What's hot?
What's hot
March 27, 2018
In this monthly column, members of Dermatology World's Editorial Advisory Workgroup identify exciting news from across the specialty.
Edward W. Cowen, MD, MHSc
Alopecia areata is frustrating to patients, parents, and practitioners, all of whom may be left with unsatisfactory response to standard therapy — typically topical or intralesional corticosteroids. However, new alopecia areata therapies may be on the way. JAK inhibitors are potent oral anti-inflammatory drugs; tofacitinib is approved for adults with rheumatoid or psoriatic arthritis and ruxolitinib is approved for myelofibrosis or polycythemia vera. Small series have suggested response rates similar to those seen with biologic therapies for psoriasis. However, responses are not seen in all patients and long-term treatment may be required to prevent recurrence of hair loss. Topical JAK inhibitors are currently in development that theoretically may provide the potential for longer term therapy with less safety risk.
In a recent update on alopecia areata management, Strazzulla et al. (J Am Acad Dermatol. 2018; 78:15-24), provide an algorithm for the current management of alopecia areata in children and adults, including where JAK inhibitor therapy may be a viable consideration. Although topical and intralesional corticosteroids are still the current standard of care, a variety of agents are now being re-purposed’ in clinical trials for alopecia areata.
Christopher Messana, DO, JD
There is a rapidly increasing incidence of skin cancer in the United States with significant costs to the health care system. Value-based health care requires development of validated and relevant outcome and quality measures for specialty services, including dermatology. In dermatology, as with other specialties, no standardized system currently exists for defining, measuring, and collecting skin cancer outcomes and quality data such as complications, local recurrence, and performance measures. Moreover, a review of the literature of the surgical treatment of nonmelanoma skin cancer demonstrates that there are numerous and inconsistent definitions of local recurrence.
To improve the practice of skin cancer surgery, the American College of Mohs Surgery appointed a Registry and Outcomes Committee tasked with standardizing key data elements/components of the surgical care process and developing an outcomes registry. The Committee created a clear and concise definition of local recurrence and defined the minimal surveillance period and tracking intervals after skin cancer surgery (J Am Acad Dermatol. 2016;75(5):1022-1031). The subcommittee’s useful algorithm should aid Mohs surgeons in demonstrating to all stakeholders the high degree of quality and value they provide to patients with skin cancer.
Corey Hartman, MD
Current available therapies for vitiligo include topical steroids, topical calcineurin inhibitors, vitamins, and narrow band UV-B phototherapy, but success is limited on these treatment modalities. There is only one FDA approved treatment, monobenzyl ether of hydroquinone (MBEH), which aims to depigment the remaining normal skin through destruction of melanocytes and does not restore pigmentation. Two recent case studies have described a novel treatment combination that has produced dramatic repigmentation (JAMA Dermatol. doi:10.1001/jamadermatol.2017.5778).
Tofacitinib, or Xeljanz, is a janus kinase (JAK) 1/3 inhibitor currently approved for the treatment of rheumatoid and psoriatic arthritis. You may have also heard about successful treatment of alopecia areata with this same medication. Two patients recently achieved 50-75% repigmentation after taking tofacitinib 5mg twice daily and having two full-body narrow-band UV-B treatments per week for three months. The mechanism of action in vitiligo may involve interferon-gamma, which signals JAK 1/2. It is important to note that treatment with tofacitinib alone was insufficient to produce repigmentation. The phototherapy stimulates melanocytes to migrate to the epidermis from their stem cell niche, while the tofacitinib suppresses the autoimmune response. Particularly interesting is that one of the two patients had previously been treated with MBEH and had achieved depigmentation, suggesting that the melanocytes that are destroyed by MBEH are in the epidermis only, leaving the stem cell melanocytes intact and available to be reactivated later. Although the results were remarkable and labs were normal, further studies are needed in a larger population of patients.
Michel McDonald, MD
Expedient surgical removal of stage I melanoma is associated with improved outcomes. A recent article (J Am Acad Dermatol. 2018;78:40-6) analyzed the time to definitive surgery in patients with stage I to III cutaneous melanoma. In their review 44.9% of stage I melanomas were treated greater than 29 or more days after biopsy and approximately 50% of stages II to III had treatment after 29 days. Patients with a longer time to treatment were older with a male predominance and multiple comorbidities. They were also more likely to have head and neck melanoma, a higher Breslow thickness, and a higher stage. Overall survival decreased in all stages if not treated within 90 days of diagnosis. In stage I, the critical time point which leads to worse outcomes in the 30-59 day group was between 43 and 56 days. While it is intuitive that shorter time to treatment is preferable, this study definitively demonstrates the effect of delayed treatment time on overall survival.
Deepti Gupta, MD
Pediatric melanoma is a rare but potentially fatal disease. Modified ABCD (amelanotic, bleeding, color uniformity, and de novo lesion of any diameter) criteria were developed to be used in conjunction with classic ABCD criteria (asymmetry, border irregularity, multiple colors, diameter >6mm) to improve detection of pediatric melanomas. Dermoscopy in adults can lead to early detection of melanoma, but there is little to date in the literature regarding pediatric melanoma. A recent article characterized the dermoscopic and clinical features of pediatric melanoma and parallelled them to the histologic features found in 52 cases of pediatric melanoma occurring across 9 institutions worldwide (J Am Acad Dermatol. 2018; 78:278-88). In this cohort, pediatric melanoma was classified into two main subgroups, termed spitzoid and nonspitzoid melanoma. The majority of melanomas were nonspitzoid melanoma (70%), which was found to be similar to adult type superficial spreading melanoma. They were often seen in adolescents, patients harbored melanoma risk factors such as fair skin type and family history of melanoma, and there were a high burden of mutations associated with the TERT promoter, activating BRAF proto-oncogene, and BRAF with suggestion of ultraviolet damage. On dermoscopy, a multicomponent pattern and nevus-like pattern were most observed with most common features of irregular globules, an atypical network, a blue white veil, atypical vessels, and a negative network. Patients presenting with a spitzoid melanoma were younger in age, rarely had risk factors associated with melanoma, lesions were nodular/polypoid in appearance, and arose de novo. These melanomas were invasive, thicker than nonspitzoid melanomas, and frequently ulcerated. They were more likely to be associated with chromosomal arrangements. On dermoscopy, a vascular pink spitz-like pattern was seen with presence of atypical vessels (polymorphic vessels, dotted vessels, and/or milky red areas) and shiny white structures. The presence of both red color and shiny white structures greatly increased the likelihood of the lesion being a spitzoid melanoma. Dermoscopy in conjunction with clinical characteristics can aid in improving the sensitivity of detection of pediatric melanomas.
Christen Mowad, MD
Tanning beds have been identified by the Food and Drug Administration as carcinogenic and now 42 states plus the District of Columbia have some form of legislation that prevents minors from using them. A recent telephone survey looked at compliance with these laws (JAMA Dermatol. 2018:154(1): 67-72). Unfortunately, the study found that 37.2% of the 427 tanning salons surveyed were noncompliant. Noncompliance was highest in rural areas at 45.5%, the South at 49.4%, and with independently owned salons at 43.9%. The length of time the law has been in effect was not significant in compliance rates. Dermatologists have been instrumental in getting legislation passed to limit minors’ access to tanning beds. This study showed that although laws limiting tanning are now in place in the majority of states, enforcement of these laws is lacking. We need to continue educating our youth on the dangers of tanning beds and we need to continue to work with our state legislators to help encourage measures that will increase compliance and enforcement of these laws.
