What's hot?
What's hot
November 29, 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
On Oct. 5, the U.S. FDA approved the Gardasil 9 human papillomavirus (HPV) vaccine for men and women between ages 27-45. Gardasil 9 is the 2nd generation’ HPV vaccine against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 and was initially approved in 2014 — replacing the earlier quadrivalent vaccine that is no longer distributed in the U.S. This approval is important from a medical economics as well as public health standpoint as it increases the likelihood of eventual insurance coverage for the vaccine, which, according to CNN.com ranges from $400-500 for a 3-dose vaccination (www.cnn.com/2018/10/05/health/gardasil-hpv-vaccine-approved-older-ages-bn/index.html).
The CDC currently recommends two doses of HPV vaccination at ages 11-12, citing data that 80% of people will become infected with HPV. Since the introduction of the vaccine 10 years ago, infection with HPV types that cause genital warts and cervical cancer has decreased 71% among teen girls. Importantly, the Vaccines for Children program offers the HPV (and other vaccines) at no cost to children under 18 who are Medicaid eligible, uninsured, underinsured, or of American Indian or Alaska Native descent.
On a related note, off-label use of the quadrivalent vaccine has been associated with improvement in recalcitrant cutaneous warts (JAMA Derm. 2010;146:475-7) and oral squamous papillomas (JAMA Derm. 2015;151:1359-63). Most recently, Nichols et al. used a combination of systemic and intratumoral delivery of the 9-valent HPV vaccine in an elderly woman with inoperable multiple cutaneous basaloid squamous cell carcinomas, which led to resolution of all tumors (JAMA Derm. 2018;154:927-30).
Deepti Gupta, MD
CARD-14 associated papulosquamous eruptions (CAPE) should be considered in individuals with a papulosquamous eruption, which are refractory to treatment and characterized by clinic features of both psoriasis and pityriasis rubra pilara (PRP) (J. Am. Acad. Dermatol. Sept. 2018: 79 (3): 487-493). Distinguishing features of CAPE are early onset of disease often before age one, facial involvement, and family history of psoriasis or PRP. Facial involvement presented early in disease course as symmetric, well-demarcated, thin plaques on the bilateral cheeks and chin, but sparing nasolabial folds. Other described features include erythema of ears, palmoplantar keratoderma, and some with classic islands of sparing’ and follicular papules as seen in PRP. Most notably, patients were recalcitrant to a wide range of therapies, but near complete response was seen consistently seen in 5 of 6 patients on ustekinumab, an IL-12 and IL-23 inhibitor. The pathogenesis of CAPE suggests that medications blocking IL-23 (guselkumab, recently approved for plaque psoriasis), IL-22, and IL 17 (secukinumab and ixekizumab) may provide therapeutic effect, as has been demonstrated with ustekinumab in this study. Therefore, genetic testing should be considered in suspected individuals to confirm CAPE and guide treatment based on their biology rather than patient’s insurance (J. Am. Acad. Dermatol. Sept. 2018: 79 (3): 441-442).
Corey Hartman, MD
Bacterial resistance continues to pose a significant public health concern. Over-prescription of antibiotics, poor infection control, and patients not finishing their entire antibiotic course all contribute to the problem. As a result, physicians are left with infections that are more difficult to treat and contain.
Impetigo is the most common bacterial infection in children. This acute, highly contagious infection of the superficial layers of the epidermis is primarily caused by Streptococcus pyogenes or Staphylococcus aureus. Traditionally, this infection has been easy to treat with oral antibiotics or topical mupirocin. However, mupirocin resistance is on the rise and being seen with increased prevalence.
Ozenoxacin, a novel topical antibacterial agent with potent bactericidal activity against gram-positive bacteria, has been developed as a cream for the treatment of impetigo. Researchers evaluated 411 patients across six countries, comparing ozenoxacin to placebo. Ozenoxacin demonstrated superior clinical success compared with placebo, which was evident after five days of therapy. It was well tolerated, with 8 of 206 patients experiencing adverse side effects — one of these was potentially related to the study treatment. None of them were serious (doi: 10.1001/jamadermatol.2018.1103).
Topical ozenoxacin is effective and well-tolerated in patients with impetigo and offers an alternative for skin infections that demonstrate resistance to available therapies, including mupirocin. This effect is shown by rapid onset of response and superior clinical and microbiological response compared with placebo.
Michel McDonald, MD
A biopsy of 3-4mm depth has the best chance of detecting perineural invasion (PNI) in cutaneous squamous cell carcinoma (cSCC) (Dermatol Surg 2018;44:1170-1173). Forty-five specimens with PNI were evaluated for this retrospective case series which include excisions, excisional biopsies, punch biopsies, and shave biopsies. The mean histologic depth of PNI was 2.7mm. The greatest average depth was 4.3mm. The majority of the cases with PNI in this series were on the head and neck. Although it appears histological, PNI in nerves less than or equal to 0.1mm does not affect five-year recurrence rates. Histopathologic PNI may result in changing of the tumor stage and therefore may affect treatment decisions. While PNI only occurs in 2.5% to 5.95% of cSCC, if suspicion is present, then at least a 3mm deep biopsy may be indicated. If performing a shave, the authors recommend considering a scoop shave or saucerization.
Christopher Messana, DO, JD
Atypical fibroxanthoma (AFX) is a fibrohistiocytic tumor with a relatively high rate of recurrence and a relatively low risk of metastasis. A systematic review and meta-analysis of the literature (likely the first such review to be published) comparing the incidence of tumor recurrence and the incidence of metastasis in AFXs treated with Mohs micrographic surgery versus wide local excision was published in the November 2018 Journal of the American Academy of Dermatology (2018;79(5):929-934). While the authors acknowledge the overall poor quality of published literature on the subject, Mohs surgery is associated with a lower local recurrence rate than wide local excision. When selecting treatment for patients with AFX, it is useful to recall that Mohs surgery enables complete margin assessment, whereas wide local excision permits microscopic evaluation of only a small fraction of the surgical margin.
Christen Mowad, MD
Skin cancer is the most common type of cancer in the United States and skin cancer rates continue to increase. UV light is a risk factor that can be adjusted by sun protection proper use and reapplication of sunscreen, protective clothing, etc. Patient compliance with sun protection – is highly variable. A study in JAMA evaluated traditional sun education regarding sun protection of a dermatologist-delivered intervention based on the Addressing Behavior Change (ABC) method. The ABC intervention is intended to be brief and – as stated in the article – focused on six aspects of sun protection including: Assessing the risk of sun exposure, willingness to use SPF, barriers to sunscreen usage, solutions to barriers, other methods of sun protection, and additional options for sun protection. This study demonstrated that replacing the usual conversation with a focus on information from the ABC method resulted in enhanced quality and satisfaction of patient communication, as well as fewer sunburns at one month and higher sunscreen usage and reapplication at three months on the face and body (2018(9): 1010-1016).
Given that skin cancer is the most common cancer in the U.S. and continues to rise, finding and implementing tools that can help decrease risk factors while enhancing patient-physician communication — if widely used and sustained over time — could result in an improvement in sunscreen usage among our patients and a decrease in sun-related skin cancer rates. Although this was a small study with a short follow-up time, the results are promising and demonstrate a new way of engaging and educating our patients so that they may become more compliant with sun protection.
