Stratifying clinical complexity of dermatology outpatient visits: validation of a pilot instrument J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-14 Rajini K. Murthy, Benjamin J. Kahn, Chao Zhang, Suephy C. Chen
The United States population is aging and increasing in comorbidity, and patient care is accordingly growing increasingly complex. Complexity impacts patterns of resource consumption, adverse event and medical error rates, health-related quality of life, physician burnout, and more. Tools capturing complexity can be of benefit in the modern value-based reimbursement landscape and have been well-studied in specialties other than dermatology. In this paper, we describe the validation of a tool specific to outpatient dermatologic care that captures the complexity of clinical visit medical decision-making. We performed a cross-sectional retrospective study to determine the inter-rater reliability and face validity of the tool. By objectively grading a clinical encounter based on clinical complexity, there is increased awareness of opportunities to improve clinical care and the allocation of healthcare costs and resources within the dermatologic community can be better assessed.
Improving Non-attendance Rates Among Pediatric Patients with Medicaid or Private Insurance J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-13 Sofia B. Chaudhry, Elaine Siegfried, Umar A. Sheikh, Cassandra Simonetta, Niraj Butala, Eric Armbrecht
Background Access to dermatologists by Medicaid-insured patients is low. Higher clinic non-attendance (NA) among Medicaid-insured patients may impact provider decisions to accept these patients. Objectives To determine the effect of different scheduling policies on the NA among children seen at a pediatric dermatology clinic. Methods This retrospective review compared NA for three different scheduling policies implemented over 3 consecutive years. Scheduling policies utilized were a first-available open scheduling, a 2-week in advance and a 4-week in advance scheduling policy. Subset analysis was performed by clinic location and insurance type. Results The interval between scheduling and appointment date was directly related to NA rates, with higher rates for Medicaid-insured, compared to privately-insured patients. Open scheduling was associated with a 37% NA rate for Medicaid-insured, compared to 18% for privately-insured patients. A 4-week scheduling policy significantly decreased the Medicaid NA rate to 19%, compared to 7% for privately-insured patients. A 2-week policy further decreased the NA rate to 11% for Medicaid and 4% for privately insured patients. Limitations Retrospective study that could not track same-day cancellations. Conclusions Decreasing the interval between scheduling and appointment dates can significantly decrease NA. This strategy may help dermatologists incorporate more Medicaid-insured patients into their practice.
Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-13 Craig A. Elmets, Craig L. Leonardi, Dawn M.R. Davis, Joel M. Gelfand, Jason Lichten, Nehal N. Mehta, April W. Armstrong, Cody Connor, Kelly M. Cordoro, Boni E. Elewski, Kenneth B. Gordon, Alice B. Gottlieb, Daniel H. Kaplan, Arthur Kavanaugh, Dario Kivelevitch, Matthew Kiselica, Neil J. Korman, Daniela Kroshinsky, Alan Menter
Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence.
Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-13 Alan Menter, Bruce E. Strober, Daniel H. Kaplan, Dario Kivelevitch, Elizabeth Farley Prater, Benjamin Stoff, April W. Armstrong, Cody Connor, Kelly M. Cordoro, Dawn M.R. Davis, Boni E. Elewski, Joel M. Gelfand, Kenneth B. Gordon, Alice B. Gottlieb, Arthur Kavanaugh, Matthew Kiselica, Neil J. Korman, Daniela Kroshinsky, Craig A. Elmets
Psoriasis is a chronic, inflammatory multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations based on the available evidence. The treatment of psoriasis with biologic agents will be reviewed, emphasizing treatment recommendations and the role of the dermatologist in monitoring and educating patients regarding benefits as well as associated risks.
Cross cultural validation of a short-form of the Vitiligo Impact Patient scale (VIPs) J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-11 Khaled Ezzedine, Maggi Ahmed, Andrea Tovar-Garza, Carla Hajj, Maxine Whitton, Amit Pandya, Saad Altalhab, Julien Seneschal, John Harris, Charles Taieb
Backgroundthere is a lack for short forms questionnaire evaluating the burden of Vitiligo according to skin phototypeObjectiveTo develop and validate a 12-item short-form of the Vitiligo Impact Patient Scale (VIPs) that takes into account skin phototype.MethodsMulticentric, prospective, cross-sectionnal study conducted in France (Créteil and Bordeaux) and the US (Worcester, Massachusetts and Dallas, Texas).ResultsIn total, 891 patients completed the questionnaire. Of these, 509 patients belonged to the French development sample, i.e. 313 with dark skin (DS) (phototype IV to VI) and 196 with fair skin (FS) (phototype I to III). The American validation sample comprised 382 patients, i.e. 113 DS and 269 FS. There was a very high correlation between VIPs-FS and its 12-item short form, VIPs-12-FS, in both the development and validation samples (respectively rho=0.96, pvalue <0.0001 and rho=0.98, pvalue <0.0001). Similarly, the correlations between VIPs-DS and the short form, VIPs-12-DS, in both the development and validation samples were very high (respectively rho=0.95, pvalue <0.0001 and rho=0.96, pvalue <0.0001).LimitationsResponsiveness of the 12-item short forms should be confirmedConclusionsThese data enabled the development and validation of 12-item short forms of the VIPs questionnaires for fair (VIPs-12-FS) and dark (VIPs-12-DS) skin.
Are there distinct clinical and pathological features distinguishing Idiopathic from Drug-Induced Subacute Cutaneous Lupus Erythematosus? A European retrospective multicenter study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-11 Federica Guicciardi, Laura Atzori, Angelo Valerio Marzano, Simona Tavecchio, Giampiero Girolomoni, Chiara Colato, Axel Patrice Villani, Jean Kanitakis, Christina Mitteldorf, Rosanna Satta, Bernard Cribier, Laurence Gusdorf, Maria Teresa Rossi, Piergiacomo Calzavara-Pinton, Isabel Bielsa, Maria Teresa Fernandez-Figueras, Werner Kempf, Giorgio Filosa, Franco Rongioletti
BackgroundClinical and pathological criteria to distinguish drug-induced subacute lupus erythematosus (DI-SCLE) from idiopathic (I-SCLE) are controversial.ObjectiveAim of the survey was a retrospective analysis of a consistent number of iatrogenous and idiopathic SCLE cases, by means of clinical and histopathological investigation.MethodsEleven European University Dermatology Units collected all diagnosed cases from January 2000 to December 2016. Board certified dermatopathologists reviewed the histopathologic specimens. Statistical analysis included Student’s t-test, exact test of goodness-of-fit, Fisher’s test, Cochran-Mantel-Haenszel for repeated measures.ResultsOut of 232 patients, 67 (29%) belonged to the DI-SCLE group. Patients with DI-SCLE were significantly older and complained more systemic symptoms than those with I-SCLE. No statistical differences were found for presentation pattern or serology, while histopathology showed for I-SCLE a significant association of mucin deposition (p=0, 000083) and direct immunofluorescence positivity for granular IgM, C3 deposits on the basement membrane zone (p=0, 0041), and of leukocytoclastic vasculitis (p=0, 0018) for DI-SCLE.LimitationsThis is a retrospective study.ConclusionAn integrated clinical and immunopathological evaluation is useful to differentiate I-SCLE from DI-SCLE. Older age at onset and more frequent systemic symptoms characterize DI-SCLE. Mucin deposition and immunofluorescence findings are found in I-SCLE, while leukocytoclastic vasculitis in DI-SCLE.
Retrospective single-center study evaluating clinical and dermoscopic features of longitudinal melanonychia, ABCDEF criteria, and risk of malignancy J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-11 Dayoung Ko, Clara Oromendia, Richard Scher, Shari R. Lipner
BackgroundLongitudinal melanonychia (LM) is a common finding in clinical practice; however, it has a broad differential diagnosis, including subungual melanoma (SUM), which can be difficult to distinguish clinically from benign conditions.ObjectiveTo identify clinical and dermoscopic features that distinguish histopathologically diagnosed SUM from benign LM and to evaluate the validity of the ABCDEF criteria among patients on whom a biopsy was performed.MethodsRetrospective cohort study of consecutive patients who underwent nail matrix biopsy for LM at a single center from January 2011 to November 2017.ResultsA total of 84 cases in which biopsy was performed (8 cases of SUM and 76 benign) were included in the analysis. The patients with SUM were younger (P = .011), had their melanonychia longer (P = .017), and presented with a wider band (P = .002) and greater width percentage (P < .001) than patients with benign LM did. The number of ABCDEF criteria met did not differ between the groups.LimitationsRetrospective single-center study; patients who did not undergo biopsy could not be studied.ConclusionsIn the cases of LM in which biopsy was performed, SUM usually presented with a wider band and greater width percentage than benign LM did. The number of ABCDEF criteria met was not different between the groups. Because many of the clinical and dermoscopic signs were less consistent, biopsy should be performed in cases with any concerning band, especially in those with width percentage higher than 40%.
“Platelet-rich plasma and its utility in the treatment of acne scars - A systematic review” J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-08 Michael J. Hesseler, Nikhil Shyam
The field of dermatology has seen numerous therapeutic innovations in the past decade with platelet-rich plasma recently garnering significant interest in acne scarring. This review consolidates the available evidence of platelet rich plasma for the practicing dermatologist and evaluates the current evidence up to May 31, 2018. A search was conducted in the PubMed database for “platelet rich plasma” or “platelet releasate” or “platelet gel” or “PRP” and “dermatology” or “skin” or “hair” or “cutaneous” with thirteen articles meeting the inclusion criteria. The quality of each individual study was evaluated and levels of evidence were assigned according to the Centre for Evidence-Based Medicine, Oxford. This review reveals that activated, leukocyte and platelet-rich plasma in combination with fractional ablative laser treatment, administered in 2-3 sequential sessions 1 month apart, improves the appearance of acne scars. The evidence for the use of platelet-rich plasma with microneedling is less supportive. Due to the heterogeneity of studies and widely variable outcome measures, comparison between platelet-rich plasma treatments and subsequent statistical analysis could not be performed. While these studies use various subjective and objective evaluation methods, the addition of platelet-rich plasma provides improvements in acne scarring, higher patient satisfaction and decreased post-procedure downtime.
Overall and Subgroup Prevalence of Pyoderma Gangrenosum Among Patients with Hidradenitis Suppurativa: a population based analysis in the United States J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-07 R. Tannenbaum, A. Strunk, A. Garg
Background Hidradenitis suppurativa (HS) and pyoderma gangrenosum (PG) are reported to coexist, although prevalence of PG among HS patients has not been systematically evaluated. Objective To evaluate PG prevalence among HS patients. Methods Cross-sectional analysis of adults with PG among HS and non-HS patients using electronic health records data from a population-based sample of 55 million patients. Results Prevalence of PG among 68,232 HS patients was 0.18% (125/68,232), compared to 0.01% (1,835/31,435,166) among those without HS (p<0.0001). Prevalence was markedly higher among HS patients having Crohn’s disease (CD) (3.68%), compared to HS patients without CD (0.12%). Odds of having PG was 21.14 (95% CI 17.51-25.51) times greater among HS patients compared to patients without HS. HS patients with CD had 12.38 (95% CI 9.15-16.74) times the odds of having PG compared to non-HS patients with CD. Among patients without CD, those with HS had 26.51 (95% CI 21.07-33.36) times the odds of having PG compared to non-HS patients. Limitations We could not establish HS phenotype among those having coexistent PG, nor could we distinguish syndromic from non-syndromic cases. Conclusion HS patients have increased prevalence of PG, regardless of CD status. Painful ulcerations among HS patients warrant additional evaluation for PG.
Comparative Effectiveness Study of Face-to-Face and Teledermatology Workflows for Diagnosing Skin Cancer J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-07 S. Marwaha, H.B. Fevrier, S.E. Alexeeff, E. Crowley, M. Haiman, N. Pham, M.J. Tuerk, D. Wukda, M. Hartmann, L.J. Herrinton
Background The effectiveness and value of teledermatology and face-to-face workflows for diagnosing lesions are not adequately understood. Objective We compared the risks of biopsy and cancer diagnosis among two face-to-face workflows (direct referral, roving dermatologist) and four teledermatology workflows. Methods Retrospective study of 59,279 primary care patients with a lesion, January-June 2017. Results One teledermatology workflow achieved high resolution images using a dermatoscope-fitted digital camera, picture archiving and communication system, and image retrieval to a large computer monitor (in contrast to a smartphone screen). Compared with direct referral, this workflow was associated with 9% greater probability of cancer detection (95% confidence interval [CI] 2% to 16%); 4% lower probability of biopsy (relative risk [RR] 0.96; CI 0.93-0.99); and 39% fewer face-to-face visits (RR 0.61; CI, 0.57-0.65). Other workflows were less effective. Limitations Differing proficiencies across teledermatology workflows and selection of patients for direct referral could have caused bias. Conclusion Implementation is critical to the effectiveness of teledermatology
Abnormal T-cell phenotype in episodic angioedema with hypereosinophilia (Gleich’s syndrome): frequency, clinical implication and prognosis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-07 Noémie Abisror, Arsène Mekinian, Agnès Dechartres, Matthieu Groh, Alice Berezne, Nicolas Noel, Chafika Morati, Julien Haroche, Mathilde Hunault-Berger, Christian Agard, Felix Ackermann, Loïk Geffray, Pierre-Yves Jeandel, Sébastien Trouillier, Thomas Quemeneur, Jean-François Dufour, Isabelle Lamaury, François Lhote, Jean Emmanuel Kahn
Background Episodic Angioedema with eosinophilia (EAE, Gleich’s syndrome) is a rare disorder consisting of recurrent episodes of angioedema, hypereosinophilia and frequent elevated serum Immunoglobin M. Methods We conducted a retrospective multicenter nationwide study regarding the clinical spectrum and therapeutic management of patients with EAE in France. Results Thirty patients were included with a median age at diagnosis of 41 years [5-84]. The median duration of each crisis was 5.5 days [1-90] with swelling affecting mainly the face and the upper limbs. Total serum IgM levels were increased in 20 patients (67%). Abnormal T-cell immunophenotypes were detected in 12 patients (40%) among which 5 (17%) showed evidence of clonal TCR γ gene rearrangement. Median follow-up duration was 53 months [31-99]. The presence of an abnormal T-cell population was the sole factor associated with a shorter time to flare (hazard ratio 4.15 [CI 95% 1.18-14.66; p=0.02). At last follow-up, 3 patients (10%) were able to withdraw all treatments and 11 (37%) were in clinical and biological remission with less than 10 mg of daily prednisone. Conclusion EAE is a heterogeneous condition that encompasses several disease forms. Although patients usually respond well to glucocorticoids, those with evidence of abnormal T-cell phenotype have a shorter time to flare.
Vancomycin-associated Drug-Induced Hypersensitivity Syndrome (DIHS) J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-06 Lauren M. Madigan, Lindy P. Fox
Background While hypersensitivity reactions are well-characterized for certain medications, vancomycin-associated drug-induced hypersensitivity syndrome (DIHS), or drug reaction with eosinophilia and systemic symptoms (DRESS), has yet to be defined. Objective To better define the clinical phenotype of vancomycin-associated DIHS. Methods A retrospective case series was conducted over an 8-year period at a single, academic institution. Twenty-nine patients with definitive DIHS/DRESS were identified, of which four cases were attributed to vancomycin. A literature review was performed which identified 28 additional cases of vancomycin-induced DIHS. Vancomycin-associated acute interstitial nephritis (AIN) was also reviewed to detect further, previously uncharacterized cases of systemic hypersensitivity. This yielded 11 additional cases. Results In this literature review and retrospective series, the incidence of renal dysfunction among vancomycin-induced cases (75% and 68% of cases in the series and literature respectively) was notably higher than the overall reported incidence in DIHS (10-40%). The degree of renal impairment was also significantly increased in the retrospective series (median 4.98-fold change in baseline creatinine vs. 2.25-fold increase in non-vancomycin associated cases; p = 0.011). Limitations The principal limitation of this study is the small sample size. Other notable limitations include the retrospective nature of the study and absence of confirmatory renal biopsies. Conclusion While the current understanding of DIHS/DRESS is imperfect, our findings suggest that vancomycin-induced cases present with a unique phenotype characterized by a higher burden of renal involvement.
Coffee, tea, caffeine, and risk of non-melanoma skin cancer in a Chinese population: The Singapore Chinese Health Study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-05 Choon Chiat Oh, Aizhen Jin, Jian-Min Yuan, Woon-Puay Koh
Background While epidemiological studies in populations of European-descent suggest possible chemo-protective effect of caffeine against non-melanoma skin cancer (NMSC), data in Asian populations are lacking. Objectives We examined the relations between coffee, tea and caffeine consumption, and NMSC risk among Chinese in Singapore. Methods We used data from the Singapore Chinese Health Study, a prospective cohort of 63,257 men and women aged 45–74 years at recruitment from 1993 to 1998. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox proportional hazard models. Results Coffee drinking was associated with reduced NMSC risk in a dose-dependent manner (P trend<0.0001); compared with those who drank coffee less than weekly, in those who drank ≥3 cups/day, HRs (95% CIs) were 0.54 (0.31-0.93) for risk of basal cell carcinoma, and 0.33 (0.13-0.84) for risk of squamous cell carcinoma. Compared with non-drinkers, daily drinkers of black tea also had reduced NMSC risk (HR=0.70; 95% CI=0.52-0.94). Caffeine intake reduced NMSC risk in a stepwise manner (P trend=0.0025); subjects with caffeine intake ≥400 mg/day had the lowest risk (HR=0.59; 95% CI=0.34-1.04). Conclusion Consumption of caffeinated drinks such as coffee and black tea may reduce the risk of NMSC among Chinese.
Pigments in American Tattoo Inks and their Propensity to Elicit Allergic Contact Dermatitis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-05 Walter Liszewski, Erin M. Warshaw
Background Tattoos have become increasingly common in the United States. Historically, tattoo inks were comprised of metallic pigments which had the potential to cause allergic contact dermatitis. Data have been lacking on the current use of these pigments in tattoo ink. Objective Identify pigments currently used in tattoo inks manufactured in or sold by wholesalers in the United States and investigate cases of allergic contact dermatitis to these pigments. Methods Using specific keywords, an internet search was performed. Pigment information listed in tattoo product inserts was collated and evaluated. Results 1,416 unique inks were surveyed. The average bottle of ink contained 3.0 pigments. A total of 44 distinct pigments were identified, of which 10 contained metallic pigments including iron, barium, zinc, copper, molybdenum, and titanium. The remaining 34 pigments contained carbon, azo, diketopyrrolopyrrole, quinacridone, anthraquinone, dioxazine, or quinophthalone dyes. A literature search revealed that 11 of the 44 (25%) pigments had been suspected to cause contact dermatitis. Five were confirmed by patch testing. Conclusions These findings highlight the diversity of pigments currently used in tattoos. Relatively few inks contained metallic pigments to which allergic contact dermatitis has historically been attributed. Patch test clinicians should be aware of these new pigments.
Early Detection of Acral Melanoma: A Review of Clinical, Dermoscopic, Histopathologic, and Molecular Characteristics J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-05 Claudia C. Darmawan, Gwanghyun Jo, Sara E. Montenegro, Yoonjin Kwak, Lee Cheol, Kwang Hyun Cho, Je-Ho Mun
Acral lentiginous melanoma is a distinct subtype of melanoma on acral skin. Patient presentation at later stages as well as delayed diagnosis by physicians contribute to a worse associated prognosis and survival rate. Despite our progress on understanding the key features of this disease, the diagnosis of early stage acral melanoma is still challenging. It is essential to integrate clinical, dermoscopic, and histological findings in the diagnosis of acral lentiginous melanoma. In addition, molecular studies can be helpful. In this review, we summarized our current understanding of this disease entity from articles that have been published between 1969 and 2018. We outline clinical and dermoscopic features as well as pathologic and molecular findings of acral melanoma and present an algorithm for diagnosis. Understanding and integrating these characteristics may assist clinicians in the early detection of acral melanomas.
Estimating CDKN2A mutation carrier probability among global familial melanoma cases using GenoMELPREDICT J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-05 Nicholas J. Taylor, Nandita Mitra, Lu Qian, Marie-Françoise Avril, D. Timothy Bishop, Brigitte Bressac-de Paillerets, William Bruno, Donato Calista, Francisco Cuellar, Anne E. Cust, Florence Demenais, David E. Elder, Anne-Marie Gerdes, Paola Ghiorzo, Alisa M. Goldstein, Thais C. Grazziotin, Nelleke A. Gruis, Johan Hansson, Peter A. Kanetsky
Background Although rare in the general population, highly penetrant germline mutations in CDKN2A are responsible for 5-40% of melanoma cases reported in melanoma-prone families. We sought to determine whether MELPREDICT was generalizable to a global series of melanoma families and whether performance improvements can be achieved. Methods 2,116 familial melanoma cases were ascertained by the international GenoMEL Consortium. We recapitulated the MELPREDICT model within our data (GenoMELPREDICT) to assess performance improvements by adding phenotypic risk factors and history of pancreatic cancer. We report areas under the curve (AUC) with 95% confidence intervals (CI) along with net reclassification indices (NRI) as performance metrics. Results MELPREDICT performed well (AUC=0.752; 95%CI: 0.730, 0.775), and GenoMELPREDICT performance was similar (AUC=0.748; 95% CI: 0.726, 0.771). Adding a reported history of pancreatic cancer yielded discriminatory improvement (p<0.0001) in GenoMELPREDICT (AUC=0.772; 95%CI: 0.750, 0.793; NRI=0.40). Including phenotypic risk factors did not improve performance. Conclusion The MELPREDICT model functioned well in a global dataset of familial melanoma cases. Adding pancreatic cancer history improved model prediction. GenoMELPREDICT is a simple tool for predicting CDKN2A mutational status among melanoma patients from melanoma-prone families and can aid in counselling these patients towards genetic testing or cancer risk counselling.
Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: a dermatologist and nail expert group consensus J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-05 Dimitrios Rigopoulos, Robert Baran, Soumiya Chiheb, Carlton Ralph Daniel, Nilton Di Chiacchio, Stamatis Gregoriou, Chander Grover, Eckart Haneke, Matilde Iorizzo, Marcel Pasch, Bianca Maria Piraccini, Phoebe Rich, Bertrand Richert, Natalia Rompoti, Adam I. Rubin, Archana Singal, Michela Starace, Antonella Tosti, Martin Zaiac
Nail involvement in psoriasis is common, and the severity of it does not always parallel the intensity of cutaneous disease. We created a consensus group, of which the aim was to provide practical recommendations for the treatment of nail psoriasis in patients without skin psoriasis, or with mild skin lesions with no indication for a systemic treatment. This collaborative process was conducted by an international panel of dermatologists with special expertise in nail disorders, using a formal consensus methodology. During this process, the panel strived to establish an agreement regarding the definition of nail psoriasis, the severity of nail psoriasis, and treatment response. Treatment recommendations are provided regarding nail psoriasis severity and matrix or bed involvement. ”Few-nail” disease was considered as nail psoriasis affecting 3 or less nails. In the case of matrix involvement only, intralesional steroid injections were considered the treatment of choice. Topical steroids alone or in combination with topical vitamin D analogues were suggested for nail psoriasis limited to the nail bed. For the systemic treatment of nail psoriasis acitretin, methotrexate, cyclosporine, small molecules, and biologics can be employed.
Secukinumab for moderate to severe palmoplantar pustular psoriasis: Results of the 2PRECISE study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-01 Ulrich Mrowietz, Hervé Bachelez, A. David Burden, Michael Rissler, Christian Sieder, Roberto Orsenigo, Kamel Chaouche-Teyara
Background Palmoplantar pustular psoriasis (PPP) is a debilitating disease of the palms and/or soles that is resistant to treatment. Secukinumab, an anti-IL-17A monoclonal antibody, is highly efficacious in the treatment of moderate to severe psoriasis. Objective The primary objective was ppPASI75 response with secukinumab at Week 16 vs. placebo (2.5% significance level). Methods 2PRECISE was a phase 3b multicenter, randomized, double-blind, placebo-controlled, parallel-group study comparing secukinumab 300 mg (n=79) and 150 mg (n=80) to placebo (n=78) in subjects with moderate to severe PPP over 52 Weeks. Results The primary endpoint was not met. At Week 16, 26.6% of subjects with secukinumab 300 mg achieved ppPASI75 vs.. 14.1% with placebo (P=0.0411) [OR: 2.62; 95% CI: 1.04, 6.60]. At Week 52, 41.8% of subjects with secukinumab 300mg had ppPASI75. More DLQI 0/1 responses were achieved with secukinumab 300 mg (13.0%) vs. placebo (4.3%) at Week 16. At Week 52, 43.1% of subjects receiving secukinumab 300 mg had DLQI 0/1. No unexpected adverse events were observed. Limitations Small sample size and characteristics of PPP disease course. Conclusion PPP patients treated with secukinumab 300 mg showed benefit in ppPASI75 responses over 52 weeks and improved quality of life.
Follicular mucinosis in patients with hematologic malignancies other than mycosis fungoides: A clinicopathologic study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-02-01 Shamir Geller, Christian J. Gomez, Patricia L. Myskowski, Melissa Pulitzer
Background Follicular mucinosis (FM), defined by mucin accumulation within follicular epithelium, may occur in mycosis fungoides (MF). FM without MF is occasionally reported in systemic hematologic malignancies, and may be diagnostically challenging. Objective To describe clinicopathological characteristics of FM in patients with hematologic malignancies other than MF. Methods Clinical data and histopathology were analyzed in patients with FM and hematologic malignancies diagnosed between 1994 and 2017. Results Eighteen patients with FM and systemic hematologic malignancies without cutaneous T-cell lymphoma (CTCL) were identified, nine of them were post hematopoietic stem cell transplantation (HSCT). No non-CTCL associated FM cases (n=46, 37 biopsies) developed CTCL during mean follow-up of 4.3 years. Of CTCL associated with FM (n=44, 31 biopsies) MF was the most common subtype (n=38), although other CTCLs were identified. FM in patients with non-CTCL hematologic malignancies differed clinically from MF-associated FM, presenting most frequently with erythematous papules (P < .0001), without plaques (P <.0001), without alopecia (P = .001), and without histopathologically identified epidermal exocytosis (P = .013). Limitations A retrospective study in a single cancer center. Conclusions FM can present in systemic hematologic malignancies, including post-HSCT. Papular lesional morphology and histopathology may help to distinguish these cases from MF.
The Etiology, Diagnosis and Management of Hyperhidrosis: A Comprehensive Review. Part I. Etiology and Clinical Work-Up J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-31 Shiri Nawrocki, Jisun Cha
Hyperhidrosis (HH) is a dermatologic disorder defined by sweat production beyond the thermoregulatory requirements. Clinically, HH is diagnosed when excess sweating creates significant emotional, physical, or social discomfort, causing negative impact on the patient’s quality of life. Existing data imply that this condition may affect at least 4.8% of the US population. The etiology of HH may stem from autonomic nervous system complex dysfunction, resulting in neurogenic overactivity of otherwise normal eccrine sweat glands. Alternatively, HH may be a result of aberrant central control of emotions. This condition is categorized as primary or secondary HH. Approximately 93% of patients with HH have primary HH, of whom >90% have a typical focal and bilateral distribution affecting the axillae, palms, soles, and craniofacial areas. Secondary HH presents in a more generalized and asymmetric distribution and is generated by various underlying diseases or medications. Secondary causes of HH need to be excluded prior to diagnosing primary HH.
Tissue-sparing properties of Mohs micrographic surgery for infiltrative basal cell carcinoma J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-31 Marloes S. van Kester, Jelle J. Goeman, Roel E. Genders
Background Mohs micrographic surgery (MMS) should lead to tissue sparing of healthy skin compared to standard surgical excision, because smaller surgical margins are used. Objective To quantify the tissue-sparing properties of MMS in primary basal cell carcinoma (BCC) with an infiltrative growth pattern. Methods A prospective study including 256 primary BCC with an infiltrative growth pattern was performed. Tumor sizes were measured in two perpendicular directions. Surface defect areas after MMS were measured. The suspected defect surface area with standard excision using a 5 mm margin was calculated. The primary outcome of this study was the size of the defect surface area spared with MMS compared to the calculated defect surface area with a standard excision. Results Median tumor size was 71 mm2, median defect size after MMS was 154 mm2. Median defect size calculated for standard surgical excision was 298 mm2. We show that MMS had a 46.4% tissue sparing effect compared to standard surgical excision of BCC with an infiltrative growth pattern (confidence interval 43.4-49.1.4%, p-value <0.001). Limitations Single-center study design. Lack of randomized control group, due to ethical reasons. Conclusion 46% tissue sparing can be reached for primary BCC with an infiltrative growth pattern using MMS.
Extremity nevus count is an independent risk factor for basal cell carcinoma and melanoma, but not squamous cell carcinoma J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-31 Erin X. Wei, Xin Li, Hongmei Nan
Background The presence of nevi portends an increased risk for melanoma. Objective We sought to examine the association between extremity nevus count and the risk of melanoma and keratinocyte cancers. Methods We evaluated prospective cohorts of 176,317 women (the Nurses' Health Study, 1986-2012 and the Nurses’ Health Study 2, 1989-2013) and 32,383 men (Health Professionals Follow-up Study, 1986-2012). Information on nevus count (none, 1-5, 6-14, ≥15) on the extremity was collected at baseline. Results There were 1704 incident cases of melanoma, 2296 incident cases of squamous cell carcinoma, and 30,457 incident cases of basal cell carcinoma, with a total of 4,655,043 person-years for melanoma and 4,267,708 person-years for keratinocyte cancers. The presence of an extremity nevus was associated with an increased risk of melanoma in all anatomic areas and increased risk of basal cell carcinoma (BCC). Individuals with ≥15 nevi had the highest risk of melanoma and BCC compared to those without any extremity nevi (melanoma hazard ratio 2.79 [95% confidence interval 2.04-3.83]; BCC HR 1.40 [95% confidence interval 1.32-1.49]). No significant association was observed for squamous cell carcinoma. Limitations Limitations of our study included self-reported nevus count and detection bias. Conclusions Extremity nevus count is a helpful clinical marker in risk-stratifying individuals for BCC and melanoma on all body sites.
The Etiology, Diagnosis and Management of Hyperhidrosis: A Comprehensive Review. Part II. Therapeutic Options J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-31 Shiri Nawrocki, Jisun Cha
Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is considered to be the primary remedy for palmar and plantar HH. Botulinum toxin (BTX) injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.
Patients Believe Cosmetic Procedures Affect Their Quality of Life: An Interview Study of Patient-Reported Motivations J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-31 Abigail Waldman, Amanda Maisel, Alexandra Weil, Sanjana Iyengar, Kaitlyn Sacotte, Jake M. Lazaroff, Sasha Kurumety, Sara L. Shaunfield, Kelly A. Reynolds, Emily Poon, June K. Robinson, Murad Alam
Background While treatments to address cosmetic concerns are common, patients’ self-reported motives for considering such procedures have not been systematically explored. Objective To develop a framework of categories to describe patient’s self-reported motivations for undergoing minimally invasive cosmetic procedures. Methods Face-to-face, semi-structured patient interviews were conducted with adult participants who had received or were considering minimally invasive cosmetic dermatologic procedures. A qualitative constant comparative approach was employed to analyze interview transcripts, yielding themes and subthemes. Results 30 interviews were completed. Most patient-reported motivations for cosmetic procedures could be subsumed under eight general categories (themes): 1) mental and emotional health, 2) cosmetic appearance, 3) physical health, 4) work/school success, 5) social well-being, 6) cost/convenience, 7) procedural perceptions, and 8) timing of treatment. Many individual motivations in these categories were unrelated to desire for physical beauty. In particular, participants wanted to avoid being self-conscious, enhance confidence, reduce time and expense required to conceal physical imperfections, and be perceived as capable at work. Limitations Only English-speaking patients in the U.S. were interviewed. Conclusion Patient-reported motivations for cosmetic procedures mostly pertained to physical and psychosocial well-being. Indeed, a desire for improved cosmetic appearance comprised only one of the 8 themes revealed through patient interviews.
Role of imaging in low grade cutaneous B-cell lymphoma presenting in the skin J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 M.K. Kheterpal, J. Dai, S. Geller, M. Pulitzer, Andy Ni, P.L. Myskowski, A. Moskowitz, J. Kim, E.K. Hong, S. Fong, R.T. Hoppe, Y.H. Kim, S.M. Horwitz
Background Whole body imaging is current standard of care for staging all patients presenting with skin lesion(s) of B-cell lymphomas (BCL), regardless of skin disease extent, however supporting data are lacking. Objective To determine the clinical utility of imaging in detection of systemic involvement in low grade cutaneous B-cell lymphoma presenting in the skin. Methods Retrospective cohort analysis of patients presenting with cutaneous lesions of BCLs at Memorial Sloan Kettering Cancer Center (MSKCC) and Stanford University (SU) from 1997-2016. Results At initial staging, of the 522 patients (306 marginal zone and 216 follicle-center cell histology), extracutaneous disease was noted in 3.6% and 8.8% of patients with MZL and FCL histology respectively. In patients with systemic involvement, imaging alone identified 81.8% (9/11) of MZL and 89.4% of follicular lymphoma (FL) cases. In primary cutaneous MZL (pc-MZL) and primary cutaneous follicle center lymphoma (pc-FCL), 1.7% and 3.0% subsequently developed extracutaneous involvement (median follow-up of 45 and 47 months respectively). Limitations Retrospective nature of this study. Conclusions Imaging is effective in identifying the patients with systemic involvement in indolent BCLs presenting in the skin, however incidence is low. After negative initial staging, pc-MZL patients may be followed clinically without routine imaging.
Predictors of time to relapse following ustekinumab withdrawal in patients with psoriasis who had responded to therapy: An eight-year multicenter study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Hsien-Yi Chiu, Rosaline Chung-yee Hui, Tsen-Fang Tsai, Yang-Ching Chen, Nien-Feng Chang Liao, Po-Hua Chen, Po-Ju Lai, Ting-Shun Wang, Yu-Huei Huang
Background Data on predictors and time to relapse in psoriasis patients discontinuing therapy in a real world setting are scarce. Objective To investigate predictors of relapse after withdrawal of ustekinumab in psoriasis patients. Method This study screened 500 psoriasis patients who received ustekinumab (669 treatment episodes (TEs)) between 2011 and 2018. Overall, 202 patients (304 TEs), who had responded to therapy and were withdrawn from ustekinumab treatment, were included. Results The cumulative probabilities of relapse-free at 6 months, 12 months, 18 months, 24 months and 36 months of withdrawal from ustekinumab treatment was 49.3%, 12.6%, 5.3%, 4.7% and 1.6%, respectively. Multivariate regression analyses with a generalized estimating equation showed that after adjustments, biologics-naive, the maximum Psoriasis Area and Severity Index (PASI) improvement on ustekinumab, time to achieve PASI-50 after initiation of ustekinumab, family history of psoriasis, chronic kidney disease, and immunosuppressants use while off ustekinumab were significant predictors of time to relapse following ustekinumab discontinuation. Limitation Non-randomized allocation of duration of treatment and follow-up. Conclusion Given high rates of relapse, withdrawal of ustekinumab from patients with well-controlled psoriasis cannot be recommended.
Risk Factors for Keratinocyte Carcinoma Skin Cancer In Nonwhite Individuals: A Retrospective Analysis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Kumar S. Nadhan, Christina L. Chung, Erin M. Buchanan, Christine Shaver, Scott Shipman, Rina M. Allawh, Melissa L. Hoffman, Geoffrey Lim, Mark Abdelmalek, Carrie Ann Cusack
Background As the majority of the U.S. population will consist of nonwhite individuals by the year 2043, it is essential that both physicians and patients are educated about skin cancer in nonwhite individuals. Objective To update the epidemiology, investigate specific risk factors, and facilitate earlier diagnosis and intervention of KC in nonwhite individuals Methods IRB-approved retrospective chart review of all non-white individuals who had received a biopsy-proven diagnosis of skin cancer at Drexel Dermatology from June 2008 to June 2015. Results Squamous cell carcinoma (SCC) was the most commonly diagnosed skin cancer in Black and Asian populations, while basal cell carcinoma (BCC) was the most common skin cancer in Hispanics. Blacks exhibited the majority of their SCC lesions in sun-protected areas, particularly the anogenital area. On average, current smokers were diagnosed with skin cancer 12.27 years earlier than former smokers and 9.36 years earlier than nonsmokers. Limitations Single-center design and inter-practitioner variability of skin examination Conclusions The importance of photoprotection in nonwhite individuals should not go overlooked. However, emphasis should also be placed on active examination of sun-protected areas in nonwhites and recognition of the relationship between HPV and genital SCC lesions. Smoking cessation should be integrated in dermatologic counseling of all patients. Interventions tailored to each of these ethnic groups are needed.
Treatment of Morphea With Hydroxychloroquine: A Retrospective Review of 84 Patients at Mayo Clinic, 1996-2013 J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Anagha Bangalore Kumar, Elizabeth K. Blixt, Lisa A. Drage, Rokea A. el-Azhary, David A. Wetter
Background Few studies support treating morphea (localized scleroderma) with hydroxychloroquine. Objective To assess the efficacy of hydroxychloroquine treatment of morphea. Methods We conducted a retrospective study of 84 patients who had morphea and were treated with hydroxychloroquine monotherapy for at least 6 months at our institution from 1996 through 2013. The median times to initial and maximal responses were assessed. Results Of 84 patients (median age at diagnosis, 29.5 years), 65 (77.4%) were female; 36 (42.9%) had a complete response to hydroxychloroquine; 32 (38.1%) had a partial response greater than 50%; 10 (11.9%) had a partial response less than or equal to 50%; and 6 (7.1%) had no response. The median time to initial response was 4 months; the median time to maximal response was 12 months. Ten patients (11.9%) experienced adverse effects from hydroxychloroquine; the most common was nausea (6 patients). Limitations Retrospective study. Conclusions Hydroxychloroquine is a valuable treatment for morphea because of its high response rate and low rate of adverse effects; however, prospective studies are needed to determine its true efficacy.
Treatment and survival of Merkel cell carcinoma since 1993: a population-based cohort study in the Netherlands J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Sanne E. Uitentuis, Marieke W.J. Louwman, Alexander C.J. van Akkooi, Marcel Bekkenk
Background Merkel cell carcinoma (MCC) is a rare and potentially lethal skin-cancer. MCC is known for its potential rapid growth and its propensity to metastasise. Objective To describe the incidence, treatment and survival of MCC in a population-based setting. Methods All MCC’s diagnosed in the Netherlands between 1993 and 2016 were selected from the Netherlands Cancer Registry. Patient and tumour characteristics, therapy and vital status were obtained. Cox’ proportional hazards were computed and relative survival analyses were performed. Results Our cohort included 1977 patients with MCC. Incidence increased from 0.17/100,000 personyears in 1993 to 0.59/100,000 in 2016. The mean age at diagnosis was 75.5. Most MCC’s (59.8%), were treated with surgery alone. Relative five-year survival was low (63.0%) and did not improve. Mortality was higher among males (HR: 1.24, 95%CI: 1.11-1.39), higher age (HR 1.07, 95%CI: 1.06-1.07) and nodal (HR1.26, 95%CI: 1.08-1.48) and distant spread of disease (HR2.44, 95%CI: 1.99-2.99). Limitations We lacked data on cause of death, comorbidity and pathological margins, which may have led to misinterpretation of the data. Conclusion This study shows continuously increasing incidence rates of MCC in the Netherlands. Survival after MCC diagnosis remained low. Our results emphasise the need for implementation of new therapies.
Patient-Reported Outcomes are Important Elements of Psoriasis Treatment Decision Making: A Discrete Choice Experiment Survey of Dermatologists in the United States J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Steven R. Feldman, Stephane A. Regnier, Alexandra Chirilov, Felix Hey, Isabelle Gilloteau, David Cella
Background Psoriasis Area and Severity Index (PASI) response rates have been the benchmark for evaluating treatment efficacy in moderate-to-severe psoriasis trials. Objective Understand how dermatologists assess biologics and what trade-off rules they apply when planning psoriasis treatment. Methods Two online surveys of 130 and 129 U.S. dermatologists (Survey 1 and 2, respectively) were conducted using direct and indirect elicitation via discrete-choice experiment. Respondents were asked to choose hypothetical biologics based on six attributes (PASI 75 or 90 response rate, infection risk, dosing frequency, and three patient-reported outcomes [PROs] [relief of depression and itching, impact on usual activities]). Results Most dermatologists (Survey 1: 74%, Survey 2: 76%) reported using both PASI and PROs when selecting a biologic. PASI response rate was the most important attribute (35–38% of overall decision weight), while combined PRO attributes had similar importance (36% of decision weight). Infection risk and dosing frequency influenced the decision to a lesser extent. Limitations Potential bias in considering three PROs versus one PASI rate and one safety attribute. Conclusion PASI is most important for dermatologists selecting biologics, but PROs are also considered, especially when PASI response rate is similar between treatments. PRO data should be collected in moderate-to severe-psoriasis trials.
Age as key factor for pattern, timing and extent of distant metastasis in patients with cutaneous melanoma. A study of the German Central Malignant Melanoma Registry J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Maximilian Gassenmaier, Ulrike Keim, Ulrike Leiter, Thomas K. Eigentler, Martin Röcken, Anja Gesierich, Rose K.C. Moritz, Lucie Heinzerling, Thomas Tüting, Uwe Wollina, Claus Garbe
Background Melanoma incidence rates rise as people age but the impact of aging on distant metastasis is unclear. Objective To investigate how timing, pattern and extent of distant metastasis is influenced by age. Methods Analysis of a single-center cohort of 1.457 patients of the German Central Malignant Melanoma Registry with prospectively documented follow-up. Findings were compared with those of 1.682 patients from five different institutions. All patients presented initially with stage IA – IIC and developed distant metastasis in their further course. Results The number of metastatic sites decreased with increasing age at melanoma diagnosis (p < 0.001). The rate of stage M1d decreased from 50.2% in patients ≤ 50 years to 30.1% in patients > 70 years and the rate of stage M1b increased from 5.8% to 21.5%. The rate of lung metastases remained stable in all investigated age groups (p = 0.54). Distant metastases occurred earlier and more synchronized in patients > 70 years compared with patients ≤ 50 years. The age-dependent decrease of metastatic sites and stable rate of lung metastasis were confirmed by the multi-institutional cohort. Limitations The study was not population-based. Conclusion Pattern, timing and extent of distant metastasis changes as people age. These findings may be considered when treating melanoma patients of different age.
Patient Satisfaction with the Veteran’s Administration Teledermatology Service J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-29 Marissa L.H. Baranowski, Vijay Balakrishnan, Suephy C. Chen
Background Teledermatology is comparable to face-to-face visits in providing accurate diagnoses and effective treatments. However, there are limited data regarding patient satisfaction with teledermatology models that more directly convey provider recommendations to patients. Objective To assess patient satisfaction with the teledermatology service at the Atlanta Veterans Affairs Medical Center (AVAMC). Methods A cross-sectional, phone-based questionnaire study of 175 AVAMC teledermatology patients was performed to investigate patient satisfaction. Phase One (n=100) compared teleconsultative and models. Phase Two (n=75) compared patients who received one of three possible consult outcomes: (1) reassurance, (2) appointment for biopsy, or (3) appointment for face-to-face evaluation. Results There were no statistically significant differences in satisfaction between patients who were seen with the telemedicine and teleconsultative models. Patients who received appointments for face-to-face evaluation or biopsy were more satisfied than patients who received reassurance only. Both phases were remarkable for high patient satisfaction among all cohorts. Limitations This study was performed at a single VA medical center and is vulnerable to both non-response bias and recall bias. Conclusion Overall, patients are satisfied with teledermatology services at the AVAMC. Strong partnership with referring primary care providers and clear delineation of responsibilities is vital to the teledermatology process.
Inpatient consultative dermatology: Where are we now? Assessing the value and evolution of this sub-specialty over the past decade J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-24 Lauren M. Madigan, Lindy P. Fox
The importance of inpatient consultative dermatology is often under recognized and undervalued. A significant need exists as the burden of skin disease in the hospital is great and expertise regarding the recognition and management of uncommon and severe skin disorders is limited outside of the field. In response to this need the concept of a “dermatology hospitalist” was defined and the Society for Dermatology Hospitalists was created in 2009. Over the past decade, the sub-specialty has developed and fostered both research and education. Data now exist demonstrating the value of inpatient dermatology services not only to patients, but also to payors and health care systems. Future needs include strategies to improve access to expertise and additional efforts to establish our field as an indispensable and enduring component of hospital-based care.
Medical and aesthetic procedural dermatology recommendations for transgender patients undergoing transition J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-21 Nikhil Dhingra, Lauren Meshkov Bonati, Erica B. Wang, Margaret Chou, Jared Jagdeo
Transgender individuals may transition to their identified gender through social, hormonal, and procedural methods by using a multidisciplinary team of health care providers, including dermatologists. In this review, we discuss the medical and aesthetic dermatologic needs related to the transitioning of transgender patients and provide therapeutic and procedural recommendations. In addition to routine cutaneous conditions, dermatologists may need to treat hormonal therapy–related complications. Acumen for genital dermatology and familiarity with gender reassignment surgery is important for the dermatologist caring for a transgender patient. From a structural standpoint, transgender beauty poses a unique aesthetic task. We identify key differences in the facial structure and physique of males versus those of females. Dermatologists may have a tremendous impact on the lives of transgender individuals who seek to realize their gender identity.
Pressure Ulcers: Pathophysiology, Epidemiology, Risk Factors, and Presentation J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-18 Joshua S. Mervis, Tania J. Phillips
Though preventable in the vast majority of cases, pressure ulcers continue to pose a major burden to the individual and society, affecting up to 3 million adults annually in the United States alone. Despite increased national attention over the past 20 years, the prevalence of pressure ulcers has largely remained unchanged, while associated costs of care continue to increase. Dermatologists can play a significant role in pressure ulcer prevention by becoming aware of at-risk populations and implementing suitable preventive strategies. Moreover, dermatologists should be able to recognize early changes that occur prior to skin breakdown and to properly identify and stage pressure ulcers so as to prevent delay of appropriate care. The aim of the first part of this continuing medical education article is to discuss the pathophysiology, risk factors, epidemiology, social and economic burden, and clinical presentation of pressure ulcers.
Pressure Ulcers: Prevention and Management J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-18 Joshua S. Mervis, Tania J. Phillips
Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge and skills to implement pressure ulcer prevention strategies and to effectively treat pressure ulcers in their patients. This continuing medical education article will focus on pressure ulcer prevention and management, with a particular emphasis on the evidence for commonly accepted practices.
Melanoma prognosis in the United States: Identifying barriers for improved care J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-17 Zachary H. Hopkins, Christopher Moreno, Ryan Carlisle, Aaron M. Secrest
Background Despite improvements in melanoma mortality, disparities in melanoma survival persist. We evaluated possible sociodemographic and healthcare-based predictors of differences in U.S. melanoma survival using the melanoma mortality-to-incidence ratio (MIR). Methods State-based MIRs were calculated using United States Cancer Statistics data from 1999-2014. Pearson correlations and linear regressions were employed to determine associations between MIR and dermatologist density, primary care provider density, number of physicians by state, number of National Cancer Institute-designated Cancer Centers (NCIDCCs), healthcare spending per capita, average household income, racial/ethnic makeup of the population, percentage of uninsured, and percentage with a bachelor’s degree. Results Mean overall MIR was 0.15±0.04; only Alaska was an outlier (0.24). No state MIRs significantly increased over time; MIR decreased for most states. Multivariable analysis revealed that states with more active physicians (p=0.02) and a higher percentage non-Hispanic whites (p=0.004) had higher MIRs (poorer survival). Significant Pearson correlations were seen between MIR and melanoma incidence (r=-0.72, p<0.001), melanoma mortality (r=0.38, p<0.001), dermatologist density (r=0.32, p<0.001), and NCIDCC count (r=-0.12, p=0.001). Conclusions Melanoma survival is improved in higher incidence areas and areas with higher dermatologist density. These findings highlight areas of poorer melanoma survival and the need for local studies evaluating melanoma survival disparities.
Melanoma and Melanoma In-Situ Diagnosis after Excision of Atypical Intraepidermal Melanocytic Proliferation (AIMP): A Retrospective Cross-Sectional Analysis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Nina R. Blank, Brian P. Hibler, Ian W. Tattersall, Courtney J. Ensslin, Erica H. Lee, Stephen W. Dusza, Kishwer S. Nehal, Klaus J. Busam, Anthony M. Rossi
Background There is little evidence to guide surgical management of biopsies yielding the histologic descriptor “atypical intraepidermal melanocytic proliferation” (AIMP). Objective Determine frequency of and factors associated with melanoma and melanoma in-situ (MIS) diagnoses after excision of AIMP and evaluate margins used to completely excise AIMP. Methods Retrospective, cross-sectional study of 1127 biopsies reported as AIMP and subsequently excised within one academic institution. Results Melanoma (in-situ, stage 1A) was diagnosed after excision in 8.2% (92/1127) of AIMP samples. Characteristics associated with melanoma/MIS diagnosis included age 60-79 (OR 8.1, 95% CI 2.5-26.2), age >80 (OR 7.2, 95% CI 1.7-31.5), head/neck location (OR 4.9, 95% CI 3.1-7.7), clinical lesion partially biopsied (OR 11.0, 95% CI 6.7-18.1), and lesion extending to deep biopsy margin (OR 15.1, 95% CI 1.7-136.0). Average surgical margin used to excise AIMP lesions was 4.5mm (SD 1.8). Limitations Single-site, retrospective, observational study; interobserver variability across dermatopathologists. Conclusion Dermatologists and pathologists can endeavor to avoid ambiguous melanocytic designations whenever possible through excisional biopsy technique, interdisciplinary communication, and ancillary studies. In the event of AIMP biopsy, physicians should consider the term a histological description rather than a diagnosis, and, during surgical planning, use clinicopathologic correlation while bearing in mind factors that might predict true melanoma/MIS.
Clinicopathologic, misdiagnosis and survival differences between clinically amelanotic melanomas and pigmented melanomas J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Lauren C. Strazzulla, Xiaoxue Li, Kathleen Zhu, Jean-Phillip Okhovat, Sandra J. Lee, Caroline C. Kim
Background Amelanotic malignant melanoma (AMM) is challenging to diagnose. Clinical risk factors for AMM are not well defined. Objective To investigate clinicopathologic, misdiagnosis and survival differences between AMM versus (vs.) pigmented malignant melanoma (PMM) patients. Methods A cross-sectional retrospective medical record review at a tertiary academic medical center. Results 933 melanoma patients with known presenting tumor color were identified (342 AMM vs. 591 PMM). AMM was associated with older age, history of non-melanoma skin cancer and red hair, while AMM was inversely associated with a family history of melanoma, >50 nevi and a history of dysplastic nevi. AMM was more likely on the head/neck compared to PMM, had more aggressive pathologic features (greater Breslow depth/mitoses, ulceration, nodular subtype), and was less likely associated with a precursor nevus or regression. Finally, patients with AMM were more likely to be misdiagnosed than PMM (25% vs. 12% clinically; 12% vs. 7% pathologically), and had poorer melanoma-specific survival (5-year overall survival rate: 0.77 [95% confidence interval (CI): 0.72-0.82] vs. 0.84 [CI: 0.80-0.87]). Limitations Retrospective study design, single institutional study. Conclusion Greater clinician awareness, lower biopsy thresholds, and increased patient education may be useful to enhance AMM detection in patients with certain characteristics.
Hydroa vacciniforme-like lymphoproliferative disorder: Clinicopathologic study of 41 cases J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Yanghe Liu, Cuiling Ma, Gang Wang, Lei Wang
Background Hydroa vacciniforme-like lymphoproliferative disorder (HVLLPD) is a rare Epstein-Barr virus (EBV)-related disease usually found in East Asians and Latin Americans. Objective To report the characteristics of HVLLPD in Chinese patients. Methods Retrospective analysis of HVLLPD patients from a single institute. Results Forty-one patients were enrolled. All cases presented with papulovesicular lesions, mainly distributed on sun-exposed areas. Twenty-six cases showed systemic symptoms. Follow-up data was available in 20 cases, 16 patients were alive, and 4 patients died. Among the 4 deceased patients, 3 had serum EBV DNA test and showed high viral loads. These 3 patients also received chemotherapy. Histopathology was characterized by dense proliferation of lymphocytes in the dermis. Angiotropism or angiodestruction was found in majority cases, while prominent cellular polymorphism was noticed in only 4 cases. All cases were positive for CD3, TIA-1, and EBV-encoded RNA in situ hybridization. Limitations This was a retrospective study. Conclusions HVLLPD in Chinese patients showed indolent behavior in the majority of cases, which differed from HVLLPD characteristics in Latin Americans. Patients with high serum EBV DNA loads had an increased risk of evolving into aggressive disease. Chemotherapy should not be considered as first line treatment for most Chinese patients.
Efficacy and safety of antiscabietic agents: A systematic review and network meta-analysis of randomized controlled trials J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Kunlawat Thadanipon, Thunyarat Anothaisintawee, Sasivimol Rattanasiri, Ammarin Thakkinstian, John Attia
Background Many drugs have been used to treat scabies, but it is unclear which of them is the most efficacious. Objective To evaluate the comparative efficacy and safety of antiscabietic agents. Methods Systematic review of randomized controlled trials was conducted. Direct and network meta-analyses were applied to 13 antiscabietic agents on 3 outcomes (cure, persistent itching, and adverse events). Their probability of having highest efficacy and safety was estimated and ranked. Results Network meta-analysis based on 52 trials in 9917 patients indicated that permethrin (the reference treatment) had significantly higher cure rate than sulfur, malathion, lindane, crotamiton, and benzyl benzoate. Permethrin+oral ivermectin combination had non-significantly higher cure rate than permethrin. Permethrin+oral ivermectin combination, topical ivermectin, and synergized pyrethrins were the treatment ranked highest in terms of cure, persistent itching, and adverse events, respectively. Based on clusterd ranking, permethrin, oral ivermectin, and synergized pyrethrins seemed to retain balance between cure and adverse events. Limitations There are small numbers of trials and patients in some comparisons, and high risk of bias in some trials. Conclusion There is no one treatment that ranked highest in all aspects. Physicians should consider the drug’s efficacy and safety profiles, along with ease of administration.
Prevalence of clinically significant incidental findings by whole-body FDG-PET/CT scanning in moderate-to-severe psoriasis patients participating in clinical trials J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Marilyn T. Wan, Drew A. Torigian, Abass Alavi, Judith Alvarez, Zelma C. Chiesa Fuxench, Megan H. Noe, Maryte Papadopoulos, Daniel B. Shin, Junko Takeshita, Thomas J. Werner, Nehal N. Mehta, Joel M. Gelfand
Objective Determine the prevalence of incidentalomas and rate of malignancy identified by FDG-PET/CT imaging in clinical trial patients with moderate-to-severe psoriasis. Methods Cross-sectional secondary analysis of moderate-to-severe psoriasis patients who underwent FDG-PET/CT scans at the baseline visit, prior to randomization, for three phase 4 vascular inflammation in psoriasis clinical trials. Only patients without active infection, malignancy or uncontrolled comorbidities were eligible for the clinical trials. Results 259 healthy patients with moderate-to-severe psoriasis underwent an FDG-PET/CT scan as part of study procedures. Thirty-one patients (11.97% [95% Confidence Interval (CI):8.28-16.56]) had clinically significant incidentalomas on the baseline FDG-PET/CT scan. Univariate logistic regression demonstrated that with every increase in 10 years of age, there was an approximate 30% increased risk of discovering an incidentaloma (Odds Ratio 1.30 [95%CI:1.01-1.68]). Of the findings suspicious for malignancy (n=28), cancer was confirmed in 6 patients resulting in a 2.31% (95%CI:0.9-5.0) prevalence of malignancy. Positive predictive value of a true cancer was 31.58% (range 21%-54%). Limitations Generalizability and lost to follow-up. Conclusion Incidentalomas on FDG-PET/CT imaging are common in otherwise healthy, asymptomatic clinical trial patients with moderate-to-severe psoriasis. Our results can help inform clinical trials safety data interpretation and emphasizes the importance of compliance with cancer screening recommendations.
Poor prognosis for thin ulcerated melanomas and implications for a more aggressive approach to treatment J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-14 Makenzie L. Hawkins, Matthew J. Rioth, Megan M. Eguchi, Myles Cockburn
Background Clinical guidelines for the treatment of melanoma are based largely on the behavior of thicker tumors. As a result, little is known about survival differences among patients with thinner tumors. Objective To investigate the variability in survival for AJCC stage T1 thin melanoma tumors, defined as less than 1mm at diagnosis. Methods This population-based series included 43,008 non-Hispanic whites diagnosed with cutaneous melanoma between 2004 and 2013 from the California Cancer Registry. Survival outcomes estimated using the Kaplan-Meier Method. Cox proportional hazard models were used to estimate risk of death. Results Survival for patients with thin ulcerated tumors was comparable to patients with Stage II tumors, who are currently treated more aggressively. At 12 months, patients with thin ulcerated tumors had approximately 6% lower survival (92.5%, 95%CL:90.6-93.9%) compared to patients with thin non-ulcerated tumors (98.2%, 95%CL:98.0-98.3%). At 24 months, this survival difference increased (85.2% (95%CL: 82.8%-87.4%), 96.1% (95%CL:95.8-96.3%); respectively) and continued to increase over 2-fold by 60 months. Limitations Previous reports of cancer registry data have noted some evidence of miscoding of thin tumors. Conclusion The poorer survival in less than 1mm thick, ulcerated tumors implies the need for additional studies to determine potential benefits of more aggressive treatment.
Patients with Negative Patch Tests: Retrospective Analysis of North American Contact Dermatitis Group (NACDG) Data 2001-2016 J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-11 Erin M. Warshaw, Amy J. Zhang, Donald V. Belsito, Joseph F. Fowler, James S. Taylor, Howard I. Maibach, Toby Mathias, Denis Sasseville, James G. Marks, Vincent A. DeLeo, Anthony F. Fransway, Kathryn A. Zug, Melanie D. Pratt, Matthew J. Zirwas, Joel G. DeKoven
Background Little is known regarding characteristics of patients with negative patch tests (NPTs). Objective To characterize patients with NPTs. Methods Retrospective cross-sectional analysis of 34,822 patch tested patients. NPTs were defined as negative or irritant final interpretations of all North American Contact Dermatitis Group (NACDG) screening allergens and no relevant allergens on supplemental series. Results Almost one-third (n=10,888, 31.3%) of patients had negative results. NPT patients were significantly more likely to be male (p<0.0001), aged ≤40 years (p=0.0054), non-Caucasian (p=0.0005), and have dermatitis primarily involving the following body sites: scattered generalized (p=0.0007), lips (p=0.0214), or eyelids (p=0.0364). However, absolute differences in age, race, and site were small and may not be clinically meaningful. NPT patients were significantly less likely to have occupationally related skin disease (p<0.0001). Overall, 8.3% of NPT patients had occupationally related skin disease with precision production workers/machine operators (28.5%), healthcare workers (17.0%), and mechanics/repairers (7.5%) being the most commonly related occupations. 22.9% of NPT patients had relevant irritants and 41.6% of irritants were occupationally related; cosmetics/health care products and soaps were common sources for both occupationally related and non-occupationally related irritants. Limitations Retrospective cross-sectional study of tertiary referral population. Conclusions Patients with NPTs have distinct characteristics.
Cutaneous nevi and risk of melanoma death in women and men: a prospective study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-11 Wen-Qing Li, Eunyoung Cho, Martin A. Weinstock, Suyun Li, Meir J. Stampfer, Abrar A. Qureshi
Background It was unclear whether increased number of common nevi (moles) predicts melanoma death. Objective We prospectively examined the association between number of common nevi and risk of melanoma death Methods Our study was based on the Nurses’ Health Study (n=77,288 women) and Health Professionals Follow-up Study (n=32,455 men). Number of moles with ≥3 mm diameter on the upper extremity was asked in 1986 and was re-classified into three categories (none, 1-2, or ≥3) based on data distribution. Results During follow-up (1986-2012), 2,452 melanoma cases were pathologically confirmed, among whom we identified 196 deaths due to melanoma. Increased number of nevi was associated with melanoma death; the hazard ratio (HR) for ≥3 nevi compared with no nevi was 2.49 [95% confidence interval(CI): 1.50-4.12] for women and 3.97 (95%CI: 2.54-6.22) for men. Among melanoma cases, increased number of nevi was associated with melanoma death in men (≥3 nevi: HR=1.89, 95%CI: 1.17-3.05), but not in women. Similarly, number of nevi was positively associated with Breslow thickness in men only (Ptrend=0.01). Limitations This is an epidemiologic study without examination into mechanisms. Conclusions Increased number of cutaneous nevi was significantly associated with melanoma death. High nevi count may serve as an independent prognostic factor, which predicts the risk of melanoma death particularly among male melanoma cases.
Severity of disease and quality of life in parents of children with alopecia areata, totalis, and universalis: a prospective, cross-sectional study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-08 Elana Putterman, Deepa P. Patel, Gabriela Andrade, Katya L. Harfmann, Marcia Hogeling, Carol E. Cheng, Carolyn Goh, Rachel S. Rogers, Leslie Castelo-Soccio
Background Caregiver-oriented quality of life research (QoL) in alopecia areata is limited. No study has used a parent-tailored survey to examine the relationship between QoL and severity of alopecia as measured by SALT scores. Objectives This is a prospective study that describes QoL in parents of pediatric patients with all subtypes of alopecia areata and investigates the relationship between QoL and severity of disease, duration of disease, and age of patients. Methods Pediatric patients and their parents were invited to participate during clinic visits. Participating parents completed the Quality of Life in a Child’s Chronic Disease Questionnaire (QLCCDQ) and the Family Dermatology Life Quality Index (FDLQI). A subset of children completed the Children’s Dermatologic Life Quality Index (CDLQI). Severity of alopecia tool (SALT) scores at time of survey completion were recorded. Results 153 patients were included. Significant mild to moderate negative correlations were found between SALT scores and FDLQI scores, QLCCDQ scores, and QLCCDQ emotional domain scores. Age of child correlated negatively with QLCCDQ scores but not FDLQI scores. No significant correlation was found between duration of disease and FDLQI scores, QLCCDQ scores, or QLCCDQ emotional domain scores. Limitations This study is limited by its small sample size and cross-sectional design. Conclusions Impaired parental QoL may be associated with increasing severity of disease and age of affected child but not duration of disease. Providers should tailor counseling accordingly and help parents set realistic expectations for long-term experience with the disease.
Mohs micrographic surgery for eyelid sebaceous carcinoma: a multicenter cohort of 360 patients J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-09 Chuandi Zhou, Fan Wu, Peiwei Chai, Yingyun Shi, Juan Ye, Xin Shi, Jia Tan, Yi Ding, Yingxiu Luo, Bita Esmaeli, Renbing Jia, Xianqun Fan
Background The decision to perform Mohs micrographic surgery (MMS) or wide local excision (WLE) for eyelid sebaceous carcinoma (SC) is controversial. Objective To compare local recurrence, metastasis, and tumor-related mortality of patients with eyelid SC who were initially treated with MMS versus WLE. Methods A multicenter cohort study. Medical records were reviewed for factors associated with recurrence, metastasis and tumor-related mortality. All eligible patients were followed up. The impact of initial surgical modality on the prognoses were determined by Cox analyses after controlling all confounders. Results Among 360 patients included in this cohort, 115 (31.9%) of them underwent MMS as primary resection, whereas 245 (68.1%) cases underwent WLE. After a median follow-up period of 60.0 months, local recurrence was observed in 18 (15.7%) patients of the MMS group and 97 (39.6%) patients of the WLE group. Metastasis occurred in 9 (7.8%) patients who underwent MMS and 38 (15.5%) who underwent WLE. Six (5.2%) patients in the MMS group and 21 (8.6%) in the WLE group died of metastatic SC. Multivariable Cox regression indicated that, compared with the WLE group, the MMS group exhibited more favorable local recurrence control (HR=0.42; 95%CI:0.24-0.73; p=0.002), but a comparable metastasis rate (HR=1.38; 95%CI:0.60-3.18; p=0.453) and tumor-related mortality (HR=1.70; 95%CI:0.59-4.93; p=0.329). However, this beneficial effect became nonremarkable for patients with pagetoid intraepithelial neoplasia (HR=1.73; 95%CI:0.37-8.21; p=0.488). Limitations Retrospective nature. Conclusion MMS should be proposed for eyelid SC without orbital involvement to achieve recurrence control, however, this surgery did not change the long-term outcomes in terms of metastasis and tumor-related mortality. Patients with pagetoid intraepithelial neoplasia may require adjuvant measures.
Incidence of Pneumocystosis Among Patients Exposed to Immunosuppression J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-09 Sergey Rekhtman, Andrew Strunk, Amit Garg
Background The decision to administer prophylaxis to patients receiving immunosuppression against pneumocystosis remains a dilemma. Objective To determine overall and age-specific 5-year pneumocystosis incidence within a population exposed to immunosuppressants. Methods Retrospective cohort analysis identifying incident pneumocystosis cases among adults without HIV/AIDS or cancer exposed to immunosuppressant and/or corticosteroid therapy. Results We identified 406 new cases among patients prescribed an immunosuppressant, corticosteroid, or both. Overall incidence of pneumocystosis was 0.012% (406/3,366,086). Incidence was highest in those exposed to immunosuppresssant and corticosteroid medications (0.199%), followed by groups exposed to immunosuppresssant alone (0.012%), corticosteroid alone (0.008%), and neither medication (0.001%) (p<0.001). Greatest risk differences were noted between groups exposed to immunosuppresssant and corticosteroid compared with neither [0.198% (95% CI 0.166% - 0.230%)] and with immunosuppresssant alone [0.188% (95% CI 0.155% - 0.221%)]. Greatest relative risks were noted among those receiving immunosuppresssant and corticosteroid compared with those exposed to neither [RR 122.5 (95% CI 100.9-148.8)] or to immunosuppresssant alone [RR 16.5 (95% CI 7.3-37.4)]. Limitations We could not confirm dose and duration of exposures. Conclusions Incidence of pneumocystosis among patients exposed to immunosuppressants is very low. Prophylaxis for patients receiving combination immunosuppresssant and corticosteroid therapy, the group at highest risk, may be warranted.
White hair in alopecia areata: Clinical forms and proposed physiopathological mechanisms J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2019-01-08 Daniel Asz-Sigall, María Fernanda Ortega-Springall, Mariam Smith-Pliego, Erika Rodríguez-Lobato, Maria Abril Martinez-Velasco, Roberto Arenas, Colombina Vincenzi, Antonella Tosti
Alopecia areata is a common form of non-scaring type of hair loss. It is believed to be a consequence of an immune-mediated stimulus, probably involving autoreactive T-cells against antigens present in the hair follicle. The exact antigen is still unknown; however, some authors have proposed that melanogenesis-associated molecules might trigger autoimmunity. Although transient white hair regrowth is a common and well-known situation in alopecia areata, there are other different types of white hair phenomena in this context; including permanent white hair regrowth, spearing of white hair in a patchy pattern or spearing in a diffuse form giving the appearance of the so-called “overnight graying phenomena” or Canitis subita. In this review we aim to describe the different clinical aspects of white hair in alopecia areata as well as the proposed pathophysiological mechanisms involved in this phenomena.
Discrepancies in the Mohs Micrographic Surgery Appropriate Use Criteria J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-23 Julie A. Croley, Aaron K. Joseph, Richard F. Wagner
A previously unreported guideline discrepancy in the Mohs Micrographic Surgery Appropriate Use Criteria highlights the importance of the report’s disclaimer that the ultimate judgment of appropriateness must be made by the physician and the patient. Furthermore, it emphasizes the potential for future revisions in light of emerging data.
‘Prevalence and determinants for xerosis cutis in the middle-aged and elderly population: a cross-sectional study’ J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-23 Selma Mekic, Leonie C. Jacobs, David A. Gunn, Andrew E. Mayes, M. Arfan Ikram, Luba M. Pardo, Tamar Nijsten
Background Determinants and the extent of dry skin in healthy middle-aged and elderly populations have not been well established. Objective We aimed to identify the prevalence and determinants for generalized (GDS) and localized dry skin (LDS) within a large prospective population based cohort of middle-aged to elderly individuals of the Rotterdam Study. Methods Dry skin was physician-graded as none, localized or generalized. For GDS and LDS separate multivariable logistic regression analyses were performed to search for association with participant characteristics, lifestyle factors, environmental factors, several comorbidities and drug exposure. Results Among the 5547 eligible participants, 60% had dry skin of which a fifth had GDS. Age, female sex, skin color, BMI, outside temperature, eczema and chemotherapy in the past were significant determinants for both GDS and LDS. Smoking, the use of statins and diuretics, a lower self-perceived health and several dermatological conditions increased the likelihood of having GDS only. Daily cream use associated with less LDS. Limitations Inter-observer variability and residual confounding could have influenced our results. Due to our cross-sectional design we cannot infer causality. Conclusion We identified factors significantly associated with dry skin in a general middle-aged to elderly population, with health parameters more strongly associated with GDS.
All-cause and cause-specific mortality in psoriasis: a systematic review and meta-analysis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-24 Ashar Dhana, Hsi Yen, Hsuan Yen, Eunyoung Cho
Background An overview of mortality risk associated with psoriasis is lacking. Objective To perform a systematic review and meta-analysis of mortality risk in psoriasis. Methods We included studies reporting all-cause or cause-specific mortality risk estimates in psoriasis patients compared with general population or subjects free of psoriasis. We calculated pooled relative risks (RRs) and 95% confidence intervals (CIs). Results We included 12 studies. The pooled RRs for all-cause mortality were 1.21 (95% CI 1.14-1.28) in psoriasis, 1.13 (95% CI 1.09-1.16) in mild psoriasis, and 1.52 (95% CI 1.35-1.72) in severe psoriasis. The pooled RRs for cardiovascular mortality were 1.15 (95% CI 1.09-1.21) in psoriasis, 1.05 (95% CI 0.92-1.20) in mild psoriasis, and 1.38 (95% CI 1.09-1.74) in severe psoriasis. For noncardiovascular causes, mortality risk from liver disease, kidney disease, and infection was significantly increased in psoriasis, regardless of disease severity. The mortality risk from liver and kidney disease was the highest. There was also significantly increased mortality risk from neoplasms in severe psoriasis patients and from chronic lower respiratory disease in all and mild psoriasis patients. Limitations Although associations were consistent, their magnitude was heterogenous. Conclusion Psoriasis is associated with increased mortality from all-causes in a dose-response manner with disease severity and from several specific causes.
The Uses of Naltrexone in Dermatological Conditions J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-21 Brigette Lee, Dirk Elston
Background Naltrexone in standard and reduced doses is efficacious in many inflammatory and acantholytic disorders. Objective We summarized current data of naltrexone relevant to dermatological practice. Methods An English language PubMed literature search was performed using the terms naltrexone, low-dose naltrexone, Hailey-Hailey, psoriasis, lichen planopilaris, alopecia, opioid, opioid receptor, treatment, dermatology, monitoring, side effect, skin, pruritus, cutaneous, acantholytic, and Darier. Results Opioid receptors are found throughout the skin and affect cell proliferation, migration and adhesion. Mu opioid receptors have been found in all layers of the epidermis while delta receptors are concentrated at cell junctions and can reduce desmoglein expression. Typical doses of naltrexone result in continuous binding to receptors. Low doses result in intermittent blockade with increased ligand and receptor expression, potentiating their effect. Limitations Our review was restricted to the English language literature. Conclusion Naltrexone affects inflammation, cell adhesion, and keratinocyte proliferation and migration. While low-dose naltrexone has demonstrated efficacy in treating Hailey-Hailey disease, further dose-ranging studies are needed. Data suggest naltrexone could be helpful in the treatment of pruritus and a variety of inflammatory and acantholytic skin diseases refractory to other treatments. At higher doses, liver function tests should be monitored on a periodic basis.
The Diagnostic Accuracy of Dermoscopy for Basal Cell Carcinoma: A Systematic Review and Meta-Analysis J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-21 Ofer Reiter, Ilit Mimouni, Michael Gdalevich, Ashfaq Marghoob, Assi Levi, Emmilia Hodak, Yael Anne Leshem
Background Dermoscopy is a noninvasive technique for the diagnosis of skin lesions. Its accuracy for basal cell carcinoma (BCC) has not been systematically studied. Objective To systematically investigate the accuracy of dermoscopy for the diagnosis of basal cell carcinoma with comparison to naked eye examination. Methods A systematic review of studies reporting the accuracy of naked eye examination and dermoscopy for the diagnosis of BCC was conducted. A meta-analysis for sensitivity and specificity was performed using a bivariate mixed-effects logistic regression modeling framework. Results Seventeen studies were identified. The pooled sensitivity and specificity of dermoscopy for the diagnosis of basal cell carcinoma were 91.2% and 95%, respectively. In studies comparing test performance, adding dermoscopy to naked eye examination improved sensitivity from 66.9% to 85% (p=0.0001), and specificity, from 97.2% to 98.2% (p=0.006). The sensitivity and specificity of dermoscopy were higher for pigmented than non-pigmented BCC. Sensitivity increased when dermoscopy was performed by experts and when the diagnosis was based on in-person dermoscopy as opposed to dermoscopic photographs. Limitations Significant heterogeneity among studies with a medium-to-high risk of bias. Conclusion Dermoscopy is a sensitive and specific add-on tool for the diagnosis of basal cell carcinoma. It is especially valuable for pigmented BCC.
Histological subtype of treatment failures after noninvasive therapy for superficial basal-cell carcinoma: an observational study J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-21 Lieke C.J. van Delft, Patty J. Nelemans, Maud H.E. Jansen, Aimee H.M.M. Arits, Marieke H. Roozeboom, Myrurgia A. Hamid, Klara Mosterd, Nicole W.J. Kelleners-Smeets
Background There have been concerns that recurrences after noninvasive therapy for basal-cell carcinoma (BCC) transform into a ‘more aggressive’ histological subtype. Objective To evaluate the proportion of patients with a non-superficial treatment failure after noninvasive therapy for superficial BCC. Methods An observational study was performed using data from a single blind, non-inferiority, randomized controlled trial (March 2008-August 2010) with five year follow-up in patients with primary superficial BCC treated with methylaminolevulinate-photodynamic therapy (MAL-PDT), 5-fluorouracil or imiquimod. Data were used from 166 adults with a histologically confirmed treatment failure. Results A non-superficial subtype was found in 64 of 166 treatment failures (38.6%). Proportions with a ‘more aggressive’ subtype than the primary tumor were 51.3% (38/74) for early and 28.3% (26/92) for later treatment failures (p=0.003). The proportion of ‘more aggressive’ early failures was significantly lower following imiquimod (26.3%) compared to MAL-PDT (54.8%, p=0.086) and 5-fluorouracil (66.7%, p=0.011). Limitations There was limited information on the exact time of occurrence of treatment failures. Conclusion ‘More aggressive’ treatment failures after noninvasive therapy for superficial BCC occur most often within the first three months post-treatment probably indicating underdiagnosis of ‘more aggressive’ components in the primary tumor rather than transformation.
TNF-α Inhibitor-Induced psoriasis: A decade of experience at the Cleveland Clinic J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-18 Sean E. Mazloom, Di Yan, Jeffery Z. Hu, Jason Ya, M. Elaine Husni, Christine B. Warren, Anthony P. Fernandez
Background TNF-α inhibitor-induced psoriasis (TNFi-psoriasis) remains poorly understood despite being described 15 years ago. As TNF-α inhibitors (TNFis) often provide life-changing patient benefits, understanding effective treatments for TNFi-psoriasis is important. Objective We characterized a cohort of TNFi-psoriasis patients specifically diagnosed and (co)managed by dermatologists at a single tertiary care institution over a ten-year period. Methods Retrospective review of patients diagnosed with TNFi-psoriasis between 2003-2013. Results 102 patients with TNFi-psoriasis were identified. Mean age of onset was 40 years, and there was a female predominance(73.5%). Crohn’s disease(48%) and rheumatoid arthritis(24.5%) were the most common primary conditions. Infliximab(52%) was the most common inciting agent. The most common TNFi-psoriasis subtypes were plaque-type(49.5%), scalp(47.5%), and palmoplantar pustulosis(41%). Topical medications alone improved/resolved TNFi-psoriasis in 63.5% patients, and cyclosporine and methotrexate (>10mg weekly) were often effective if topicals failed. Discontinuation of the inciting TNFi with/without other interventions improved/resolved TNFi-psoriasis in 67% of refractory cases, while switching TNFis resulted in persistence/recurrence in 64%. Limitations Retrospective nature of study and some patients may have developed typical psoriasis unresponsive to TNFis, Conclusion This represents the largest single-institution cohort of TNFi-psoriasis patients diagnosed and (co)managed by dermatologists to date. Based on our findings we propose a treatment algorithm for TNFi-psoriasis.
Tumor mutational burden and response to PD-1 inhibitors in a case series of patients with metastatic desmoplastic melanoma J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-18 Lise Boussemart, Adrienne Johnson, Alexa B. Schrock, Sumanta K. Pal, Garrett M. Frampton, David Fabrizio, Zachary Chalmers, Michal Lotem, Geoffrey Gibney, Jeffery Russell, Bartosz Chmielowski, Jeffrey S. Ross, Philip J. Stephens, Vincent A. Miller, Siraj M. Ali
Desmoplastic melanoma (DM) represents an infrequently occurring and distinct histologic pattern of melanomas, often lacking mutations in genes typically altered in conventional melanomas including BRAF, NRAS, and KIT. We aimed at better characterizing the genetic profile of this subgroup of melanomas to match patients with available therapies. Pathology reports were reviewed for 1,240 consecutive melanoma cases sequenced by comprehensive genomic profiling (CGP) using a hybrid-capture based next generation sequencing during the course of clinical care. The mutational profile of the 12 DM identified was compared with the remaining 1,228 melanomas examined. We report a median tumor mutational burden (TMB) of 77 mutations per megabase (mut/Mb) in DM, which was significantly greater than a median of 35 mut/Mb in non-DM. A UV DNA damage signature was detected in 10/12 (83%) DM. For a subset of patients with available clinical course, we report that 100% (5/5) had clinical benefit from treatment with PD-1 inhibitors as monotherapy. TMB and UV signature show significant promise as an approach to identify patients who are likely to benefit from PD-1 targeted immunotherapy.
Clear cell acanthoma (CCA)-like lesions of the nipple/areola: A clinicopathological study of 12 cases supporting a nonneoplastic eczematous disease J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-14 Kang-Ling Kuo, Chi-Shou Lo, Li-yu Lee, Chih-Hsun Yang, Tseng-tong Kuo
Background Clear cell acanthoma (CCA) of the nipple/areola has been reported. The CCA-like histology more likely represents a feature of eczematous dermatitis of the nipple/areola. Objective We reviewed cases of CCA-like lesions of the nipple/areola and compared them with classic CCA to clarify their relationship. Methods The clinicopathological features of 12 cases of CCA-like lesions of the nipple/areola were compared with classic CCA. The literature on this condition was reviewed, and the results of various treatments were analyzed. Results CCA-like lesions of the nipple/areola were clinically different from those of classic CCA. Although they shared the glycogen-rich clear epidermal cells with neutrophilic exocytosis, dermal eosinophils appeared to be a distinctive feature. The anatomic site and association with atopic dermatitis suggested that CCA-like lesions of nipple/areola might represent a manifestation of atopic eczema involving nipple/areola. Topical steroids could be effective. Limitations This was a retrospective study with limited cases. Conclusions Although CCA-like lesions of the nipple/areola shared histopathological features with classic CCA, their clinical changes were consistent with dermatitis. We propose to name this condition CCA-like eczematous dermatitis of the nipple/areola.
The national burden of inpatient dermatology in adults J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-13 Justin D. Arnold, SunJung Yoon, A. Yasmine Kirkorian
Background Management of inpatient skin disease represents a unique subspecialty within dermatology. Objective To assess the national burden of inpatient dermatology in adults. Methods Using the 2014 National Inpatient Sample, we performed a retrospective cohort study of adults hospitalized for dermatologic conditions. Results In 2014, there were 644,320 weighted hospitalizations principally for skin disease in adults, which cost the health care system $5.04 billion. Overall, skin disease was diagnosed in 1 in 8 hospitalized adults. Dermatologic hospitalizations were associated with a lack of medical insurance (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.20-2.34), residence in a low-income community (OR, 1.10; 95% CI, 1.07-1.13), and small (OR, 1.27; 95% CI, 1.23-1.32) or rural hospitals (OR, 1.38; 95% CI, 1.32-1.44). Racial minorities were less likely to be hospitalized for skin disease than were whites (for blacks: OR, 0.77; 95% CI, 0.75-0.79; for Hispanics: OR, 0.85; 95% CI, 0.83-0.8; for Asians: OR, 0.59; 95% CI, 0.55-0.64). Only 0.47% of patients admitted for skin disease experienced in-hospital mortality; however, mortality rates were high in hospitalizations for cutaneous lymphomas (9.19%) and malignant melanoma (6.54%). Limitations We could not assess the impact of inpatient dermatology consultations on hospitalization outcomes. Conclusions Skin disease is highly prevalent among hospitalized patients.
Tezepelumab, an anti-TSLP monoclonal antibody, in the treatment of moderate to severe atopic dermatitis: A randomized phase 2a clinical trial J. Am. Acad. Dermatol. (IF 6.898) Pub Date : 2018-12-12 Eric L. Simpson, Jane R. Parnes, Dewei She, Sarah Crouch, William Rees, May Mo, René van der Merwe
Background Tezepelumab (AMG 157/MEDI9929), a first-in-class monoclonal antibody, targets thymic stromal lymphopoietin, a cytokine implicated in atopic dermatitis (AD) pathogenesis. Objective Evaluate efficacy and safety of tezepelumab in adults with moderate to severe AD. Methods In this phase 2a study (NCT02525094), 113 patients were randomized 1:1 to subcutaneous tezepelumab 280 mg or placebo every 2 weeks, plus Class 3 topical corticosteroids (TCS). The primary endpoint was the Week-12 response rate for a ≥50% reduction in Eczema Area and Severity Index (EASI50). Secondary endpoints including EASI75, Investigator’s Global Assessment, Scoring of Atopic Dermatitis (SCORAD) 50, SCORAD75, pruritus numeric rating and 5-D itch scales, and exploratory endpoints (including EASI90) were assessed at Week 12, and Week 16 (post hoc). Results A numerically greater percentage of tezepelumab plus TCS-treated patients achieved EASI50 (64.7%) versus placebo plus TCS (48.2%; P = .091). Numerical improvements over placebo were demonstrated for Week 12 secondary and exploratory endpoints, with further improvements at Week 16. Treatment-emergent adverse events were similar between treatment groups. Limitations Greater than expected response rates in placebo-treated patients were possibly attributable to TCS. Conclusion Although not statistically significant, numerical improvements over placebo for all Week 12 endpoints were demonstrated, with greater Week 16 responses.
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