What's hot?
What's hot
July 24, 2018
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Edward W. Cowen, MD, MHSc
The first human retrovirus, identified in 1980, was not HIV, but human T-cell lymphotrophic virus-1 (HTLV-1). It was reported in a patient with cutaneous T-cell lymphoma by Robert Gallo (who would co-discover HIV 3 years later) (Proc Natl Acad Sci USA. 1980;77(12):74157419). HTLV-1 infection may cause a myelopathy/spastic paraparesis syndrome or lead to adult T-cell leukemia/lymphoma (ATLL) with skin involvement resembling mycosis fungoides. And, similar to mycosis fungoides, ATLL can present with a smoldering or chronic variant characterized by patch and plaque disease or by acute leukemic involvement with lymphadenopathy, organomegaly, and hypercalcemia.
Although only a fraction of individuals infected with HTLV-1 infection develop ATLL (3-5%), seropositivity in endemic areas (Japanese, Caribbean, Aboriginal Australian populations) ranges from 10-45%. As with HIV, the virus is spread via sexual contact, mother-to-child transmission, and exposure to contaminated blood, suggesting that prevention strategies employed in the HIV/AIDS epidemic could control the spread of HLTV-1 in endemic areas.
In a May 10 open letter, Gallo and 59 other leading researchers and patient advocates called on the World Health Organization to undertake a global campaign against HLTV-1 using strategies proven to reduce the risk of transmission of HIV and hepatitis B and C virus (http://gvn.org/who). For instance, universal antenatal screening for HLTV-1 is mandated in Japan (the only country doing so), and has reduced the rate of mother to child transmission in that country from 20% to 2.5% (Lancet. 2018 May 12;391(10133):1893-1894). In the interim, dermatologists should remain vigilant regarding the possibility of HLTV-1 infection in patients with CTCL from endemic areas or with other risk factors such as IV drug use.
Deepti Gupta, MD
Biotin has become a popular dietary supplement recommended by dermatologists, both in the U.S. and abroad, to improve disorders of the skin, hair, and nails. Deficiency of biotin can lead to alopecia, dermatitis, and neuromuscular dysfunction. However, the data is limited on biotin supplementation to treat dermatologic conditions, especially in patients with normal biotin levels.
The Food and Drug Administration (FDA) issued a recent warning that consumption of biotin may lead to falsely elevated or diminished laboratory test results. A biotin-streptavidin based immunoassay is required for many examinations. A clinical trial in healthy adults taking 10mg of biotin per day for 7 days resulted in falsely diminished levels of thyroid stimulating hormone, parathyroid hormone, and N-terminal pro-brain natriuretic peptide, and falsely elevated free triiodothyronine. Misdiagnosis of Graves disease has been reported in euthyroid children and adults on biotin. Troponin levels have also been reported to be falsely diminished leading to one reported case of death.
Biotin supplementation should be discussed with patients and the lab should be notified if a test was done while a patient was taking biotin. Based on biotin pharmacokinetic data it is recommended that adults taking biotin 10mg/day wait 8 hours prior to labs being drawn, those taking 100-300mg/day wait 3 days, and children taking 2-15mg/kg/day of biotin wait 1 week (J Am Acad Dermatol. 2018; 78:1236-8).
Corey Hartman, MD
Harmful chemicals in black hair care products may affect health. A recent study found that hair care products used primarily by black women in the U.S. contain a variety of chemicals that have been linked to asthma, hormone disruptions, and even cancer (Environ Res. 2018 Apr 24. pii: S0013-9351(18)30151-8. doi: 10.1016/j.envres.2018.03.030. [Epub ahead of print]).
An analysis of 18 commonly used hair cosmetics such as relaxers (which chemically straighten hair), root stimulators, and anti-frizz products detected 66 chemicals with potentially toxic effects. The majority of such compounds were not mentioned on the products’ ingredient labels, researchers say. Eight in 10 of the products studied contained parabens and phthalates, which are known endocrine disruptors – substances that disturb the body’s hormone balance. Regular exposure to phthalates can cause early puberty and preterm births. The researchers also detected nonylphenol, a compound associated with obesity and a higher risk of breast cancer, in 30% of the hair treatments. These substances are mostly used as preservatives or plasticizers to create the products’ creamy consistency. Five of the compounds studied had the highest concentrations in products aimed at children, and the largest variety of chemicals was often present in products marketed for everyday use.
One problem the researchers identified was incorrect labeling. Some of the substances were not mentioned on the product packaging at all whereas others were referred to by vague terms such as “fragrances.” Black women are more likely than white or Hispanic women to suffer from hormonal diseases that are exacerbated by substances that disrupt hormonal balance. A 2016 study showed black women in the U.S. have higher concentrations of such chemicals in their bodies than do women from other ethnicities.
Michel McDonald, MD
Maintaining patient comfort and minimizing pain when performing multiple stages of Mohs surgery can sometimes be challenging. The use of 0.5% bupivacaine with 1:200,000 epinephrine as an adjuvant to 1% lidocaine with 1:100,000 epinephrine is useful in prolonging anesthesia in Mohs micrographic surgery (MMS) (Dermatol Surg. 2018;44:607-610). In a randomized trial of 51 patients undergoing MMS, all patients received 2.5ml of lidocaine with 1:100,000 epinephrine prior to the procedure. At the end of Stage 1, the first group of patients received 2.5ml of 0.5% bupivacaine with 1:200,000 epinephrine and a second group received 2.5ml of 1% lidocaine with 1:100,000 epinephrine. With a mean time of 76 minutes to retest, zero of the 20 patients given bupivacaine had a positive response to pain stimuli, and seven of the 25 patients receiving only lidocaine had a positive response to pain stimuli. While this study has limitations, bupivacaine does appear to be useful as an adjuvant anesthetic to decrease patient discomfort.
Christopher Messana, DO, JD
Earlobe keloids are a common and challenging problem. Many treatment options exist, including silicone gel/sheeting, intralesional steroid injection, surgical excision, excision followed by adjuvant radiotherapy, and injection of bleomycin, mitomycin, and imiquimod. While no uniformly effective treatment exists for keloids, surgical excision in combination with intralesional steroid injection is often effective. However, evidence-based treatment protocols for this approach are lacking.
A multispecialty retrospective review was published in the June 2018 issue of Dermatologic Surgery and demonstrated that surgical excision followed by serial injection along the suture line of intralesional triamcinolone acetonide 40 mg/mL at the time of surgical excision and at postoperative weeks 1, 2, 4, 6, 10, and 14 statistically minimizes the risk of earlobe keloid recurrence (Derm Surg. 2018; 44(6):865-9). In patients that received serial intralesional steroid injection following surgical excision, the recurrence rate was 26.2%. Interestingly, the authors found that after six injections the recurrence rate increased, perhaps, because these are the most challenging refractory cases.
The authors highlight the importance of postoperative treatment planning prior to surgery to maximize patients’ compliance with a serial injection treatment plan.
Christen Mowad, MD
Allergic contact dermatitis is a common cause of dermatitis in the United States. The system standard for diagnosing allergic contact dermatitis is patch testing, which allows for accurate diagnosis of the allergens that are causative in the dermatitis. The identification and subsequent avoidance of the causative allergens results in clearance of the dermatitis. The FDA-approved allergen series of 36 allergens has a reported detection rate of 66%. Testing beyond a screening series increases the ability to detect relevant allergens in the patient’s environment. Supplemental allergens are needed to better evaluate and diagnose a patient’s allergens. Although screening series are sometimes a reasonable way to begin the evaluation of a patient suspected of allergic contact dermatitis, comprehensive patch testing is often required to adequately assess patients, identify their allergens, and help resolve their dermatitis (Dermatitis. 29(3): 107-111). A patient’s history, physical exam, occupational, avocational, and personal care product exposure history is integral in selecting the additional allergens to test with. Patch testing is an effective way to evaluate and treat allergic contact dermatitis and expanded testing is most beneficial. This can dramatically improve the quality of life of the patients we treat. Providers who are familiar with the allergens, the process, and the allergen education and available resources are key to the success of this tool.
