing radiation

Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention

Standard of care in diagnosis

    • Obtaining a skin biopsy specimen is the standard of care for diagnosing basal cell carcinoma
    • Dermoscopy is a novel noninvasive technique that improves prebiopsy accuracy

Novel noninvasive modalities in diagnosis

    • Reflectance confocal microscopy and optical coherence tomography are noninvasive diagnostic techniques for BCC diagnosis

Standard of care in treating primary tumors

    • Depending on the individual clinical presentation, standard surgical excision with postoperative margin evaluation and electrodessication and curettage are often 2 appropriate treatment options for “low-risk” BCCs
    • For “high-risk” BCCs, Mohs micrographic surgery is associated with lowest recurrence rates

Treatment approaches in difficult and advanced disease

    • Adjuvant RT may be considered for deeply invasive BCCs that are resected to positive margins or have clinically significant PNI
    • Unresectable BCCs can be cured with definitive RT
    • Unresectable or metastatic BCC that is not amenable to RT can be treated with systemic therapy

Quality of life and treatment in the elderly and disease follow-up and prevention

    • Quality of life concerns for skin cancer patients include diagnosis-related anxiety, scarring, and fear of future skin cancers
    • The incidence of BCCs is anticipated to increase in the United States with the aging population
    • Oral nicotinamide and retinoids are preventative therapies for high-risk patients with varying levels of evidence

Dermoscopy and dermatopathology correlates of cutaneous neoplasms

Dermoscopic structures and colors and their histopathologic correlates

    • Colors seen in dermoscopy depend on the type of chromophores in the skin and their location
    • Melanin appears in multiple colors (black, brown, gray, or blue) depending on its superficial or deep location
    • Dermoscopic structures with high specificity for melanocytic neoplasms include network, negative network, angulated lines, aggregated globules, streaks, and parallel patterns on volar surfaces
    • When these structures are atypical (differences in size, shape, color, or distribution), a diagnosis of melanoma is favored

Usefulness of dermoscopy to improve the clinical and histopathologic diagnosis of skin cancers

Use of dermoscopy to improve the clinical diagnostic accuracy for skin cancer detection

    • Dermoscopy increases the sensitivity for skin cancer detection and lowers the benign to malignant biopsy ratio
    • Limitations of dermoscopy include the learning curve and the occasional nonconformity of skin cancers to defined diagnostic criteria
    • Ultimately, the decision to obtain a biopsy specimen from a lesion requires the integration of multiple parameters, including clinical information, morphologic analysis, and comparative and pattern analysis

Using dermoscopy to improve histologic analysis

    • Dermoscopy can inform the pathologist on how best to process and section the tissue. This dermoscopic information can be provided to the pathologist via dermoscopic images or descriptions and by the clinician marking the area of most concern before submitting the specimen to the laboratory
    • Most dermoscopic features are visible after formalin fixation, and therefore dermoscopy can be used to guide step sectioning in the laboratory in a technique called ex vivo dermoscopy
    • Marking the specimen in vivo or ex vivo using dermoscopy improves the histologic diagnostic accuracy and potentially reduces the costs of histologic processing

Dermoscopic features with special relevance for the clinician and the pathologist

    • Several dermoscopic features are highly specific for melanoma and are called melanoma-specific structures
    • Select dermoscopic findings can predict the presence of aggressive melanomas and the presence of genetic mutations
    • Dermoscopy can predict the indolent versus aggressive subtypes of keratinocyte carcinomas and may help triage lesions
    • Although relatively specific, the structures suggestive for melanocytic lesions can be encountered in nonmelanocytic lesions, and this may explain the discordance between the clinical/dermoscopic and the final histopathologic diagnosis of many cases

Systemic Therapies for Moderate-to-Severe Atopic Dermatitis: Expert Perspectives in Practice

Patients with moderate-to-severe disease who have failed to achieve disease control may benefit from systemic immunomodulatory treatments. AD severity, treatment response, and treatment failure can be assessed, and the role of emerging systemic treatments in the management of moderate-to-severe AD

Superficial Radiation Therapy: A Viable Nonsurgical Option for Treating Basal and Squamous Cell Carcinoma of the Lower Extremities

Superficial radiation therapy is an effective option for eliminating BCC and SCC on lower extremities of patients who opt for nonsurgical treatment. Using SRT for BCC and SCC in elderly patients resulted in a 97.4% cure rate. 

Histopathology of Basal Cell Carcinoma After Treatment With Vismogedib
The histologic findings of BCCs treated with vismodegib correlate with clinical response.

Is It Time to Rethink What Thickness Really Means as a Prognostic Indicator in Melanoma? Ten Questions We Should Be Asking Ourselves

Tumor thickness has been a key tool for prognosis of melanoma. However, with the advent of gene expression profile (GEP) assays for melanoma and the discovery of multiple melanoma subtypes, it is time to reassess how we view tumor thickness as a prognostic indicator

A Review of the Dermatologic Symptoms of Idiopathic Mast Cell Activation Syndrome

Evidence to date suggests that flushing, pruritus, and clotting dysfunction or bleeding disorder are the most frequently observed dermatologic symptoms in idiopathic mast cell activation syndrome, while dermatographism has been identified as a common finding in patients as well. Mast cell activation syndromes have also been linked to connective tissue disorders, including an Ehlers-Danlos Syndrome-like phenotype possibly mediated by matrix metalloproteinases and tryptase released by mast cells. 

Apremilast for the Treatment of Mild-to-Moderate Hidradenitis Suppurativa in a Prospective, Open-Label, Phase 2 Study

Apremilast was safe and effective in improving HS disease activity, pain, and QoL in patients with mild-to-moderate HS. These data suggest that apremilast may have a role in the early treatment of less severe HS. 

Tavaborole 5% Topical Solution for the Treatment of Toenail Onychomycosis in Pediatric Patients: Results from a Phase 4 Open-Label Study

Tavaborole was well tolerated in this pediatric population, and safety, PK, and efficacy profiles were comparable with those in adults.

Cortexolone 17α-Propionate (Clascoterone) is an Androgen Receptor Antagonist in Dermal Papilla Cells In Vitro

Clascoterone may be an excellent candidate to be the first topical antiandrogen for treating AGA

Improving Dermatologic Care for Sexual and Gender Minority Patients Through Routine Sexual Orientation and Gender Identity Data Collection

Sexual and gender minority (SGM) populations, including people who are lesbian, gay, bisexual, and transgender (LGBT), face unique health disparities, such as dermatology-specific health disparities.1 Mitigating those disparities is a national public health priority, which is reflected in the federal government’s public health agenda, Healthy People 2020. These efforts can succeed only if physicians ascertain whether patients are of an SGM, which might not be outwardly apparent, and then act on that knowledge to provide medically appropriate and culturally sensitive care.

Association of Dipeptidyl Peptidase 4 Inhibitor Use With Risk of Bullous Pemphigoid in Patients With Diabetes

The findings suggest that DPP-4 inhibitors are associated with a significantly increased risk of the development of BP in patients with diabetes. Of the DPP-4 inhibitors available in Korea, vildagliptin was associated with the highest risk, particularly in male patients. Practitioners should consider that DPP-4 inhibitors, particularly vildagliptin, may be associated with the development of BP in patients with diabetes. These nationwide, population-based results may serve as a foundation for further studies seeking to understand how DPP-4 inhibitors contribute to the development of BP. Use of dipeptidyl peptidase 4 inhibitors, particularly vildagliptin, may be associated with the development of bullous pemphigoid in male patients with diabetes.

Efficacy of Transplantation of Combination of Noncultured Dermal and Epidermal Cell Suspension vs Epidermal Cell Suspension Alone in Vitiligo. A Randomized Clinical Trial.

Combined noncultured dermal and epidermal cell suspension (NCES and NDCS) is a novel technique that can be used successfully in patients with vitiligo with shorter duration of disease stability (3-6 months). Combination of NCES and NDCS resulted in excellent response in patients with vitiligo with shorter duration of clinical stability compared with NCES alone. This combination may be used early in the course of stable vitiligo without waiting for a period of 12 months or more since last clinical activity.

Dermatologic care for lesbian, gay, bisexual, and transgender persons: Terminology, demographics, health disparities, and approaches to care

Terminology important to caring for LGBT persons

    • Terminology important in caring for LGBT persons relates to sexual orientation, sexual behavior, sex assigned at birth, gender identity, and gender expression
    • Terminology is complex and fluid and might not be used uniformly by all LGBT persons

LGBT demographics in the United States

    • Approximately 10.1 million adults in the United States (4.1%) identify as LGBT
    • More than 8 million (3.5%) adults identify as lesbian, gay, or bisexual and 1.4 million (0.6%) adults identify as transgender
    • More than 19 million (8.2%) adults reported ever having engaged in same-sex sexual behaviors

Health care disparities among LGBT persons

    • LGBT individuals face substantial disparities in physical and psychosocial health conditions
    • Disparities in health risk factors, barriers in health care access, discrimination, and minority stress may contribute to LGBT health disparities
    • The minority stress model proposes that prejudice and stigma can generate chronic psychosocial stressors that mediate health disparities

Approaches to caring for LGBT patients

    • Eliciting a sexual history, including gender(s) of sex partners, and asking about gender identity can enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients
    • Using nonjudgmental language and avoiding assumptions are important to creating a welcoming care environment for LGBT patients

Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention

MSM

    • MSM are at higher risk than men who have sex with women for certain infectious conditions, including HIV and other sexually transmitted diseases, Kaposi sarcoma, viral hepatitides, methicillin-resistant Staphylococcus aureus skin infections, and invasive meningococcal disease and might be at higher risk for certain noninfectious conditions, including skin cancer
    • Recommendations regarding HIV and sexually transmitted disease screening, sexual health–related vaccinations, and HIV preexposure prophylaxis differ for MSM compared with men who have sex with women
    • Recommendations for HIV nonoccupational postexposure prophylaxis apply to MSM

WSW

    • WSW are at risk for HIV and other STDs
    • Guidelines for HIV, STD, and cervical cancer screening and HPV vaccination apply to both WSW and heterosexual women

Transgender individuals

    • Transgender individuals, particularly those receiving gender-affirming hormone and surgical treatments, have unique skin health needs
    • Dermatologists should be aware of potential complications of gender-affirming treatments and offer appropriate counseling for patients seeking those treatments

March 2019

Onset of Action of Antipsoriatic Drugs for Moderate-to-Severe Plaque Psoriasis: An Update

Brodalumab may continue to have the most rapid onset of action of available antipsoriatic therapies.

Low Dose Naltrexone in Dermatology

Off label low dose naltrexone has been shown to improve dermatologic conditions such as systemic sclerosis, Hailey-Hailey Disease, lichen planopilaris, guttate psoriasis, and potentially atopic dermatitis.

Treating Acne With Topical Antibiotics: Current Obstacles and the Introduction of Topical Minocycline as a New Treatment Option

Hydrophilic minocycline gel (BPX-01) and a lipophilic minocycline foam (FMX101) both reduced acne lesion counts with negligible systemic absorption. Head-to-head studies have yet to be completed, but the hydrophilic gel studies reported greater treatment efficacy than the lipophilic foam studies.

Dual Immunostaining With SOX10 and AE1/AE3 to Confirm Perineural Invasion on Mohs Sections

Double staining frozen tissue is feasible and can be beneficial for real time confirmation of perineural invasion during Mohs.

0.5% 5-Fluorouracil/10% Salicylic Acid for the Treatment of Distal Actinic Keratoses Under Daily Practice Conditions

Findings indicate that topical 5FU/AS is an effective treatment for multiple distal AKs, with a proper safety profile.

Association of HLA Antigen Mismatch With Risk of Developing Skin Cancer After Solid-Organ Transplant

Tumor surveillance mechanisms may be activated by HLA antigen mismatch, and well-matched heart and lung transplant recipients may have a higher risk of skin cancer after transplant. The HLA antigen mismatch appears to be associated with reductions in the risk of skin cancer after solid-organ transplant among heart and lung transplant recipients; this finding suggests that HLA antigen mismatch activates the tumor surveillance mechanisms that protect against skin cancer in transplant recipients and that skin cancer risk may be higher in patients who received a well-matched organ.

Comparison of Narrowband UV-B With Psoralen–UV-A Phototherapy for Patients With Early-Stage Mycosis Fungoides. A Systematic Review and Meta-analysis.

The findings suggest that narrowband UV-B is a viable and safe alternative to psoralen–UV-A for treatment of early-stage mycosis fungoides as response rates are similar and no difference was found in terms of adverse effects. These findings have implications for clinicians involved in the management of early-stage MF. The findings suggest that PUVA is a potential alternative to NBUVB in the management of early-stage MF.

Comparison of Running Cutaneous Suture Spacing During Linear Wound Closures and the Effect on Wound Cosmesis of the Face and Neck. A Randomized Clinical Trial.

Running cutaneous sutures spaced 2 vs 5 mm apart result in similar cosmetic outcomes. No statistically significant difference in wound cosmesis or total complications were noted between running cuticular sutures spaced 2 vs 5 mm apart. Both suturing techniques resulted in similar cosmetic outcomes and complication rates. Surgeons may want to consider whether the extra time involved in placing very closely spaced cuticular sutures is worthwhile.

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