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  • Association of antinuclear antibody status with clinical features and malignancy risk in adult-onset dermatomyositis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-17
    Paul M. Hoesly, Jason C. Sluzevich, Anokhi Jambusaria-Pahlajani, Elizabeth R. Lesser, Michael G. Heckman, Andy Abril

    Background The clinical significance of antinuclear antibody (ANA) status in adults with dermatomyositis (DM) has yet to be fully defined. Objective We compared the incidence of amyopathic disease, risk of malignancy, and clinical findings in ANA-positive and ANA-negative patients with adult-onset DM. Methods This was a retrospective cohort study of patients with ANA-positive or ANA-negative adult-onset DM determined by enzyme-linked immunosorbent assay. Results Of 231 patients, 140 (61%) were ANA-positive and 91 (39%) were ANA-negative. Compared to ANA-negative patients, ANA-positive patients had a lower frequency of dysphagia (15% vs 26%, P=0.033) and heliotrope rash (38% vs 53%, P=0.026). Fifty-four patients (23%) developed malignancy within 3 years of DM diagnosis. Eleven percent of ANA-positive patients developed malignancy versus 43% of ANA-negative patients (P<0.001). There was a strong association between ANA positivity and lower likelihood of malignancy in multivariable analysis (OR: 0.16, P<0.001). Conversely, ANA positivity was not associated with amyopathic disease (OR: 0.94, P=0.87). Limitations The retrospective nature of the study was a limitation. Conclusion In patients with adult-onset DM, negative ANA is associated with increased likelihood of developing malignancy within three years of DM diagnosis. Particularly close follow-up and frequent malignancy screening may be warranted in ANA-negative individuals with DM.

    更新日期:2018-11-17
  • Comparative effectiveness of treatment of actinic keratosis with topical fluorouracil and imiquimod in the prevention of keratinocyte carcinoma: a cohort study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-17
    Romain Neugebauer, Katherine A. Su, Zheng Zhu, Monica Sokil, Mary-Margaret Chren, Gary D. Friedman, Maryam M. Asgari

    Background The effectiveness of 5-fluorouracil compared to imiquimod for preventing keratinocyte carcinoma is unknown. Objective To compare the effectiveness of 5-fluorouracil and imiquimod in preventing keratinocyte carcinoma in a real-world practice setting. Methods We identified 5,700 subjects who filled prescriptions for 5-fluorouracil or imiquimod for actinic keratosis treatment in 2007. An intention-to-treat analysis controlling for potential confounding variables was used to calculate 2- and 5-year cumulative risk differences for subsequent keratinocyte carcinoma overall and in field-treated areas. Results 5-fluorouracil was associated with a statistically significant decreased risk of any keratinocyte carcinoma compared to imiquimod (adjusted hazard ratio [aHR] 0.86, 95% CI 0.76-0.97), but there were no significant differences in risk by tumor subtype (squamous cell carcinoma aHR 0.89, 95% CI 0.74-1.07; basal cell carcinoma aHR 0.87, 95% CI 0.74-1.03), or site-specific keratinocyte carcinoma (aHR 0.96, 95% CI 0.81-1.14). There were no significant differences in 2- or 5-year cumulative risk for keratinocyte carcinoma among those treated with 5-fluorouracil versus imiquimod. Limitations Generalizability to other practice settings may be limited. Conclusions Whereas 5-fluorouracil was more effective in reducing keratinocyte carcinoma risk overall, we found no differences in the short- or long-term risk of subsequent site-specific keratinocyte carcinoma in a real-world practice setting.

    更新日期:2018-11-17
  • Melanomas of the head and neck have high local recurrence risk features and require tissue rearranging reconstruction more commonly than BCC and SCC: A comparison of indications for microscopic margin control prior to reconstruction in 13,664 tumors
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-17
    William Fix, Jeremy R. Etzkorn, Thuzar M. Shin, Nicole Howe, Mehul Bhatt, Joseph F. Sobanko, Christopher J. Miller

    Background Consensus guidelines recommend microscopic margin control based on high local recurrence risk features and tissue-rearranging reconstruction for keratinocyte carcinomas (KC) but not for cutaneous melanoma. Objective To compare high local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC versus melanoma. Methods Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery (MMS). Results 12,189 KCs (8,743 BCC, 3,343 SCC) and 1,475 melanomas (1065 melanomas in situ, 410 invasive melanomas) were identified from a prospectively updated MMS database. Compared to KCs, melanomas were significantly more likely to have high local recurrence risk features, including larger preoperative size [2.10 cm vs 1.30 cm, (p <0.0001)], recurrent status [5.08% vs 3.91%, (p = 0.031)], and subclinical spread [31.73% vs 26.52%, (p <0.0001)]. Tissue rearranging reconstruction was significantly more common for melanoma versus KCs [44.68% vs 33.02%, (p < 0.0001); OR 1.98 (p<0.0001)]. Limitations This was a retrospective study and did not compare outcomes to other treatment methods, such as “slow-Mohs” or conventional excision. Conclusion Melanomas of the head and neck have high local recurrence risk features and require tissue rearranging reconstruction more frequently than KCs.

    更新日期:2018-11-17
  • Vulvar Paget disease: a national retrospective cohort study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-17
    Michelle van der Linden, Maaike H.M. Oonk, Helena C. van Doorn, Johan Bulten, Eleonora B.L. van Dorst, Guus Fons, Christianne A.R. Lok, Mariëtte I.E. van Poelgeest, Brigitte M.F. Slangen, Leon F.A.G. Massuger, Joanne A. de Hullu

    Background Vulvar Paget disease (VPD) is a rare skin disorder, considered premalignant. Objective To assess the clinical course, treatment schedules and the effect of invasion and treatment on recurrence and survival in patients with VPD. Methods Data on women with VPD were retrieved from the medical files and pathology reports in all Dutch tertiary university medical centres. Disease free survival (DFS) and 5-year disease specific survival (DSS) were estimated using Kaplan-Meier curves. Results Data of 113 patients diagnosed between 1991 and 2016 were analysed. Seventy-seven percent had non-invasive VPD. Most women underwent surgery (65%). Recurrences were reported in 40%. Of women with non-invasive VPD 8% developed invasion. There were no disease specific deaths reported in women with non-invasive VPD. The 5 year DSS was over 98% in non-invasive and micro-invasive VPD, but significantly worse in invasive VPD: 50% (p<0.0005). Limitations The main limitations of this study are its retrospective character and that original pathology samples were not available for reassessment. Conclusions VPD is extremely rare and recurrence rates are high. Most patients have non-invasive VPD, which does not affect survival and should be considered a chronic disorder with a limited invasive potential. In case of invasive disease survival decreases significantly.

    更新日期:2018-11-17
  • Skin Diseases of the Breast and Nipple Part 2: Inflammatory and Infectious Diseases
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-16
    Reid A. Waldman, Justin Finch, Jane M. Grant-Kels, Diane Whitaker-Worth

    Certain dermatologic conditions are unique to the breast and nipple, whereas others may incidentally involve these structures. All require a nuanced approach to diagnosis and treatment due to the functional, sexual and aesthetic importance of this area. The lactating patient requires special management since certain treatment options are contraindicated. All dermatologic conditions involving the breast and nipple require careful evaluation since breast malignancy can be mistaken for a benign condition or may trigger the development of certain dermatologic conditions. This article reviews common and uncommon inflammatory and infectious conditions of the breast and nipple and provides insight into diagnosis and treatment of this heterogeneous group of diseases. For the purposes of this article, these conditions are divided into 4 distinct categories: 1) Dermatitis; 2) Radiation-induced Changes; 3) Mastitis; and 4) miscellaneous dermatologic conditions of the breast and nipple.

    更新日期:2018-11-16
  • Skin Diseases of the Breast and Nipple Part I: Benign and Malignant Tumors
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-16
    Reid A. Waldman, Justin Finch, Jane M. Grant-Kels, Christina Stevenson, Diane Whitaker-Worth

    Evaluation and management of dermatologic diseases of the breast and nipple requires an understanding of the unique anatomy of the breast and nipple as well as an awareness of the significant emotional, cultural, and sexual considerations that may come into play when treating this anatomic area. Part I of this 2 Part CME Series reviews breast anatomy, congenital breast anomalies, and benign and malignant breast tumors. Specifically, an emphasis is placed on inflammatory breast cancer and breast cancer with non-inflammatory skin involvement as well as on cutaneous metastases to the breast and from breast cancer. Familiarity of the dermatologist with the cutaneous manifestations of breast cancer will facilitate the diagnosis of breast malignancy and assist with staging, prognostication, and evaluation for recurrence. This article also discusses genodermatoses that predispose to breast pathology and provides imaging recommendations for evaluating a palpable breast mass.

    更新日期:2018-11-16
  • The “Rule of 10s” versus the “Rule of 2s”: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-14
    Alexandra K. Rzepecki, Charles D. Hwang, Jeremy R. Etzkorn, Thuzar M. Shin, Joseph F. Sobanko, Nicole M. Howe, Christopher J. Miller

    Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared to trunk and proximal extremity (T&PE) melanomas. The “rule of 10s” describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk of upstaging, ∼10% risk of positive excision margins, ∼10% risk of local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. T&PE melanomas encounter these complications at a lower rate, according to the “rule of 2s.” Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs decrease complications for surgery of specialty site melanomas by detecting upstaging and confirming tumor removal with comprehensive microscopic margin assessment prior to reconstruction. This review article summarizes information that is important to counsel melanoma patients about surgical treatment options and to encourage development of consensus guidelines with clear indications for MMS-I or slow Mohs.

    更新日期:2018-11-14
  • Benign Oral Mucosal Lesions: Clinical and Pathological Findings Part I- Benign Oral Mucosal lesions
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-14
    Mayra B.C. Maymone, Robert O. Greer, Lauren K. Burdine, Anh Dao-Cheng, Samantha Venkatesh, Priya Cherukuri Sahitya, Alexandre C. Maymone, Jeffery Kesecker, Neelam A. Vashi

    A diverse spectrum of benign oral mucosal lesions exists, presenting as either isolated oral findings or in association with dermatological conditions. Oral lesions can closely resemble one another; therefore, it is important for clinicians to be able to recognize their distinctive features and recognize benign versus malignant disease and when a biopsy is warranted. 1 In this continuing medical education series, we review oral anatomy and the clinical attributes of several benign lesions of the oral cavity along with the appropriate management and therapeutic modalities.

    更新日期:2018-11-14
  • Review of environmental effects of oxybenzone and other sunscreen active ingredients
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-14
    Samantha L. Schneider, Henry W. Lim

    With increasing awareness regarding the risks of sunburn, photoaging, and skin cancer, the use of sunscreens has increased. Organic and inorganic filters are used in sunscreen products worldwide. Concerns have been raised regarding the environmental effects of commonly used organic ultraviolet (UV) filters, including oxybenzone (benzophenone-3), 4-methylbenzylidene camphor, octocrylene, and octinoxate (ethylhexyl methoxycinnamate). Studies have identified UV filters such as oxybenzone, octocrylene, octinoxate, and ethylhexyl salicylate in almost all water sources around the world and have commented that these filters are not easily removed by common wastewater treatment plant techniques. Additionally, in laboratory settings, oxybenzone has been implicated specifically as a possible contributor to coral reef bleaching. Furthermore, UV filters such as 4-methylbenzylidene camphor, oxybenzone, octocrylene, and octinoxate have been identified in various species of fish worldwide, which has possible consequences for the food chain. As dermatologists, it is important for us to continue to emphasize the public health impact of excessive sun exposure and advise our patients about proper photoprotection practice, which consists of seeking shade, wearing photoprotective clothing (including hats and sunglasses), and applying appropriate sunscreens.

    更新日期:2018-11-14
  • Prognostic impact of regression in patients with primary cutaneous melanoma >1 mm in thickness
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-14
    Simone Ribero, Francesca Galli, Simona Osella-Abate, Luca Bertero, Laura Cattaneo, Barbara Merelli, Carlo Tondini, Laura Ghilardi, Vincenzo De Giorgi, Marcella Occelli, Pietro Quaglino, Paola Cassoni, Giuseppe Palmieri, Daniela Massi, Mario Mandala

    BackgroundThe impact of histologic regression on sentinel lymph node biopsy (SLNB) status and on clinical outcome is uncertain.ObjectiveTo investigate whether and to what extent regression <75% is able to predict SLNB status and clinical outcome of patients with melanoma >1-mm thick.MethodsThe study included patients with diagnoses given at 4 centers of the Italian Melanoma Intergroup. Univariate and multivariate Cox proportional hazard models stratified by center were used to analyze the effect of regression on disease-free interval and melanoma-specific survival.ResultsOut of 1182 patients given primary cutaneous melanoma diagnoses during 1998-2015 with a Breslow thickness >1 mm, 954 (304 with and 650 without regression) were included in the analysis. The proportion of patients with a positive SLNB was lower in patients with regression than without (24.4% vs 31.6%, chi-squared test P = .0368). At multivariate analysis, no association was detected between regression and disease-free interval (hazard ratio 1.11, 95% confidence interval 0.85-1.46; P = .4509) or melanoma-specific survival (hazard ratio 1.05, 95% confidence interval 0.77-1.44; P = .7600).LimitationRetrospective analysis.ConclusionIn our series, regression was not an independent prognostic factor in primary cutaneous melanoma patients with Breslow thickness >1 mm whereas it was associated with a lower incidence of SLNB positivity.

    更新日期:2018-11-14
  • Premalignant and Malignant Mucosal lesions: Clinical and Pathological Findings Part II. Premalignant and malignant mucosal lesions
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-14
    Mayra B.C. Maymone, Robert O. Greer, Jeffery Kesecker, Priya Cherukuri Sahitya, Lauren K. Burdine, Anh-Dao Cheng, Alexandre C. Maymone, Neelam A. Vashi

    Part 2 of this 2-part continuing medical education series discusses the clinical and histopathologic features of common premalignant and malignant lesions of the oral cavity. It is imperative for dermatologists to be able to recognize suspicious lesions, determine biopsy need, counsel, and refer patients presenting with premalignant or malignant conditions appropriately. Given the higher rates of mortality and morbidity of oral mucosal malignancies due to late diagnosis, appropriate treatment with multidisciplinary care in a timely manner is essential to these neoplasms.

    更新日期:2018-11-14
  • Prognostic Factors, Treatment, and Survival in Cutaneous Pleomorphic Sarcoma
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-08
    Maria A. Ibanez, Kyle Rismiller, Thomas Knackstedt

    Background Limited information exists on the influence of demographics, tumor characteristics, and treatment on survival in cutaneous pleomorphic sarcoma (CPS). Objective To describe incidence rates and prognostic factors affecting survival in CPS. Methods National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) data (1972-2013) was analyzed for 2423 patients diagnosed with CPS. Results Age-adjusted incidence rate was 0.152 cases per 100,000 person-years and was 4.5-fold higher in males than females. Male gender, white race, and increasing age over 40 were significantly associated with decreased overall survival. Head and neck tumors, tumors over 15mm, and with grade III or IV histology had significantly decreased survival. Surgical excision had a survival benefit compared no treatment. Radiation therapy did not provide a survival benefit. Patients with localized disease had the greatest survival followed by regional and distant disease. Limitations SEER data may not be reflective of all CPS patients. Recurrences, restaging, or additional non-mortality events over time are not tracked. Conclusions and Relevance: Tumor size, grade, gender, age at diagnosis, and race appear to influence survival as prognostic factors in CPS. Surgical tumor extirpation provides a survival benefit over no treatment whereas primary or adjuvant radiation does not provide a survival benefit.

    更新日期:2018-11-09
  • A nomogram to identify high-risk melanoma patients with a negative sentinel node biopsy
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-02
    Eduardo Bertolli, Mariana Petaccia de Macedo, Vinícius Fernando Calsavara, Clovis Antonio Lopes Pinto, João Pedreira Duprat Neto

    Background Melanoma patients with negative nodes following sentinel node biopsy are a heterogeneous group. Current guidelines fail to adequately stratify surveillance and treatment for this group. Also, there is scarce data on adjuvant treatments for these patients. Objectives To create a nomogram based on clinical and pathological characteristics of primary melanoma to evaluate the risk of recurrence in patients with negative SNB. Methods Retrospective cohort of patients who underwent SNB from 2000 to 2015 in a single institution. Results Our cohort comprised 1,213 patients. Among these patients, 967 (79.7%) had a negative SNB and mean follow up was 59.67 months. There were 133 recurrences (13.8%) - 45 (33.8%) presented with nodal recurrence, and 35 (26.3%) recurred where SNB was performed. Breslow thickness, ulceration, and microsatellitosis were found to be predictive of risk of recurrence at one, two, five, and ten years. Limitations single center analysis. Conclusions we created a predictive nomogram for melanoma patients after a negative SNB. It is easy to use and identifies high-risk patients who should have more strict surveillance and consideration of adjuvant treatment.

    更新日期:2018-11-05
  • Inflammatory eruptions associated with immune checkpoint inhibitor therapy: A single-institutional, retrospective analysis with stratification of reactions by toxicity and implications for management
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-03
    Emily Coleman, Christine Ko, Feng Dai, Mary M. Tomayko, Harriet Kluger, Jonathan S. Leventhal

    Background There is increasing recognition of distinct inflammatory eruptions associated with checkpoint inhibitors. A better understanding of their severity, therapeutic response and impact on cancer treatment is needed. Objective To analyze the different rashes associated with immunotherapy referred to our institution’s oncodermatology clinic and inpatient consultative service, and to evaluate their therapeutic response and impact on immunotherapy. Methods We retrospectively reviewed patients’ medical records referred to the oncodermatology clinic or inpatient dermatology service between 2016-2018 at Yale-New Haven Hospital for eruptions that developed during immunotherapy. Results 98 patients (51 men, 47 women) treated with checkpoint inhibitors developed 103 inflammatory eruptions, with a range of mean latency of 0.2-17.7 months. A minority (25/103; 24.3%) required immunotherapy interruption, most notably immunobullous (7/8; 87.5%), lichenoid (8/26; 30.8%), maculopapular (6/18; 33.3%), and SJS-like (2/2, 100%) reactions. Only 3/16 (18.8%) interrupted cases developed a grade 2 or 3 flare on rechallenge. Most reactions (93/103; 90.3%) responded to dermatologic therapy and/or immunotherapy interruption. Limitations This was a retrospective study from a single tertiary care center. Conclusion A variety of inflammatory reactions may occur from immunotherapy with differing degrees of severity. While most rashes responded to topical treatment, immunobullous and exfoliative presentations frequently interrupted immunotherapy. Increased awareness and early recognition may reduce the need for unnecessary immunotherapy interruption.

    更新日期:2018-11-05
  • Insect Repellents: An Updated Review for the Clinician
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-03
    Quoc-Bao D. Nguyen, Mai-Anh N. Vu, Adelaide A. Hebert

    Malaria, Zika virus, West Nile virus, Dengue fever, and Lyme disease are common causes of morbidity and mortality around the world. While arthropod bites may cause local inflammation and discomfort, a greater concern is the potential to develop deadly systemic infection. The use of insect repellents (IR) to prevent systemic infections constitutes a fundamental public health effort. Cost-effectiveness, availability, and high-efficacy against arthropod vectors are key characteristics of an ideal IR. Currently, numerous IRs are available on the market, with DEET (N,N-diethyl-3-methylbenzamide) being the most widely used. DEET has an excellent safety profile and remarkable protection against mosquitoes and various other arthropods. Other EPA-registered IR ingredients (permethrin, picaridin, IR3535, oil of lemon eucalyptus, oil of citronella, catnip oil, and 2-undecanone) are alternative IRs of great interest due to some having efficacies comparable to that of DEET. These alternative IRs possess low toxicity and favorable customer experiences in utilization (e.g., cosmetically pleasant, naturally occurring). This review summarizes currently available EPA-registered IRs: the origins, mechanisms of action, side effect profiles, and available formulations will be discussed. This review will enable the clinician to select the best IR option to meet patients’ needs and provide the greatest protection from arthropod bites and sequelae.

    更新日期:2018-11-05
  • Guidelines of care for the management of primary cutaneous melanoma
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-11-01
    , Susan M. Swetter, Hensin Tsao, Christopher K. Bichakjian, Clara Curiel-Lewandrowski, David E. Elder, Jeffrey E. Gershenwald, Valerie Guild, Jane M. Grant-Kels, Allan C. Halpern, Timothy M. Johnson, Arthur J. Sober, John A. Thompson, Oliver J. Wisco, Samantha Wyatt, Shasa Hu, Toyin Lamina

    The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer–related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

    更新日期:2018-11-02
  • Present and future perspective of photodynamic therapy for cutaneous squamous cell carcinoma
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-28
    Uma Keyal, Anil Kumar Bhatta, Guolong Zhang, Xiuli Wang

    Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer. Surgery remains the main stay of treatment but, some patients are not eligible for surgery and more importantly, lesions at critical site need nonsurgical approach for tissue preservation. In this context, photodynamic therapy (PDT) has been extensively studied as noninvasive or minimally invasive treatment and studies have shown promising results in terms of safety, efficacy and cosmetic outcome. Also, studies have proposed different mechanism for its efficacy. However, human studies demonstrating its efficacy are limited in terms of sample size and tumor depth of invasion. Exciting results are mainly seen in case report in microinvasive SCC, which is defined as SCC limited to papillary dermis. This inadequacy is due to inadequate penetration of topically applied photosensitizers through keratinized tumor surface. To overcome these hurdles, pretreatment with lasers or microneedles and encapsulation of photosensitizers into nanoparticles have been tried. Hence, present paper will discuss studies that have demonstrated the efficacy and safety of PDT for cSCC, studies that have postulated the mechanism of action of PDT, agents that have been used as PDT enhancers and finally, the recent use of adjuvant therapy in combination with PDT.

    更新日期:2018-10-30
  • Markers of systemic involvement and death in hospitalized cancer patients with severe cutaneous adverse reactions
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-26
    Shoko Mori, Alanna Hickey, Stephen W. Dusza, Mario E. Lacouture, Alina Markova

    Background Severe cutaneous adverse reactions (SCARs) are frequent in inpatient oncology. Early intervention may reduce morbidity, mortality, and hospitalization costs, however current clinical and histologic features are unreliable SCAR predictors. There is a need to identify rational markers of SCARs that could lead to effective therapeutic interventions. Objective To characterize the clinical and serologic features of hospitalized patients with cancer who developed SCARs. Methods Retrospective review of 49 hospitalized cancer patients with a morbilliform rash and recorded testing for serum cytokines (IL-6, IL-10, TNF-α) or elafin, and prior dermatology consultation. Patients were categorized as having a ‘simple’ morbilliform rash without systemic involvement or ‘complex’ morbilliform rash with systemic involvement. Results Fifteen out of 49 patients (30.6%) were deceased at 6 months from time of dermatologic consultation. Elafin, IL-6, and TNF-α were significantly higher in patients who died compared to patients who were still alive at 6 months. IL-6 and IL-10 were significantly higher in patients with a drug-related ‘complex’ rash. Limitations Retrospective design, limited sample size, high-risk patient population. Conclusion In cancer patients with SCARs, elafin, IL-6, and TNF- α may predict a poor outcome. Agents directed towards these targets may represent rational treatments for the prevention of fatal SCARs.

    更新日期:2018-10-27
  • A Phase 2, Randomized Dose-Finding Study of Tapinarof (GSK2894512 Cream) for the Treatment of Plaque Psoriasis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-26
    Kevin Robbins, Robert Bissonnette, Tomoko Maeda-Chubachi, Li Ye, Johnny Peppers, Kelly Gallagher, John E. Kraus

    Background There is a significant need for novel, safe and efficacious topical treatments for psoriasis. Objective We assessed the safety and efficacy of tapinarof in a new cream formulation in 2 concentrations and 2 application frequencies in adults with psoriasis. Methods Double-blind, vehicle-controlled, randomized, 6-arm trial (1:1:1:1:1:1) in adults, with psoriasis with body surface (BSA) involvement ≥1% and ≤15% and PGA ≥2 at Baseline. Primary endpoint included PGA = 0 or 1 at Week 12, and a 2-grade improvement from Baseline. Additional analyses included PASI75 and mean percent change in PASI and BSA. Results Treatment success defined by PGA 0 or 1 and a 2-Grade Improvement at Week 12 were statistically significantly higher (at a 0.05 significance level) in the tapinarof groups than the vehicle groups: (65% [1%BID]; 56% [1%QD]; 46% [0.5%BID]; 36% [0.5%QD]; 11% [vehicle BID], and 5% [vehicle QD]) and was maintained for 4 weeks post-treatment. Treatment-emergent adverse events (TEAEs) were higher with tapinarof (85/152 patients [56%] compared to vehicle 19/75 patients [25%]) and mild-to-moderate in intensity. Severe TEAEs were reported in all tapinarof groups except 0.5% QD. Limitations Large confirmation trials are needed. Conclusions Tapinarof cream is efficacious and well tolerated in adult patients with psoriasis.

    更新日期:2018-10-27
  • Erosive pustular dermatosis of the scalp: a neutrophilic folliculitis within the spectrum of neutrophilic dermatoses. A clinicopathologic study of thirty cases
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-25
    Carlo Tomasini, Andrea Michelerio

    Background It is general opinion that histopathology is nonspecific and of little value in diagnosing erosive pustular dermatosis of the scalp (EPDS). Objectives Clinicopathologic correlation of erosive pustular dermatosis of the scalp. Methods The clinical and pathological records of patients with a clinicopathologic diagnosis of EPDS, between 2011-2016, at the Dermatopathology Unit of the Turin University were reviewed. Results Thirty elderly patients with EPDS were identified, 22 males and 8 females. Androgenetic alopecia was present in 19/30 patients. Triggering factors included mechanical trauma in 10/30 cases, surgical procedures in 4/30, herpes zoster in 1/30. Three patients were affected by autoimmune disorders. The vertex was the most common location. Disease presentation varied markedly from tiny, erosive, scaly lesions to crusted and hemorrhagic plaques, mimicking pustular pyoderma gangrenosum. The pathologic changes differed according to the lesion type and disease duration. Interestingly, a spongiotic and suppurative infundibulo-folliculitis was observed in 8/30 cases. Limitations This was a retrospective study. Conclusions We believe that the primary lesion of erosive pustular dermatosis of the scalp is a spongiotic, pustular superficial folliculitis. The clinicopathologic similarities with other neutrophilic dermatoses, such as pustular pyoderma gangrenosum, suggest this condition should be included in this spectrum, where pathergy plays a pathogenetic role.

    更新日期:2018-10-26
  • The Prognostic Value of Inositol Polyphosphate 5-Phosphatase in Cutaneous Squamous Cell Carcinoma
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-22
    Helen JL. Cumksy, Collin M. Costello, Nan Zhang, Richard Butterfield, Matthew Buras, Jessica Schmidt, Kevin Drenner, Steven A. Nelson, Shari A. Ochoa, Christian Baum, Mark R. Pittelkow, David J. DiCaudo, Aleksandar Sekulic, Aaron R. Mangold

    Background Inositol Phosphate 5-Phosphatase (INPP5A) has been shown to play a role in development and progression of cutaneous squamous cell carcinoma (cSCC). The goal of the current study is to explore the prognostic value of INPP5A expression in cSCC. Methods A total of 189 cases of actinic keratoses and SCCs from 174 patients were identified, clinical and outcome data abstracted, histopathology re-rereviewed, and immunohistochemical (IHC) staining and interpretation was performed for INPP5A. Results The majority of tumors (89.4%) had an INPP5A score of 2 or 3. No patients had complete loss of INPP5A. Tumors with INPP5A score of 1 were more likely to be intermediate to high risk (BWH stage T2a and above 85.0% vs 23.7%, p < 0.0001), have a larger diameter (2.4 cm vs. 1.3 cm, p = 0.0004), moderate to poor differentiation (86.7% vs. 17.6%, p < 0.0001), and perineural invasion (37.5% vs. 5.3%, p < 0.0001). INPP5A score of 1 has worse 3-year survival of 42.3% (HR = 2.81, p = 0.0006) and local metastatic rates of 48.0% (HR=4.71, p < 0.0001). Conclusions Low INPP5A scores are predictive of aggressive tumors and may be a useful adjunct to guide clinical management of cSCC.

    更新日期:2018-10-23
  • Association between atopic dermatitis, depression and suicidal ideation: A systematic review and meta-analysis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-23
    Kevin R. Patel, Supriya Immaneni, Vivek Singam, Supriya Rastogi, Jonathan I. Silverberg

    Background Atopic dermatitis (AD) is associated with psychological distress. However, previous studies found conflicting results about whether AD is associated with increased depression or suicidality. Objectives To determine the complex relationship between AD and depression. Methods A systematic review was performed of all published observational studies in MEDLINE, Pubmed, EMBASE, GREAT, LILACS, Cochrane Library, Scopus and PsychInfo that analyzed depression in AD. Two reviewers performed study title/abstract review and data abstraction. Pooled meta-analysis was performed using random-effects weighting. Results Overall, 106 studies met inclusion criteria; 36 had sufficient data for meta-analysis. The prevalence of any depression was higher in persons with vs. without AD (20.1% vs. 14.8%). Similar results were found in sensitivity analyses of studies assessing clinical depression, depressive symptoms, and adults, with healthy controls, low and high study quality. AD was associated with significantly higher depression scales, parental depression, anti-depressant use, and suicidality. No publication bias was detected Limitations Individual level data were not available. Conclusions AD patients have higher odds of depression and suicidality.

    更新日期:2018-10-23
  • Treatment of primary non-metastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-23
    Shayan Cheraghlou, George O. Agogo, Michael Girardi

    Background Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary non-metastatic melanoma is not currently established. Objective We aimed to investigate the association of cancer treatment center case volume and academic affiliation on long-term patient survival for cases of primary non-metastatic melanoma. Methods US adult melanoma cases diagnosed from 2004-2014 in the NCDB were identified. Hospitals were grouped by yearly case volume quartile: bottom quartile, middle quartiles, and top quartile. Results Facility case volume was significantly associated with long-term patient survival (p<0.0001). Five-year survival was 76.8%, 81.9%, and 86.4% respectively for patients treated at institutions in the bottom, middle, and top quartiles of case volume respectively. On multivariate analysis, treatment at both middle-quartile (HR 0.834;95% CI 0.778-0.895) and top-quartile (HR 0.691;95% CI 0.644-0.741) volume centers was associated with improved survival relative to bottom-quartile volume hospitals. Academic affiliation was associated with improved outcomes for top-quartile but not middle-quartile volume facilities. Limitations Disease-specific survival was not available. Conclusions Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared to other high-volume centers.

    更新日期:2018-10-23
  • Second primary melanomas: Increased risk and decreased time to presentation in patients exposed to tanning beds
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-19
    Yang Li, Mukti Kulkarni, Kathryn Trinkaus, Lynn A. Cornelius

    Background Melanoma incidence has increased; the primary modifiable risk factor is ultraviolet radiation (UVR) from the sun or artificial UVR (arUVR) from tanning beds. Objective To determine whether patients who developed melanoma after arUVR exposure from tanning beds have unique characteristics. Methods A retrospective study of 434 melanoma patients was performed. Patients who consented at the initial appointment completed a questionnaire regarding phenotypic traits, medical history, and UVR exposure. Results Compared with patients aged ≥40 years, younger patients, especially women, had greater lifetime exposure to arUVR. At any age, patients with multiple primary melanomas had a higher probability of exposure to arUVR. For all patients with additional primary melanomas, those exposed to arUVR acquired their second primary melanoma significantly earlier; 67% of patients exposed to arUVR through tanning beds had their second primary diagnosed at the time of or within 1 year of their original diagnosis compared with 28% of nontanners (P = .011). Median time to diagnosis of second primary melanoma in patients exposed to arUVR versus those not exposed was 225 days versus 3.5 years, respectively (P = .027). Limitations The study was conducted in 1 geographic area with a relatively small sample size. Conclusion Our findings provide evidence for heightened surveillance in melanoma patients exposed to arUVR.

    更新日期:2018-10-22
  • Epidemiology of Nickel Sensitivity: Retrospective Cross-Sectional Analysis of North American Contact Dermatitis Group (NACDG) Data 1994-2014
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-18
    Erin M. Warshaw, Amy J. Zhang, Joel G. DeKoven, Howard I. Maibach, Donald V. Belsito, Denis Sasseville, Joseph F. Fowler, Anthony F. Fransway, Toby Mathias, Melanie D. Pratt, James G. Marks, Kathryn A. Zug, Matthew J. Zirwas, James S. Taylor, Vincent A. DeLeo

    Background Nickel is a common allergen. Objective To examine the epidemiology of nickel sensitivity in North America. Methods Retrospective, cross-sectional analysis of 44,097 patients patch tested by the North American Contact Dermatitis Group from 1994-2014. Nickel sensitivity was defined as a positive patch test to nickel. We evaluated frequency of nickel sensitivity and patient demographics. For each positive nickel reaction, we tabulated clinical relevance, occupational relatedness, and exposure sources. Results Average frequency of nickel sensitivity was 17.5% (1994-2014). Nickel sensitivity significantly increased over time (14.3% 1994-1996 to 20.1% 2013-2014, p<0.0001). Nickel sensitive patients were significantly more likely to be female, young, non-Caucasian, atopic (eczema and asthma), and/or have dermatitis affecting the face, scalp, ears, neck, arm, or trunk (p values ≤0.0474). Overall, 55.5% of reactions were currently clinically relevant; this frequency significantly increased over time (44.1% 1994-1996 to 51.6% 2013-2014, p<0.0001). Occupational relatedness was 3.7% overall with a significant decrease over time (7.9% 1994-1996 to 1.9% 2013-2014, p<0.0001). Jewelry was the most common source. Limitations Tertiary referral population. Conclusions Nickel allergy is of significant public health importance in North America. The frequency of nickel sensitivity in patients referred for patch testing has significantly increased over a 20-year period.

    更新日期:2018-10-19
  • Usefulness of dermoscopy/dermatoscopy to improve the clinical and histopathologic diagnosis of skin cancers
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-13
    Oriol Yélamos, Ralph P. Braun, Konstantinos Liopyris, Zachary J. Wolner, Katrin Kerl, Pedram Gerami, Ashfaq A. Marghoob

    Multiple studies have shown that dermoscopy increases the sensitivity and specificity for the detection of skin cancers compared to naked-eye examination. Dermoscopy can also lead to the detection of thinner and smaller cancers. Furthermore, dermoscopy leads to more precise selection of lesions requiring excision. In essence, dermoscopy helps clinicians differentiate benign from malignant lesions through the presence or absence of specific dermoscopic structures. Therefore, since most dermoscopic structures have direct histopathologic correlates, dermoscopy can allow the prediction of certain histologic findings present in skin cancers, thus helping select management and treatment options for select types of skin cancers. Visualizing dermoscopic structures in the ex vivo specimens can also be beneficial. It can improve the histologic diagnostic accuracy by targeted step-sectioning in areas of concern, which can be marked by the clinician before sending the specimen to the pathologist, or by the pathologist on the excised specimen in the laboratory. In addition, ex vivo dermoscopy can also be used to select tumor areas with genetic importance since some dermoscopic structures have been related to mutations with theragnostic relevance. In the second article of this continuing medical education series we review the impact of dermoscopy on the diagnostic accuracy of skin cancer, how can dermoscopy affect the histopathologic examination, and which dermoscopic features may be more relevant in terms of histological and genetic prediction.

    更新日期:2018-10-14
  • Dermoscopy/dermatoscopy and dermatopathology correlates of cutaneous neoplasms
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-13
    Oriol Yélamos, Ralph P. Braun, Konstantinos Liopyris, Zachary J. Wolner, Katrin Kerl, Pedram Gerami, Ashfaq A. Marghoob

    Dermoscopy is increasingly used by clinicians (dermatologists, family physicians, podiatrists, doctors of osteopathic medicine, etc.) to inform clinical management decisions. Dermoscopic findings and/or images provided to pathologists offer an important insight into the clinician’s diagnostic and management thought process. However, with limited dermoscopic training in dermatopathology, dermoscopic descriptions and images provided in the requisition form will provide little value to pathologists. Since most dermoscopic structures have direct histopathological correlates, dermoscopy can act as an excellent communication bridge between the clinician and the pathologist. In the first article of this continuing medical education series we review dermoscopic features and their histopathologic correlates.

    更新日期:2018-10-14
  • Androgens in Women: Androgen mediated skin disease and patient evaluation (Part I)
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-10
    Amanda Bienenfeld, Sarah Azarchi, Kristen Lo Sicco, Shari Marchbein, Jerry Shapiro, Arielle R. Nagler

    Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, as well as in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEA-S), testosterone, dihydrotestosterone (DHT), and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL) – androgen mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production as well as the impact of androgens on the skin in women. Specifically, we review the necessary, but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, and/or FPHL. We review available evidence regarding when to consider an endocrinologic work-up in women presenting with AMCDs, including the appropriate type and timing of testing.

    更新日期:2018-10-10
  • Androgens in Women: Hormone modulating therapies for skin disease (Part II)
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-10
    Sarah Azarchi, Amanda Bienenfeld, Kristen Lo Sicco, Shari Marchbein, Jerry Shapiro, Arielle R. Nagler

    Androgen-mediated cutaneous disorders (AMCDs) in women including acne, hirsutism, and female pattern hair loss (FPHL) can be treated with hormone-modulating therapies. In the second part of this Continuing Medical Education series, we discuss the hormone-modulating therapies available to dermatologists for the treatment of AMCDs including combined oral contraceptives, spironolactone, finasteride, dutasteride, and flutamide. Available hormone-modulating treatments utilized for each AMCDs are reviewed, along with mechanisms of androgen modulation, safety profile, contraindications, monitoring parameters, and evidence of efficacy. Medications discussed include ones that are FDA-approved for certain AMCDs as well as some that are used off-label. Despite the ubiquity of hormone-modulating therapies used for AMCDs, this review highlights the need for more rigorous studies to evaluate these therapies for acne, hirsutism, and FPHL.

    更新日期:2018-10-10
  • Analysis of cutaneous Merkel Cell Carcinoma outcomes after different surgical interventions
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    Lu Yan, Ledong Sun, Zhiguang Guan, Shanshan Wei, Yanru Wang, Pengfei Li

    Background Current guidelines recommend local excision margin (EM) with 1 to 2cm on primary merkel cell carcinoma (MCC) site. Objective We compared survival outcomes of MCC patients treated with different surgical interventions. Methods A retrospective analysis of MCC cases in the SEER database was performed by Kaplan-Meier, competing risk and Cox proportional hazards regression model analyses. Influence of age, T stage, AJCC stage, adjuvant radiotherapy and other subgroups were also analyzed by pair-wise log-rank test. Results Our results indicated significant association between local destruction method and inferior survival, while EM>2cm showed significantly higher overall survival (OS). In addition, competing risk analysis depicted similar trend as Kaplan-Meier analysis, and considerably reduced estimated cumulative incidence. Further subgroup pair-wise analysis demonstrated that EM>2cm method had better survival in patients younger than 60 years, having smaller tumor diameters (T1 and T2) or undergone adjuvant radiotherapy (p<0.05). In contrast, different EMs did not show any significant association with survival rate in patients older than 75 years or stage III tumors. Limitations This study was not prospectively randomized without relapse data. Conclusions It is challenging to make optimal EM recommendations, as surgical options may depend on individual case situations. Further prospective randomized studies are warranted.

    更新日期:2018-10-06
  • The use of topical rapamycin in the treatment of superficial lymphatic malformations
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    Pablo García Montero, Javier del Boz, Eulalia Baselga Torres, José Manuel Azaña Defez, Manuel Alcaraz Vera, Jesús Tercedor Sánchez, Lucero Noguera Morel, Ángel Vera Casaño

    Background The superficial lymphatic component of vascular malformations poses a significant treatment challenge. It is responsible for the majority of symptoms presented and to date there is no consensus regarding treatment. Objective To evaluate the effectiveness of topical rapamycin in treating superficial lymphatic malformations (LM). Methods A case series study was performed of patients with superficial LM, treated with topical rapamycin. The clinical characteristics of the patients and the concentration and application mode of the drug were recorded. The changes in the signs and symptoms observed, and associated adverse effects, were then noted and analysed. Results The study population consisted of 11 patients, average age 10.5 years. All were treated with topical rapamycin, in six cases at 1%, in one at 0.8% and in four at 0.4%. Changes in the clinical appearance of the lesions were observed in all patients. The associated symptoms, present in 9 of the 11 patients, improved in every case. The mean follow-up time was 16.1 months. Limitations This study is retrospective, with a small sample size and considerable heterogeneity of lesions and treatment approaches. Conclusions Treatment with topical rapamycin modifies the clinical appearance and alleviates the symptoms of superficial LM.

    更新日期:2018-10-06
  • Future considerations for clinical dermatology in the setting of 21st century American policy reform: corporatization and the rise of private equity in dermatology
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    Sailesh Konda, Joseph Francis, Kiran Motaparthi, Jane M. Grant-Kels,

    Within the last two decades, for-profit financial groups have become increasingly involved in health care. Outlier dermatology practices with high volumes of well-reimbursed procedures are attractive to consolidation backed by private equity. With fewer choices for independent or group private practice, junior dermatologists are increasingly seeking employment without ownership in private equity-backed corporate groups, whose primary fiscal responsibility lies with investors. Medicare’s response to corporatization and consolidation has already changed the practice of dermatopathology. Dermatologists should be aware of this history, given the ability of corporations and private equity groups to shape the present and future of our field.

    更新日期:2018-10-06
  • Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    John S. Barbieri, Natalie Spaccarelli, David J. Margolis, William D. James

    Acne is one of the most common diseases worldwide and affects approximately 50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use may be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications such as spironolactone, combined oral contraceptives, and oral isotretinoin.

    更新日期:2018-10-06
  • Predictors of mucosal melanoma survival in a population-based setting
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    Lisa Altieri, Megan Eguchi, David H. Peng, Myles Cockburn

    Background Mucosal melanomas are rare and aggressive neoplasms, with little published population-based data on predictors of survival. Objective To assess the influences of race/ethnicity, sex, tumor stage, tumor thickness, and anatomic site on mucosal melanoma survival estimates. Methods We analyzed 132,751 cases of melanoma, including 1,824 mucosal melanomas, diagnosed between 1994 and 2015 and reported to the California Cancer Registry. Kaplan-Meier survival analysis and Cox proportional hazards regression assessed the prognostic variables. Results The 5-year relative survival for mucosal melanomas (27.64%, 95% confidence interval [CI] 25.42 – 29.91) was significantly lower than for cutaneous melanomas (76.28%, 95% CI 76.03 – 76.53). Stage independently influenced survival, and thickness did not predict survival for neoplasms of known depth. Less common anatomic sites conferred worse prognoses (hazard ratio [HR] 1.93, 95% CI: 1.41 – 2.64). Limitations Lack of a standardized staging system may have resulted in misclassification of stage for some neoplasms. The influence of genetics is unknown because our database did not contain genetic characteristics. Conclusions Stage and anatomic site, but not thickness (i.e. Breslow depth), race, or ethnicity, determine prognosis of mucosal melanomas. Considering the poor prognosis for all stages of mucosal melanoma, dermatologists should incorporate examination of the oropharynx and genitalia in the full body skin exam.

    更新日期:2018-10-06
  • Relative efficacy of systemic treatments for atopic dermatitis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-06
    Edward W. Seger, Todd Wechter, Lindsay Strowd, Steven R. Feldman

    Background Systemic medications are often required for severe atopic dermatitis (AD) refractory to topical therapies. Biologic medications are a recent advancement in the field and a comparison to traditional systemic approaches would be beneficial. Objective To compare efficacies of systemic therapies for the treatment of AD Methods A systematic literature review was performed using Medline, Ovid and Embase. Randomized controlled trials looking at the efficacy of systemic treatments for AD in adults and children were included. Results A total of 41 studies met criteria and were included in our final analysis. Consistent improvements in Eczema Area and Severity Index (EASI) and Scoring Atopic Dermatitis (SCORAD) were reported with dupilumab and cyclosporine. Phase 2 clinical trials for lebrikizumab and tralokinumab were effective and would benefit from Phase 3 trials. No study reported efficacy of biologic medications in pediatric patients, however cyclosporine improved clinical severity by the greatest amount in this group. Limitations A lack of well controlled comparison studies make direct comparisons between the treatments difficult. Conclusion For treatment of severe AD, the strongest evidence currently exists for dupilumab and cyclosporine at improving clinical disease severity. Further research is required to determine long term safety and efficacy of biologic medications.

    更新日期:2018-10-06
  • Late growth of infantile hemangiomas in children >3 years of age: A retrospective study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-05
    Kathleen F. O'Brien, Sonal D. Shah, Elena Pope, Roderic J. Phillips, Francine Blei, Eulalia Baselga, Maria C. Garzon, Catherine McCuaig, Anita N. Haggstrom, Peter H. Hoeger, James R. Treat, Marissa J. Perman, Jane S. Bellet, Xavier Cubiró, Jeffrey Poole, Ilona J. Frieden

    Background The proliferative phase of infantile hemangiomas (IHs) is usually complete by 9 months of life. Late growth beyond age 3 years is rarely reported. Objective To describe the demographic and clinic characteristics of a cohort of patients with late growth of IH, defined as growth in a patient >3 years of age. Methods A multicenter, retrospective cohort study. Results In total, 59 patients, 85% of which were female, met the inclusion criteria. The mean first episode of late growth was 4.3 (range 3-8.5) years. Head and neck location (55/59; 93%) and presence of deep hemangioma (52/59; 88%) were common characteristics. Posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities (PHACE) syndrome was noted in 20 of 38 (53%) children with segmental facial IH. Systemic therapy (corticosteroid or β-blocker) was given during infancy in 58 of 59 (98%) and 24 of 59 (41%) received systemic therapy (β-blockers) for late IH growth. Limitations The retrospective nature and ascertainment by investigator recall are limitations of the study. Conclusion Late IH growth can occur in children after 3 years of age. Risk factors include head and neck location, segmental morphology, and involvement of deep dermal/subcutaneous tissues.

    更新日期:2018-10-05
  • Lower Socioeconomic Status is Associated with Delayed Access to Care for Infantile Hemangioma, a Cohort Study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-01
    Erina Lie, Kevin J. Psoter, Katherine B. Püttgen

    Background Early specialist evaluation during rapid proliferative growth of complicated infantile hemangiomas (IH) is crucial. Health disparities and barriers of access-to-care for children with IH have not been examined. Objective Investigate whether socioeconomic status (SES) is associated with age at subspecialist presentation for IH evaluation. Method Retrospective cohort study of 804 children presenting to a large academic hospital. Primary outcome was age at initial presentation. Covariates included demographic, socioeconomic, geographic, and clinical characteristics. Medicaid or Children's Health Insurance Program (CHIP) were proxies for lower SES. Analysis of covariance, χ2 tests, and generalized ordered logistic regressions were performed. Results Children with lower SES had higher odds of presenting after 3 months of age (OR 2.11, 95% CI 1.31-3.38). In the subset that qualified for institutional care management program (ICMP), no risk factors were associated with delayed presentation. Limitations Use of insurance and economic distress as proxies for SES; exclusion of uninsured children may underestimate racioethnic effects; single academic center study limiting generalizability. Conclusions Children with IH and lower SES were more likely to present later to specialists, but those enrolled in an ICMP did not, suggesting that integrated ICMPs may mitigate disparities and delayed access-to-care for IH among lower SES populations.

    更新日期:2018-10-02
  • Association between atopic dermatitis and autoimmune disorders in US adults and children: A cross-sectional study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-01
    Shanthi Narla, Jonathan I. Silverberg

    Background Little is known about the risk and predictors of autoimmune diseases in children and adults. Objective To determine the prevalence, predictors and excess costs of autoimmune disease in AD patients. Methods Cross-sectional study of the 2002–2012 National Inpatient Sample, including a ∼20% sample of all US hospitalizations (n=87,053,155 adults and children). Results The prevalence [95% confidence interval {CI95}] of autoimmune disease was higher in adults (7.9% [7.3-8.5%] vs. 5.7 [5.7-5.8%]) and children (2.0% [1.7-2.3%] vs. 1.0% [0.9-1.1%]) with vs. without AD. In multivariable logistic regression models controlling for socio-demographics, adult (adjusted odds ratio [CI95]: 1.45 [1.32-1.8]) and pediatric (2.08 [1.73-2.50]) AD were associated with any autoimmune disorder. In particular, AD was associated with 18 of 32 autoimmune disorders examined in adults and 12 of 24 examined in children, including disorders of the skin, endocrine, gastrointestinal, hematologic and musculoskeletal systems. AD patients hospitalized with any autoimmune disorder had higher cost of inpatient care with $2.5-$50 million excess annual costs. Conclusions Adults and children with AD had increased cutaneous and extra-cutaneous autoimmune disorders, which were associated with a considerable cost-burden.

    更新日期:2018-10-02
  • A systematic review and meta-analysis of the regional and age-related differences of atopic dermatitis clinical characteristics
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-01
    Yik Weng Yew, Jacob P. Thyssen, Jonathan I. Silverberg

    Background Previous studies found conflicting results about the commonality of different atopic dermatitis (AD) signs and symptoms. Objective To determine the prevalences of AD characteristics and differences by region and age. Methods A systematic review was performed of all published studies in MEDLINE, EMBASE, SCOPUS, LILACS, Cochrane, China National Knowledge Infrastructure, Taiwan electronic periodical services and CiNii that analyzed the proportion of AD characteristics. Two reviewers performed study title/abstract review and data abstraction. Results One hundred and one studies reported proportion of AD features with sufficient data for meta-analysis. The most prevalent AD features were pruritus, lichenification and xerosis. There were differences of AD characteristics by study region. Flexural involvement was less commonly reported in India, America and Iran. East Asian studies reported more erythroderma, truncal, extensor, scalp and auricular involvement. Southeast Asian studies reported more exudative eczema, truncal involvement, lichenification and prurigo nodules. Studies from Iran reported more head, face and neck involvement, pityriasis alba, and xerosis. Studies from Africa reported more papular lichenoid lesions, palmar hyperlinearity, ichthyosis and orbital darkening. Limitations Heterogeneity between studies and limited reporting of certain AD clinical characteristics. Conclusions AD characteristics are heterogeneous and vary by region and age.

    更新日期:2018-10-02
  • The role of TERT promoter mutations in differentiating recurrent nevi from recurrent melanomas: a retrospective, case-control study
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-01
    Kara E. Walton, Erin M. Garfield, Bin Zhang, Victor L. Quan, Katherine Shi, Lauren S. Mohan, Alexandra M. Haugh, Timothy VandenBoom, Pedram Yazdan, Maria Cristina Isales, Elnaz Panah, Pedram Gerami

    Background Repigmentation at previous biopsy sites pose a significant diagnostic dilemma given clinical and histologic similarities between recurrent nevi and locally recurrent melanoma. While common in melanoma, the role of TERT promoter mutations (TPMs) in recurrent nevi is unknown. Objective We investigated the role of TPMs in recurrent nevi and whether the presence of hotspot TPM distinguishes recurrent nevi from locally recurrent melanoma. We also characterized clinical and histologic features differentiating these lesions. Methods We analyzed 11 locally recurrent melanomas, 17 recurrent nevi, and melanoma and nevus controls to determine TPM status. We also assessed clinical and histologic features of the recurrent groups. Results Hotspot TPMs were more common in recurrent melanomas compared to recurrent nevi (p=0.008). Recurrent melanomas were more likely to have solar elastosis (p=0.0047), multi-layering of melanocytes in the epidermis (p=0.0221), adnexal involvement (p=0.0069), and epidermal consumption (p=0.0204). Recurrent nevi had intra-epidermal atypia limited to the area above the scar (p<0.0001) and occurred earlier after the original biopsy (p<0.0008). Solar elastosis, months to recurrence, and hotspot TPM were independently associated with recurrent melanoma in multivariate analysis. Limitations This was a retrospective study. Conclusion Hotspot TPMs are significantly more frequent in recurrent melanomas and may serve as a diagnostic clue in histologically ambiguous cases.

    更新日期:2018-10-02
  • Overall and Subgroup Prevalence of Acne Vulgaris Among Patients with Hidradenitis Suppurativa
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-01
    Sara Wertenteil, Andrew Strunk, Amit Garg

    Background Evidence establishing the link between acne vulgaris (AV) and hidradenitis suppurativa (HS) is limited, and the burden of AV in this group is unknown. Objective To determine prevalence of AV among adults with HS, and to determine the strength of this association. Methods Cross-sectional analysis identifying adults with AV among HS and non-HS patients using electronic health records data from a population-based sample of over 55 million patients. Results Prevalence of AV among adults with HS was 15.2% (7,315 /48,050), compared to 2.9% (497,360 /16,899,470) for adults without HS (p<0.001). Prevalence was greatest among HS patients who were female (5,870/35,790; 16.4%), ages 18-44 years (5,260/28,870; 18.2%), non-white (3,120/17,825); 17.5%), obese (5,430/35,135; 15.5%), and had PCOS (685/2,385; 28.7%). HS patients had 4.51 [95% CI 4.40-4.63] times the odds of having AV compared to non-HS patients, and the higher likelihood of having AV persisted across all HS subgroups. The association between HS and AV was generally stronger for patients who were male, aged ≥ 65 years, non-whites, and obese. Limitations Influence of disease severity in HS, or in acne, on the strength of the association could not be assessed. Conclusion Patients with HS may benefit from assessment of acne status and optimization of co-management strategies.

    更新日期:2018-10-02
  • Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Jonathan J. Lopez, Nafisseh S. Warner, Christopher J. Arpey, Christian L. Baum, Jerry D. Brewer, Clark C. Otley, Halena M. Gazelka, Randall K. Roenigk

    Background Little information is available to predict which patients require opioid analgesia following cutaneous surgery. When opioids are indicated, information is lacking regarding the optimal opioid agent selection and dosage. Objective To make recommendations for opioid prescription after cutaneous surgery. Methods A PubMed literature search was conducted to review the available literature. Recommendations are presented on the basis of available evidence and the opinion of the authors. Results Most patients undergoing cutaneous surgery do not require opioid analgesia. For those who do, the pain duration warranting opioid analgesia is generally less than 36 hours. Opioid refill requests warrant a follow-up visit to ascertain the cause of ongoing pain after excisional procedures. Limitations The recommendations are not based on prospective randomized trials. Conclusions The presented recommendations for opioid prescription practice are derived from available evidence, recommendations, and expert opinion.

    更新日期:2018-10-02
  • Guideline-Based Medicine Grading based upon the Guidelines of Care for Ambulatory Atopic Dermatitis Treatment in the United States
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Alan B. Fleischer

    Purpose This study was designed to assess the adherence to evidence-based guideline of care for atopic dermatitis (AD). Methods To characterize AD treatment for United States, ambulatory visits from the 2006 to 2015 National Ambulatory Medical Care Survey were analyzed. For each medication prescription, a grade was assigned based upon the American Academy of Dermatology (AAD) treatment guidelines for topical and systemic medications. A composite grade, analogous to the US academic grading system, from A to F, based upon all visit prescriptions was calculated. Results Across specialty groups, prescribing differences were noted. Systemic corticosteroids were more likely to be prescribed by family and general physicians (FPGP) and less likely by pediatricians. Dermatologists were more likely than other specialties to prescribe nonsedating antihistamines, which lack a guideline-base supporting their use. Depending upon modeling of care assumptions, all physician specialty visits earned mean guideline-based grades of B or C in their care of AD patients. Limitations The clinical, social, and demographic factors influencing prescribing behavior cannot be completely assessed using extant data. Conclusions This preliminary study demonstrates that physicians may benefit from reviewing guidelines of care and there may be an educational gap in the implementation of these guidelines.

    更新日期:2018-10-02
  • Association of multiple primary melanomas with malignancy risk: a population-based analysis of the Surveillance, Epidemiology, and End Results Program database from 1973-2014
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Emily D. Cai, Susan M. Swetter, Kavita Y. Sarin

    Background Genetic and environmental risk factors have been associated with the development of multiple primary melanomas (MPM). We hypothesized that individuals with MPM may have increased predisposition to developing internal malignancies. Objective To identify the risk of subsequent malignancies in MPM patients. Methods Multiple primary standardized incidence ratios were analyzed for individuals with ≥1, ≥2 and ≥3 primary melanomas (PM) in the SEER database from 1973-2014. Results 223,799 individuals with ≥1, 19,709 with ≥2 and 3,995 with ≥3 PM were identified. Risks of subsequent internal malignancy increased with number of PM, with observed to expected (O/E) ratios of 0.99, 1.14, and 1.23 (p<0.05) for patients with at least one, two and three PM respectively. Internal malignancy was higher in younger MPM patients and those with superficial spreading melanoma. The most common malignancies amongst MPM patients include breast, prostate, thyroid, soft tissue, brain, kidney, non-Hodgkin's lymphoma, and chronic lymphocytic leukemia. Risk of subsequent cutaneous melanoma increased with O/E ratios of 8.09, to 22.52, to 41.03 (p<0.05) respectively. Limitations SEER records limited information about pigmentation phenotypes, histology, and treatments. Conclusion Patients with MPM have increased risk of subsequent internal and cutaneous malignancies and may benefit from tight adherence to age-specific cancer screening.

    更新日期:2018-10-02
  • Cost Analysis of a Store and Forward Teledermatology Consult System in Philadelphia
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Xiaoshi Yang, John S. Barbieri, Carrie L. Kovarik

    Background Store-and-forward (SAF) teledermatology (TD) has the potential to increase access to timely, high-quality care for underserved populations. However, the cost-effectiveness of TD for underserved populations is uncertain. Objective This study evaluates the potential cost savings associated with a SAF TD program implemented for an underserved population in the city health clinics of urban Philadelphia. Methods We performed a retrospective analysis of SAF TD consultations for 700 outpatients managed in 12 Philadelphia primary care clinics. Primary care providers (PCPs) were asked to specify a treatment plan, as well as the type of care for the patient, in the absence of the TD service. Analysis compared cost of each patient case using the TD consult model versus conventional care. Results Twenty-seven percent (189/700) of in-person dermatology clinic visits and 3.29% (23/700) of emergency room (ER) visits were avoided using TD. Compared to conventional care, mean expected cost savings were $10.00-$52.65 per TD consult. In sensitivity analyses, these estimated savings remained positive across a range of parameters. Limitations The cost analysis relies on several assumptions regarding the cost of care, and indirect costs were not included. Conclusion Teledermatology can be a cost saving model while increasing access to dermatologic care.

    更新日期:2018-10-02
  • Infertility and Teratogenicity after Paternal Exposure to Systemic Dermatologic Medications: A Systematic Review
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    George A. Zakhem, Catherine C. Motosko, Euphemia W. Mu, Roger S. Ho

    Background This systematic review assesses effects of paternal exposure of dermatologic medications, using the former US Food and Drug Administration (FDA) pregnancy categories as a benchmark. Objective To assess whether systemic dermatologic medications can cause infertility and teratogenicity when taken by men. Methods Category D and X dermatologic medications were identified; a systematic review of the literature and reviews of the FDA Adverse Events Reporting System (FAERS) and prescribing information were performed to identify effects on male fertility and teratogenicity. Secondary search was performed to assess for other systemic dermatologic medications causing teratogenicity or infertility following paternal exposure. Results Thirteen medications met inclusion criteria. Nineteen of 1,032 studies were included after systematic review of the literature. Studies evaluating medication effects with paternal exposure were identified for 10 of 13 evaluated medications, and evidence of a negative effect was identified for 6 medications. Limitations We did not encounter any studies for 3 medications that met inclusion criteria. Information submitted to the FAERS may not reflect incidence of side effects. Conclusions Many former pregnancy category D and X systemic dermatologic medications also have effects on male fertility. More research and better-quality studies are required in this area, particularly assessing potential teratogenicity.

    更新日期:2018-10-02
  • "Treatment of male pattern alopecia with platelet-rich plasma: a double blind controlled study with analysis of platelet number and growth factor levels"
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Bruno L. Rodrigues, Silmara AL. Montalvão, Rebeca BB. Cancela, Francesca AR. Silva, Aline Urban, Stephany C. Huber, José Luiz RC Júnior, José Fábio SD. Lana, Joyce M. Annichinno-Bizzacchi

    Background Promising results were described with platelet-rich plasma (PRP) in androgenetic alopecia that could be associated to platelet number and growth factor levels. Objective Analyze the platelet number and growth factor levels in PRP and its correlation with hair growth parameters evaluated by TrichoScan. Methods Twenty-six patients randomized to receive four subcutaneous injections of PRP or saline. Hair growth, hair density, and percentage of anagen hairs were evaluated before, after and three months after the last injection using TrichoScan method. Growth factors (PDGF, EGF and VEGF) were measured by Luminex method. Results We demonstrated a significant increase in hair count (p = 0.0016), hair density (p = 0.012) and percentage of anagen hairs (p = 0.007) in PRP group when compared to control group, without correlation with platelet counts or quantification of the growth factors in PRP. Conclusion Our data favors the use of PRP as therapeutic alternative in the treatment of androgenetic alopecia. The lack of association between platelet count, PDGF, EGF and VEGF levels and clinical improvement suggest that other mechanisms could be involved in this response. Limitations Other growth factors that could be related with PRP response were not evaluated

    更新日期:2018-10-02
  • More than keratitis, ichthyosis, and deafness: multisystem effects of lethal GJB2 mutations
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-10-02
    Evelyn Lilly, Christopher G. Bunick, Alexander M. Maley, Shali Zhang, Mary K. Spraker, Amy J. Theos, Karina L. Vivar, Lucia Seminario-Vidal, Adam E. Bennett, Robert Sidbury, Yasushi Ogawa, Masashi Akiyama, Barbara Binder, Smail Hadj-Rabia, Raffaella A. Morotti, Earl J. Glusac, Keith A. Choate, Gabriele Richard, Leonard M. Milstone

    Background Infant death in KID syndrome is recognized; its association with specific genotypes and pathophysiology is inadequately understood. Objective To discover characteristics that account for poor outcomes in lethal KID syndrome. Methods We collected four new cases and nine previously reported, genotyped cases of lethal KID syndrome. We performed new molecular modeling of the lethal mutants GJB2 p.A88V and GJB2 p.G45E. Results Infant death occurred in all patients with GJB2 p.G45E and p.A88V; it is unusual with other GJB2 mutations. Early death with those two “lethal” mutations is likely multifactorial: during life all had at least one serious infection; most had poor weight gain and severe respiratory difficulties; many had additional anatomic abnormalities. Structural modeling of GJB2 p.G45E identified no impact on the salt bridge previously predicted to account for abnormal central CO2 sensing of GJB2 p.A88V. Limitations Clinical review was retrospective. Conclusion GJB2 p.G45E and p.A88V are the only KID syndrome mutations associated with uniform early lethality. Those electro-physiologically severe mutations in GJB2 reveal abnormalities in many organs in lethal KID syndrome. All KID syndrome patients may have subtle abnormalities beyond eyes, ears and skin. Early genotyping of KID syndrome births will inform prognostic discussion.

    更新日期:2018-10-02
  • CDKN2A germline mutations are not associated with poor survival in an Italian cohort of melanoma patients
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-28
    Bruna Dalmasso, Lorenza Pastorino, Giulia Ciccarese, Virginia Andreotti, Federica Grillo, Luca Mastracci, Francesco Spagnolo, Alberto Ballestrero, Paola Queirolo, William Bruno, Paola Ghiorzo

    Background Cyclin dependent kinase inhibitor 2A gene (CDKN2A) germline mutations have recently been associated with poor survival in patients with melanoma. Despite the high mutation rate in our cohort (up to 10% in patients with apparently sporadic melanoma), information on the impact of CDKN2A on survival in this cohort is lacking. Objective To investigate whether poor survival associated with CDKN2A germline mutations was confirmed in a high mutation–prevalence cohort of Italian patients with melanoma undergoing a mutation-based follow-up. Methods A total of 1239 patients with cutaneous melanoma were tested for CDKN2A mutational status and then assigned to a follow-up scheme according not only to family history but also to CDKN2A mutational status, as follow-up intervals were more frequent for CDKN2A germline mutation–positive (MUT+) patients. From this cohort, we selected 106 MUT+ patients (with familial melanoma or apparently sporadic melanoma) and 199 CDKN2A germline mutation–negative (MUT–) patients with sporadic melanoma who were matched by age and sex and had a similar tumor stage distribution. Results We found no difference in overall survival (hazard ratio, 0.85; 95% confidence interval, 0.48-1.52; P = .592,) or melanoma-specific survival (hazard ratio, 0.86; 95% confidence interval, 0.38-1.95; P = .718,) between MUT+ and MUT– patients. MUT+ patients were more likely to develop multiple melanomas and to undergo surgical excision of dysplastic nevi than were MUT– patients. Limitations Retrospective study. Conclusion CDKN2A mutations were not associated with survival in our cohort.

    更新日期:2018-09-28
  • Results of a nationwide epidemiologic survey of autosomal recessive congenital ichthyosis and ichthyosis syndromes in Japan
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-26
    Michiko Kurosawa, Ritei Uehara, Atsushi Takagi, Yumi Aoyama, Keiji Iwatsuki, Masayuki Amagai, Masaki Nagai, Yosikazu Nakamura, Yutaka Inaba, Kazuhito Yokoyama, Shigaku Ikeda

    Background Autosomal recessive congenital ichthyosis (ARCI) and ichthyosis syndrome (IS) are rare genetic skin disorders. Objective To estimate the number of patients with ARCI and IS in Japan and clarify the clinicoepidemiologic features of these diseases. Methods We performed a nationwide survey of patients treated for ARCI or IS during January 2005-December 2009. We developed diagnostic criteria and conducted a primary survey in a stratified random sample of Japanese hospitals to quantify the number of outpatients and inpatients with ARCI or IS. We performed a secondary survey of clinicoepidemiologic features in positive cases. Results The estimated number of patients receiving treatment for ARCI and IS during 2005-2009 was 220 (95% confidence interval [CI] 180-260). The estimated disease distribution was as follows: 95 (95% CI 80-110) patients with nonbullous congenital ichthyosiform erythroderma, 30 (95% CI 20-40) with lamellar ichthyosis, 15 (95% CI 10-20) with harlequin ichthyosis, and 85 (95% CI 50-120) with IS. Limitations Patients with a mild case of the disease might not have visited a dermatology department, potentially causing underestimation of affected patients. Conclusion We report the estimated number of patients with ARCI and IS in Japan and sex differences in the age distribution.

    更新日期:2018-09-27
  • Laser-assisted photodynamic therapy for actinic keratosis: A systematic review and meta-analysis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-27
    Theresa Steeb, Justin Gabriel Schlager, Christoph Kohl, Thomas Ruzicka, Markus V. Heppt, Carola Berking

    Background Photodynamic therapy (PDT) is an effective intervention for actinic keratosis (AK) and field-cancerization. Ablative fractional laser may facilitate the delivery of photosensitizers and thereby improve the effects of PDT. Objective To summarize the current evidence on the efficacy and safety of laser-assisted PDT. Methods We performed a systematic literature research in Medline, Embase, and CENTRAL and hand-searched pertinent trial registers for eligible randomized controlled trials (RCTs). Results from individual studies were pooled using a random-effects model. The risk of bias was estimated with the Cochrane Risk of Bias Tool and the quality of evidence of the outcomes with the GRADE approach. Results Out of 817 records initially identified, 7 RCTs were included in the qualitative analysis and 4 in the meta-analysis. Laser-assisted PDT showed significantly higher clearance rates compared to PDT monotherapy (risk ratio 1.33, 95% CI 1.24 to 1.42, I2=25%, p<0.01). There was no difference in pain intensity between laser-assisted PDT and other interventions (mean difference 0.31, 95% CI to 0.12 to 0.74, I2=0%, p=0.16). The included studies showed a high risk of bias. Limitations The clinical heterogeneity of included studies. Conclusion Laser-assisted PDT is more efficient but not more painful than PDT or laser treatment only.

    更新日期:2018-09-27
  • Follicular Involvement is Frequent in Lentigo Maligna: Implications for Treatment
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-26
    Karen L. Connolly, Cerrene Giordano, Stephen Dusza, Klaus J. Busam, Kishwer Nehal

    Background Follicular involvement of lentigo maligna (LM) is considered a histopathologic hallmark, but its prevalence and characteristics have not been well-defined. The depth of intrafollicular extension by neoplastic melanocytes may have clinical importance in the treatment of lentigo maligna. Objective To describe the prevalence and features of follicular involvement in LM, including depth of follicular growth by melanocytes. Methods & Materials Single-center retrospective study of 100 consecutive cases of surgically excised LM treated from 2013 to 2015. Slide review for cases with residual LM on debulk specimen was performed by a dermatologic surgeon and dermatopathologist to characterize follicular involvement. Results Seventy-two of 100 specimens met inclusion criteria for histopathologic evaluation. Follicular involvement was seen in 95.8% of specimens (95% CI: 88.3%-99.1%), with a mean 68% of follicles involved in a single specimen. The mean depth of intrafollicular growth by lesional melanocytes was 0.45 mm (SD=0.23, range 0.1 mm to 1.1 mm). Tumor cells were confined to the infundibular portion of the hair follicle in 60.9% of specimens. Conclusion Superficial follicular involvement is a ubiquitous finding in LM. When considering treatment options for LM with a depth-dependent modality aiming for tumor clearance, mean and maximum depths of involvement should be considered.

    更新日期:2018-09-26
  • A Systematic Review of Evidence-Based Treatments for Prurigo Nodularis
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-25
    Azam A. Qureshi, Laura E. Abate, Gil Yosipovitch, Adam J. Friedman

    Prurigo nodularis is a chronic dermatologic condition involving the development of multiple cutaneous nodules in the setting of intractable pruritus. Given emerging treatment options for this difficult-to-treat condition, a current review of therapeutics is needed. A systematic review was performed for clinical studies investigating prurigo nodularis treatment published from 1990 to present including at least 5 subjects. A total of 35 articles were assigned a level of evidence according to the Oxford Center for Evidence-based Medicine. All five studies investigating topical agents, including corticosteroids, calcineurin inhibitors, calcipotriol, and capsaicin, conveyed some beneficial effect with level of evidence 2b or higher. Six of eight reports investigating photo- and photochemotherapy achieved levels of evidence 2b or greater and showed good partial response rates. Thalidomide was studied by six reports providing evidence of good symptom response, but only two of which were rated level 2b or greater. Cyclosporine and methotrexate have demonstrated benefit in four combined studies, albeit with level four evidence. Pregabalin, amitriptyline, paroxetine, fluvoxamine, and neurokinin-1 receptor antagonists have demonstrated promising evidence in five level 2b studies. Higher-powered studies and additional randomized controlled trials are needed for evaluation of safe and efficacious systemic treatment options for prurigo nodularis.

    更新日期:2018-09-25
  • Global Epidemiology and Clinical Spectrum of Rosacea, Highlighting Skin of Color: Review and Clinical Practice Experience
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-19
    Andrew F. Alexis, Valerie D. Callender, Hilary E. Baldwin, Seemal R. Desai, Marta I. Rendon, Susan C. Taylor

    Among individuals with skin of color, rosacea has been reported less frequently than in those with white skin, but it is not a rare disease. In fact, rosacea may be underreported and underdiagnosed in populations with skin of color because of the difficulty of discerning erythema and telangiectasia in dark skin, as well as underestimation of the susceptibility of more highly pigmented skin to dermatologic conditions like rosacea whose triggers include sun exposure. Many people with skin of color who have rosacea may experience delayed diagnosis leading to inappropriate or inadequate treatment, greater morbidity, and uncontrolled, progressive disease with disfiguring manifestations, including phymatous rosacea. This paper reviews the epidemiology of rosacea in skin of color and highlights variations in the clinical presentation of rosacea across the diverse spectrum of patient populations affected. It presents strategies to aid in the timely diagnosis and effective treatment of rosacea in patients with skin of color, with an aim of promoting increased awareness of rosacea in these patients and reducing disparities in the management of their disease.

    更新日期:2018-09-20
  • A population-based registry study on relative survival from melanoma in Germany stratified by tumor thickness for each histological subtype
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-20
    Alicia Brunssen, Lina Jansen, Nora Eisemann, Annika Waldmann, Janick Weberpals, Klaus Kraywinkel, Andrea Eberle, Bernd Holleczek, Sylke Ruth Zeissig, Hermann Brenner, Alexander Katalinic,

    Background Differences in melanoma relative survival (RS) between histologies were discussed to be mainly caused by tumor thickness. Objective To investigate RS from melanoma, stratified by tumor thickness for each histological subtype, and identify survival trends. Methods Using cancer registry data on melanoma cases (ICD-10: C43.0-C43.9) diagnosed in Germany in 1997-2013, 5- and 10-year age-standardized RS stratified by histology and stratified or standardized by T-stage was estimated using standard and modelled period analyses. We restricted 10-year RS analyses to patients younger than 75 years. Results We analyzed 82,901 cases. Overall, 5- and 10-year RS was 91.7% and 90.8%, respectively. Prognosis worsened with increasing T-stage for all histologies but T-stage distribution varied substantially. Survival differences by histology were strongly alleviated after adjustment for T-stage, but remained significant. Overall, 5-year RS increased significantly by 3.8 percentage points between 2002-2005 and 2010-2013. This increase was no longer seen after adjustment for T-stage. Limitations Exclusion of cases due to missing information on T-stages, changes in the definition of T-stages, and lack of information on screening and treatment limit our analyses. Conclusion Differences in RS between histologies were strongly mediated by tumor thickness. Over time, melanoma RS increased due to changes in T-stage distribution.

    更新日期:2018-09-20
  • Clinical and dermoscopic features of cutaneous BAP1 inactivated melanocytic tumors: results of a multicenter case-control study by the International Dermoscopy Society (IDS)
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-20
    Oriol Yélamos, Cristián Navarrete-Dechent, Michael A. Marchetti, Tova Rogers, Zoe Apalla, Philippe Bahadoran, Nuria Blázquez-Sánchez, Klaus Busam, Cristina Carrera, Stephen W. Dusza, Arnaud de la Fouchardière, Gerardo Ferrara, Pedram Gerami, Harald Kittler, Aimilios Lallas, Josep Malvehy, José F. Millán-Cayetano, Kelly C. Nelson, Ashfaq A. Marghoob

    Background Multiple BAP-1 inactivated melanocytic tumors (BIMTs) have been associated with a familial cancer-syndrome involving germline mutations in BAP1. Objectives We sought to describe the clinical and dermoscopic features of BIMTs. Methods Retrospective, multicenter, case-control study. Participating centers clinical data, dermoscopic images, and histopathological data of biopsy-proven BIMTs. We compared the dermoscopic features between BIMTs and controls. Results The dataset consisted of 48 BIMTs from 31 patients (22 females, median age=37 years), and 80 controls. Eleven patients had a BAP1 germline mutation. Clinically, most BIMTs presented as pink, dome-shaped papules (n=24). Dermoscopically, we identified 5 patterns: structureless pink-to-tan with irregular eccentric dots/globules (n=14, 29.8%); structureless pink-to-tan with a peripheral vessels (n=10, 21.3%); structureless pink-to-tan (n=7, 14.9%); network with raised, structureless, pink-to-tan areas (n=7, 14.9%); and globular pattern (n=4, 8.5%). The structureless with eccentric dots/globules pattern and network with raised structureless areas pattern were only identified in BIMT and were more common in patients with BAP1 germline mutations (p<0.0001 and p=0.001, respectively) Limitations Small sample size, retrospective design, absence of germline genetic testing in all patients, inclusion bias towards more atypical-looking BIMTs. Conclusion Dome-shaped papules with pink-to-tan structureless areas and peripheral irregular dots/globules or network should raise suspicion for BIMT.

    更新日期:2018-09-20
  • A Provider Global Assessment Quality Measure for Clinical Practice for Inflammatory Skin Disorders
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-20
    , Alice Gottlieb, Nicole Salame, April W. Armstrong, Joseph F. Merola, Sylvia Parra, Junko Takeshita, Suephy C. Chen, John Latella, Marta Van Beek

    In our evolving healthcare system, dermatologists are increasingly being asked to prove the value of care they provide to patients with severe skin diseases. Current quality measures for inflammatory dermatoses have limited validity and feasibility. Through collaboration and a modified Delphi process, the International Dermatology Outcome Measures (IDEOM) group and American Academy of Dermatology (AAD) sought to reach consensus on a valid and feasible provider-assessed global disease severity metric to be incorporated into a quality measure for inflammatory dermatoses. To inform the modified Delphi process, a review of the literature was performed, and data was collected on current provider-assessed global disease severity metrics. Following literature review, 36 members of IDEOM and the AAD participated in the modified Delphi process to reach consensus on features of the metric. Psoriasis, atopic dermatitis, and acne achieved overwhelming consensus for inflammatory dermatoses that could be measured in a global disease severity metric. Consensus was also reached on the utilization of a 5-point ordinal scale with descriptors provided through referenced electronic platforms. Expert development of quality measures incorporating this metric and its inclusion in data collection platforms are critical to enabling dermatologists to prove the value of care provided to patients with severe inflammatory dermatoses.

    更新日期:2018-09-20
  • Clinical outcomes in high-risk squamous cell carcinoma patients treated with Mohs micrographic surgery alone
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-20
    Gerardo Marrazzo, John A. Zitelli, David Brodland

    Background There is little evidence to predict patient outcomes following the treatment of high risk cutaneous SCC (hrSCC) using Mohs micrographic surgery (MMS). Objective To report the rates of poor outcomes in patients with hrSCC treated by MMS alone, and determine if any specific clinical factors may be more predictive of these outcomes. Methods We conducted a retrospective chart review of all hrSCC patients treated in our clinic from October 2011 to December 2015. Results We identified 647 hrSCC tumors that met inclusion criteria. During the follow-up period, there were 19 local recurrences(LR) (2.9%), 31 nodal metastases(NM) (4.8%), 7 distant metastases(DM) (1.1%), and 7 disease-specific deaths(DSD) (1.1%). Two factors, poor differentiation and invasion beyond the subcutaneous fat, were positively associated with local recurrence, nodal metastasis, and disease-specific death through multivariate analysis. Conclusions Invasion beyond subcutaneous fat and poor histologic differentiation may carry a greater risk of poor outcomes than other factors in hrSCC. Mohs surgery alone provides excellent marginal control with low rates of local recurrence, nodal metastasis and disease-specific death.

    更新日期:2018-09-20
  • Predictors of Sentinel Lymph Node Positivity in Thin Melanoma Using the National Cancer Database
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-18
    Ruzica Z. Conic, Jennifer Ko, Giovanni Damiani, Pauline Funchain, Thomas Knackstedt, Alok Vij, Allison Vidimos, Brian R. Gastman

    Background Following melanoma excision, patients often receive sentinel lymph node biopsy (SLNB) for further staging. Limited data regarding predictors of SLNB positivity in thin melanoma are available. Objective To evaluate predictors of SLNB positivity in thin melanoma. Methods Patients with cutaneous melanoma, Breslow thickness ≤1.00 mm who received a SLNB were identified from the National Cancer Database in the period from 2004-2014 (n=9,186). Predictors of SLNB positivity were analyzed using logistic regression. Results In a multivariate analysis, patients with age less than 60 (p<0.001) and Breslow thickness >0.8mm (p=0.03) were at increased risk for positive SLN. Moreover, on multivariate analysis, presence dermal mitoses increased odds of SLN positivity by 95% (OR 1.95, 95%C 1.53-2.5, p<0.001), ulceration by 63% (OR 1.63, 95%CI 1.21-2.18, p<0.001) and Clark level IV-V by 48% (OR 1.48, 95%CI 1.19-1.85). Patients without ulceration but with dermal mitoses had 92% (OR 1.92, 95%CI 1.5-2.48, p<0.001) increased SLN positivity. Limitations Limited survival data available. Conclusions Younger age, Breslow thickness >0.8 mm, presence of dermal mitoses, ulceration and Clark level IV-V are positive predictors of positive SLN. While the new AJCC system has removed dermal mitotic rate from staging, continued evaluation of dermal mitotic rate could be valuable for guiding surgical decision making about SLNB.

    更新日期:2018-09-19
  • Drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) severity score: A useful tool for assessing disease severity and predicting fatal cytomegalovirus disease
    J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-09-18
    Yoshiko Mizukawa, Kazuhisa Hirahara, Yoko Kano, Tetsuo Shiohara

    Background The prognosis of drug-induced hypersensitivity syndrome (DiHS)/drug reaction with eosinophilia and systemic symptoms (DRESS) is highly unpredictable. Severe complications, either related or unrelated to cytomegalovirus (CMV) reactivation, are highly probable cause of death. Objectives The aim was to establish a scoring system for DiHS/DRESS that can be used to monitor severity, predict the prognosis, and to stratify the risk of developing CMV disease and complications. Methods A retrospective analysis of 55 patients with DiHS/DRESS was performed. A composite score was created using clinical data. DiHS/DRESS patients were also stratified into three groups based on the scores to predict the risk of CMV reactivation and complications. Results This scoring system made it possible to predict CMV disease and complications. Scores ≥ 4 were associated with the later development of CMV disease and complications, while no patients with scores < 4 developed complications. Limitation A single-institutional study with a relatively small patient cohort, lacking a validation cohort. Conclusions Our scoring system may be useful for predicting CMV-related complications and early intervention with anti-CMV agents should be considered in patients with scores ≥4 and/or evidence of CMV reactivation.

    更新日期:2018-09-19
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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