Including the latest on acne, atopic dermatitis, COVID-19, contact dermatitis, cutaneous oncology, drugs and devices, infectious disease, psoriasis, and more.
GENERAL DERMATOLOGY
One-hundred-twenty-five cases of DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) were identified, validated, and analyzed. A widespread eruption (>50% body surface area) was frequently present (97.6%). This eruption most often consisted of polymorphous erythematous maculopapules, although both urticarial and purpuric lesions also occurred in some patients. Facial edema, a hallmark of DRESS, was found in only 53.6% of patients, while mucosal involvement was detected in 32.8% of patients.
TO READ MORE: Lee JW, et al. Skin manifestations and clinical features of drug reaction with eosinophilia and systemic symptoms: a retrospective multicentre study of 125 patients [published online ahead of print, 2022 Mar 28]. J Eur Acad Dermatol Venereol. 2022;10.1111/jdv.18100. doi:10.1111/jdv.18100.
Investigators compared 327,502 patients with PRURITUS drawn from a global medical records database with the same number of non-itchy controls. The two groups had an insignificant difference in overall cancer incidence, but those with pruritus has a significantly increased risk of hematological malignancy. The latter included: Hodgkin lymphoma, myeloid and lymphocytic leukemia, multiple myeloma, non-Hodgkin lymphoma, monoclonal gammopathy, and myelodysplastic syndrome.
TO READ MORE: Deng J, et al. Risk of Hematologic Cancer in Patients With Undifferentiated Pruritus [published online ahead of print, 2022 May 25]. JAMA Dermatol. 2022;e221562. doi:10.1001/jamadermatol.2022.1562.
A small retrospective study of drug “survival” (continued administration indicative of efficacy) in PITYRIASIS RUBRA PILARIS was done at the University of Pittsburgh. Drug survival at 600 days was highest for methotrexate, intermediate for biologics, and lowest for retinoids, apremilast and cyclosporine, In general, TNF-α blockers outperformed IL-17 blockers. A prior study suggested that retinoids were the most effective modalities of therapy for pityriasis rubra pilaris.
TO READ MORE: Kettering C, et al. Drug survival of systemic and biologic monotherapy treatments for pityriasis rubra pilaris: A retrospective observational study. J Am Acad Dermatol. 2022;86(5):1142-1143. doi:10.1016/j.jaad.2021.04.041.
Investigators conducted a population-based cross-sectional analysis utilizing the National Ambulatory Medical Care Survey. Over the most recent 10-year interval available, actinic keratosis, acne vulgaris, and benign skin neoplasms consistently remained the MOST COMMON VISIT DIAGNOSES in the dermatological setting.
TO READ MORE: Grada A, et al. Trends in Office Visits for the Five Most Common Skin Diseases in the United States. J Clin Aesthet Dermatol. 2022;15(5):E82-E86.
ACNE
A small (N=19) retrospective U.S. study failed to find a statistically significant association between ISOTRETINOIN administration and flares of pre-existing inflammatory bowel disease (Crohn’s disease or ulcerative colitis).
TO READ MORE: Lopez CG, et al. Impact of Isotretinoin on IBD Flare in Patients with Pre-Existing IBD Diagnosis: A Cross-Sectional Study [published online ahead of print, 2022 May 18]. J Am Acad Dermatol. 2022;S0190-9622(22)00818-0. doi:10.1016/j.jaad.2022.05.024.
C. acnes specimens were acquired from 915 Chinese acne patients during 2017-2020. Macrolide resistance was detected in 75.5% of tested organisms. Researchers concluded that 23S rDNA mutations conferring MACROLIDE RESISTANCE are more widespread than previously thought.
TO READ MORE: Zhang J, et al. C. acnes qPCR-Based Antibiotics Resistance Assay (ACQUIRE) Reveals Widespread Macrolide Resistance in Acne Patients and Can Eliminate Macrolide Misuse in Acne Treatment. Front Public Health. 2022;10:787299. Published 2022 Mar 18. doi:10.3389/fpubh.2022.787299.
PEDIATRIC DERMATOLOGY
About 1% of children and adolescents are afflicted with PSORIASIS. This long-term (108 weeks) extension study of ixekizumab in a cohort of pediatric patients (age 6 to under 18) found that nearly 92% achieved Psoriasis Area and Severity Index (PASI) 75, 79% achieved PASI 90, and 55% achieved PASI 100. More than 78% achieved a static Physician’s Global Assessment (sPGA) of clear or almost clear. There were also high rates of clearance for palmoplantar, scalp, genital, and nail disease. Despite prolonged exposure, there were no new safety concerns elicited.
TO READ MORE: Paller AS, et al. Long-term Efficacy and Safety of Up to 108 Weeks of Ixekizumab in Pediatric Patients With Moderate to Severe Plaque Psoriasis: The IXORA-PEDS Randomized Clinical Trial. JAMA Dermatol. 2022;158(5):533-541. doi:10.1001/jamadermatol.2022.0655.
PSORIASIS
RESPONSE TO BIOLOGIC DRUGS lies on a bell-shaped curve. Some patients clear completely and remain in that state (super-responders), whereas others either fail (even multiple therapies involving different cytokine pathways) or rapidly lose response. A Danish retrospective analysis of 3280 patients over nearly an 18-year time span attempted to characterize which patients are likely to fall into these treatment response extremes. Patients in the “refractory” group tended to have a higher mean body weight and a higher BMI. Super-responders tended to be in a higher socioeconomic group, had fewer co-morbidities and had a low percentage of “ever-smokers.”
TO READ MORE: Loft N, Egeberg A, Rasmussen MK, et al. Prevalence and characterization of treatment-refractory psoriasis and super-responders to biologic treatment: a nationwide study [published online ahead of print, 2022 Apr 2]. J Eur Acad Dermatol Venereol. 2022;10.1111/jdv.18126. doi:10.1111/jdv.18126.
An international consensus working group (N=180) attempted to devise uniform METHOTREXATE DOSING recommendations for healthy and vulnerable adults, as well as for children with psoriasis. Twenty proposals achieved consensus; readers are urged to consult the original article to read these in detail. Of note, this group did not feel that a “maximum” dose could be determined for more frail individuals. Nor did they feel that a test dose was really required for low-dose methotrexate. Dosing and precise regimen of folic acid to be given with methotrexate remains open for future study.
TO READ THE CONSENSUS PROPOSALS: van Huizen AM, et al. International eDelphi Study to Reach Consensus on the Methotrexate Dosing Regimen in Patients With Psoriasis. JAMA Dermatol. 2022;158(5):561-572. doi:10.1001/jamadermatol.2022.0434.
Researchers evaluated 33 PSORIASIS CLINICAL PRACTICE GUIDELINES from the U.S., Europe, Brazil, Canada, and Japan. This critical evaluation utilized three different processes: the validated AGREE II tool, Lenzer’s red flags, and the Institute of Medicine’s trustworthiness criteria. (Readers are referred to the original article for details on the domains covered by each of the three.) Most guidelines scored well on scope, purpose, and clarity of presentation. But many guidelines had low quality when it came to stakeholder involvement, rigor of development, applicability, external review and updating procedures. It appears that this particular review favors the British Association of Dermatologists Guidelines for Biologic Therapy for Psoriasis 2020: A Rapid Update.
TO READ MORE: Yen H, et al. Systematic review and critical appraisal of psoriasis clinical practice guidelines: a Global Guidelines in Dermatology Mapping Project (GUIDEMAP) [published online ahead of print, 2022 Feb 13]. Br J Dermatol. 2022;10.1111/bjd.21047. doi:10.1111/bjd.21047.
Analysis of the Danish National Patient Register between January 1997 and December 2018 included 94,450 adult psoriasis patients and 566,700 matched controls. Patients with severe psoriasis had higher incidence RATES OF SEVERE OR RARE INFECTIONS compared with patients with mild psoriasis and non-psoriatic controls. Severe infections were defined as any infection requiring treatment in a hospital setting and rare infections included HIV, hepatitis B and C, and tuberculosis.
TO READ MORE: Loft N, et al. A nationwide population-based cohort study of the incidence of severe and rare infections among adults with psoriasis in Denmark [published online ahead of print, 2022 Apr 5]. Br J Dermatol. 2022;10.1111/bjd.21595. doi:10.1111/bjd.21595.
Editor’s note: While this cautionary study is interesting, it suffers from some serious limitations. For example, there was no correction done for type of treatment, and confounding factors (such as obesity and smoking) were also not taken into account.
ATOPIC DERMATITIS
A Spanish study pointed out that SEXUAL DYSFUNCTION was common among adults with moderate to severe atopic dermatitis. Treatment with dupilumab produced improvement in sexual functioning as evidenced by objective scores on validated surveys.
TO READ MORE: Linares-Gonzalez L, et al. Sexual dysfunction in a cohort of patients with moderate-to-severe atopic dermatitis. Influence of dupilumab treatment. Int J Dermatol. 2022;61(5):607-610. doi:10.1111/ijd.15938.
CONTACT DERMATITIS
Although not uniformly effective, DUPILUMAB has proven beneficial in many cases of otherwise refractory allergic contact dermatitis. Clinical effect may be seen in as little as 1-4 weeks or may take 4-6 months. There is contradictory evidence regarding the effect of dupilumab on patch testing.
TO READ MORE: Johnson H, et al. Dupilumab for Allergic Contact Dermatitis: An Overview of Its Use and Impact on Patch Testing. Cutis. 2022 May;109(5):265-267,E4-E5. doi:10.12788/cutis.0519.
INFECTIOUS DISEASES
A prospective study of about 400 patients presenting with pneumonia-like symptoms in Arizona (endemic area) were evaluated for a wide variety of findings to determine any that might be predictive of an ultimate diagnosis of COCCIDIOIDOMYCOSIS. In both outpatient and inpatient settings, the most sensitive predictor was elevated absolute eosinophil count. In the outpatient setting, the presence of a “rash” (not further specified) was a predictive sign of coccidioidomycosis.
TO READ MORE: Ramadan FA, et al. Cross-Sectional Study of Clinical Predictors of Coccidioidomycosis, Arizona, USA. Emerg Infect Dis. 2022;28(6):1091-1100. doi:10.3201/eid2806.212311.
The Massachusetts Department of Public Health confirmed a single case of MONKEYPOX in a man who recently traveled to Canada. As this is being written, there are multiple cases in multiple U.S. states. However, the United Kingdom has recently identified 20 cases and about 20 confirmed or suspected cases have been reported in both Spain and Portugal. Belgium, France, Germany, Italy, Holland, Sweden, Argentina, and the United Arab Emirates have also identified monkeypox cases. These most recent cases have been encountered mostly in men who have sex with men (MSM; gay or bisexual men). It should be noted that there is an approved vaccine against monkeypox and a medication to treat both smallpox and monkeypox.
TO READ MORE: Massachusetts Department of Public Health. Massachusetts public health officials confirm case of monkeypox (news release). 2022; May 18. Accessible at: https://www.mass.gov/news/massachusetts-public-health-officials-confirm-case-of-monkeypox. And this related article: Soucheray S. More nations report monkeypox; possible case in New York. Center for Infectious Disease Research and Policy (CIDRAP). 2022; May 20. Accessible at: https://www.cidrap.umn.edu/news-perspective/2022/05/more-nations-report-monkeypox-possible-case-new-york
Guidelines for the use of live, non-replicating MONKEYPOX VIRAL VACCINE have just been issued. They mostly apply to researchers, health care workers, military personnel, and first responders. However, some states have received doses of this vaccine for administration to close personal contacts of confirmed monkeypox patients.
TO READ THE PRECISE GUIDELINES: Rao AK, et al. Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(22):734-742. Published 2022 Jun 3. doi:10.15585/mmwr.mm7122e1.
Before the worldwide outbreak of monkeypox, some authors suggested that LACK OF SMALLPOX VACCINATION IN YOUNGER INDIVIDUALS AND WANING SMALLPOX IMMUNITY IN OLDER ONES might be setting the stage for precisely what we have now: a widespread monkeypox outbreak.
TO READ THIS SADLY CORRECT PREDICTION: Bunge EM, et al. The changing epidemiology of human monkeypox-A potential threat? A systematic review. PLoS Negl Trop Dis. 2022;16(2):e0010141. Published 2022 Feb 11. doi:10.1371/journal.pntd.0010141.
A report from Israel documents a new cause for facial pigmentation: Demodex infestation. Nineteen patients are described, both men and women, aged mid-40s through 70. Only 16% complained of itching or burning. Anti-demodex intervention (e.g., 1% ivermectin cream or 2.5% benzoyl peroxide gel) led to resolution of facial dyschromia. The authors have dubbed this “PIGMENTED DEMODICIDOSIS.”
TO READ MORE: Feuerman H, Atzmony L, Glick M, et al. Pigmented demodicidosis – an under-recognized cause of facial hyperpigmentation. Int J Dermatol. 2022;61(5):564-569. doi:10.1111/ijd.15992.
A good read: instructive report of a hypopigmented, painful, fungating perianal mass which proved to be CONDYLOMA LATUM, a manifestation of secondary syphilis. The patient sought medical attention for two months, being given various erroneous diagnoses and inappropriate therapies (sulfamethoxazole-trimethoprin, clotrimazole, valacyclovir, hydrocortisone and pramoxine creams, lidocaine gel, and imiquimod). Because of frequently ambiguous clinical presentations for perianal lesions, a biopsy and syphilis serology should always be considered.
TO READ MORE: Marinelli KC, et al. Painful Fungating Perianal Mass. Cutis. 2022 May;109(5):249,277-278 | doi:10.12788/cutis.0517.
A prospective, multicenter French study of 130 routine SCABIES patients found that, at day 28, 91.5% were clinically cured following two 24-hour applications of 10% benzoyl benzoate emulsion. At 12 weeks, among those cured at 28 days, 89.9% remained cured.
TO READ MORE: Caumes E, et al. A prospective cohort of patients with common scabies treated with 10% benzyl benzoate emulsion as monotherapy: EPIGALE study. Int J Dermatol. 2022;61(4):434-441. doi:10.1111/ijd.15879.
COSMETIC DERMATOLOGY
An experimental combination therapy containing LYT2 (hydroquinone and retinol-free brightener) and LVS (a broad antioxidant) proved very efficacious in REDUCING PATHOLOGICAL HYPERPIGMENTATION. Study subjects consisted of African American, Asian, and Hispanic individuals.
TO READ MORE: Desai S, et al. Assessment of Circadian-based Antioxidants Plus a Comprehensive Brightener in Skin of Color Patients With Hyperpigmentation. J Drugs Dermatol. 2022;21(4):376-380. doi:10.36849/JDD.6687.
CUTANEOUS ONCOLOGY, SURGERY AND LASERS
TO READ MORE: Di Carlo V, et al. Does the morphology of cutaneous melanoma help explain the international differences in survival? Results from 1,578,482 adults diagnosed during 2000-2014 in 59 countries (CONCORD-3) [published online ahead of print, 2022 Mar 29]. Br J Dermatol. 2022;10.1111/bjd.21274. doi:10.1111/bjd.21274.
Compared with the general population, patients with MULTIPLE MYELOMA appear to demonstrate a higher incidence of melanoma and increased overall mortality. Melanoma tends to occur 2-119 months following the myeloma diagnosis. This association holds true regardless of racial/ethnic background.
SOURCE: Singh P, Tomtschik J, Ibrahim S. Incidence and prognosis of melanoma in patients with multiple myeloma. Poster presented at 2022 American College of Mohs Surgery Annual Meeting. May 12-15, 2022, Philadelphia, Pennsylvania.
After correcting for underlying predisposing factors, data from Australia clearly demonstrates that the diagnosis of cutaneous melanoma, especially in-situ disease, goes up when considering those who participate in SKIN CANCER SCREENING programs.
TO READ MORE: Whiteman DC, et al. The effect of screening on melanoma incidence and biopsy rates [published online ahead of print, 2022 May 9]. Br J Dermatol. 2022;10.1111/bjd.21649. doi:10.1111/bjd.21649.
Researchers analyzed 108 patients with unresectable melanoma whose disease was progressing despite immune checkpoint inhibition therapy. Due to failure of pembrolizumab, nivolumab, or nivolumab plus ipilimumab, the patients received second line BRAF/MEK therapy. The objective response rate and disease control rate were actually quite good at 42.6% and 55.6%, respectively. Although immune checkpoint inhibition remains the treatment of choice for advanced melanoma, BRAF/MEK INHIBITION is an excellent second line approach.
TO READ MORE: Kreft S, et al. MAPKinase inhibition after failure of immune checkpoint blockade in patients with advanced melanoma – An evaluation of the multicenter prospective skin cancer registry ADOREG. Eur J Cancer. 2022;167:32-41. doi:10.1016/j.ejca.2022.02.023.
DRUGS AND DEVICES
Approval of the much-anticipated precision delivery system of cantharidin 0.7% (VP-102, YCANTH) has been denied by the FDA. The denial has nothing to do with drug safety or efficacy in treating molluscum. Instead, it was based upon deficiencies found at Sterling Pharmaceuticals, the contract manufacturer of the product.
SOURCE: Verrica Pharmaceuticals. Verrica Receives Complete Response Letter from the FDA for its NDA for VP-102 as a Direct Result of Deficiencies at General Reinspection of Sterling Pharmaceuticals Services, LLC. News release. May 24, 2022. Verrica Receives Complete Response Letter from the FDA for its NDA for VP-102 as a Direct Result of Deficiencies at General Reinspection of Sterling Pharmaceuticals Services, LLC – Verrica Pharmaceuticals
On May 4, 2022, the FDA approved a first-in-class RT-PCR MULTIPLEX DETECTION DEVICE FOR SEXUALLY TRANSMITTED DISEASES. The Alinity m-STI Assay (Abbott) can simultaneously detect Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, and Neisseria gonorrhoeae. The test takes about one hour to perform and can utilize endocervical or vaginal swabs or both male and female urine.
SOURCE: https://www.molecular.abbott/us/en/alinity-m-sti-assay
COVID19
POLICIES AND PROCESSES to facilitate COVID-19 health care are now facing expiration and a dubious future. For example, various federal and state waivers that allowed expansion of telemedicine are ending. A fund that provided near universal payment for COVID-related hospital care is now bankrupt. Enhanced premium subsidies to broaden Affordable Care Act (ACA) enrollment were only temporary and will expire at the end of 2022.
TO READ MORE: Levitt L. The Uncertain Future of Policies to Promote Access and Affordability Put in Place During the COVID-19 Pandemic. JAMA Health Forum. 2022;3(5):e221980. doi:10.1001/jamahealthforum.2022.1980.
InspectIR COVID-19 Breathalyzer (InspectIR Systems) uses gas chromatography–mass spectrometry to identify volatile organic compounds in exhaled breath that are associated with SARS-CoV-2 infection. During a study involving 2409 people, the BREATHALYZER correctly identified 91.2% of positive samples and 99.3% of negative samples. During maximal use, the instrument (the size of a small carry-on piece of luggage) can analyze 160 breath samples per day. This was just approved for emergency use by the FDA.
TO READ MORE: Rubin R. First Breathalyzer Test to Diagnose COVID-19. JAMA. 2022;327(19):1860. doi:10.1001/jama.2022.7700.
A retrospective EHR review of 353,164 COVID-19 cases and matched controls from the same source, indicated that 1 in 5 COVID-19 SURVIVORS developed an incident “long haul” sign or symptom; this number increased to 1 in 4 among those over age 65. The most common problems were persistent respiratory symptoms, acute pulmonary embolism, and myalgia/arthralgia.
TO READ MORE: Bull-Otterson L, Baca S, Saydah S, et al. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021. MMWR Morb Mortal Wkly Rep 2022;71:713–717. DOI: http://dx.doi.org/10.15585/mmwr.mm7121e1
Can COVID-19 VACCINATION INDUCE AUTOIMMUNE SKIN DISEASE? The most recent issue of International Journal of Dermatology contains articles documenting the close temporal relationship between vaccination and new onset or exacerbation of: morphea, alopecia areata, and bullous pemphigoid. Food for thought and cautionary for dermatologists!
TO READ MORE:
Metin Z, et al. A case of morphea following the COVID-19 mRNA vaccine: on the basis of viral spike proteins. Int J Dermatol. 2022;61(5):639-641. doi:10.1111/ijd.16062.
May Lee M, et al. Alopecia areata following COVID-19 vaccination: vaccine-induced autoimmunity? Int J Dermatol. 2022;61(5):634-635. doi:10.1111/ijd.16113.
Afacan E. et al. Can Covid-19 vaccines cause or exacerbate bullous pemphigoid? A report of seven cases from one center. Int J Dermatol. 2022;61(5):626-627. doi:10.1111/ijd.16086.