What's hot?
What's hot
January 30, 2018
In this monthly column, members of Dermatology World's Editorial Advisory Workgroup identify exciting news from across the specialty.
Lakshi Aldredge, MSN, ANP-BC
It seems like everywhere you turn, there is a new comorbidity associated with psoriasis. This is especially important to understand when it comes to caring for our pediatric patients with psoriasis. A recent update by Dr. Amy Paller and colleagues (www.uptodate.com/contents/psoriasis-in-children-epidemiology-clinical-manifestations-and-diagnosis) provides a comprehensive overview of psoriasis in children with a special focus on their risk for developing comorbidities. The article notes that pediatric psoriasis is associated with a higher risk of developing cardiovascular disease, including higher incidences of the specific CVD risk factors of obesity, hyperlipidemia, hypertension, and diabetes. Children with psoriasis also have a higher risk of developing psoriatic arthritis: in a U.S. study of 181 children with chronic plaque psoriasis, 19 (10%) also developed PsA. In addition, pediatric psoriasis is also associated with increased risk of anxiety, depression, and Crohn’s disease. Early screening for risk factors associated with these comorbidities can potentially prevent morbidity and increase the quality of life for pediatric psoriasis patients, enabling them to live happy and productive lives.
Rosalie Elenitsas, MD
Making the diagnosis of Szary syndrome is difficult and sometimes impossible for the dermatopathologist. The histopathological findings may show changes of mycosis fungoides (cutaneous T-cell lymphoma), but often they show eczematous features or changes resembling a drug reaction. A recent multicenter study examined the early manifestations of 263 cases of Szary syndrome (J Am Acad Dermatol. 77:4; 719-727). Erythroderma was an early sign in 25.5% of the cases, and 10.6% of the patients had plaques of mycosis fungoides. 54% of the patients had a nonspecific dermatitis or an atopic dermatitis-like rash.
For patients who do not develop eryrthroderma at presentation, there was a 5.0 year delay in diagnosis. Dermatologists must keep Szary syndrome in the differential diagnosis for refractory non-erythrodermic dermatitis. Examination of the blood for T-cell receptor gene rearrangement studies and for flow cytometry may be beneficial in making the diagnosis.
Christopher Messana, DO, JD
A retrospective cohort study recently published by Adamson et al concluded that a statistically significant percentage of patients in North Carolina with Medicaid received delayed treatment for melanoma compared to otherwise similar patients with Medicare or commercial insurance (JAMA Dermatol. 2017;153(11):1106-1113). This disparity persisted even after sophisticated statistical analysis to remove potential confounding patient factors such as age, sex, race/ethnicity, severity of illness, geographic location, AJCC tumor stage, tumor site, and year of diagnosis. The authors also took into account whether the diagnosing physician was a dermatologist or non-dermatologist given the potential delay of treatment that could be attributed to the coordination of care. The authors also report that nonwhite patients experience greater risk of delay of treatment as compared with white patients as well as patients who live in rural versus non-rural areas. Patients who had both the diagnostic biopsy and definitive surgical treatment performed by a dermatologist experienced the lowest adjusted risk of surgical delay compared with patients treated by a non-dermatologist.
While the study was not designed to answer many questions it raises, it does raise many compelling questions that require further investigation. Among them, what factors are involved in variation of time to treatment among patients including the specialty of the diagnosing clinician and the treating physician, patient’s type of insurance, their race/ethnicity, where they live, and other factors. Within our respective practices as dermatologists and leaders in melanoma diagnosis and treatment, we must attempt to identify variations in quality and timeliness of care among patients and eliminate them wherever possible.
Michel McDonald, MD
Individuals presenting with actinic keratoses may need more aggressive forms of treatment with chemopreventive agents if they have the Bsml single nucleotide polymorphism (SNP) (JAMA Dermatol. 2017;153(10):983-989). This polymorphism is a known vitamin D receptor (VDR) polymorphism. Signaling mechanisms involving the VDR exert protective effects against nonmelanoma skin cancer (NMSC). A total of 97 patients and 100 controls were tested, and a model including age, sex, and skin color was created to predict NMSC risk. Risk factors for NMSC development were light skin color, greater number of severe sunburns, and less ability to tan. Bsml mutation resulted in twice the likelihood of developing NMSC. A screening for the Bsml SNP may be helpful to emphasize to patients the role for photoprotection to help prevent NMSC.
Christen Mowad, MD
During the course of a day of seeing patients, dermatologists often encourage moisturizer usage in the management of many skin conditions and invariably patients request recommendations regarding which moisturizer to use. A recent study looked at the top 100 best-selling moisturizing products at three major retailers available online (JAMA Dermatol. 2017:153(11):1099-1105). The study found that lotions were the most popular at 59% of those purchased and were also the least expensive per ounce. Creams were the next most commonly purchased at 13%. When observing for allergens contained in these products, fragrance mix, paraben mix, and tocopherol were the most common allergens identified. Only 12% of the best-selling products contained no allergens as identified by the North American Contact Dermatitis Group (NACDG). Products free of all allergens as identified by the NACDG were no more expensive than those containing allergens; however, the term “dermatologist recommended” carried a higher price tag per ounce. Additionally, as we are all aware, the term “fragrance free” does not ensure that a product is free of fragrance. The authors confirmed this statement. At least 45% of those products claiming to be free of fragrance actually contained at least 1 fragrance or botanical allergen.
This study provides an interesting look at the best-selling moisturizers online, gives us a glimpse at what our patients are choosing, and reinforces the belief that lotions are more commonly purchased by our patients and that advertising claims do not always hold firm. Given the large number of choices available to our patients, we should remember to counsel our patients on the preferred vehicles to purchase and to avoid known allergens or those with high allergen content especially in those with sensitive or irritated skin.
Simon Ritchie, MD
A common concern among patients and dermatologists when treating psoriasis is the risk of the systemic medications used to treat the disease. Past observational studies have indicated an association between psoriasis and the development of malignancies, but it has not been clear if that was due to treatment or the underlying disease state. Fiorentino, et al recently reported in the November issue of JAAD the results of their study looking at the rate of malignancies in psoriatic patients both with and without systemic treatments (77:5; 845854.e5). They used a database known as PSOLAR, sponsored by Janssen, to identify 252 psoriatic patients who developed malignancies and matched them to 1008 psoriatics without malignancies. Their most significant finding was that 12 months or more of exposure to a TNF-alpha blocking agent led to an increased risk of malignancy (OR 1.54, p = 0.01). They found no risk of malignancy with methotrexate or with ustekinumab. Of particular significance was an odds ratio of 3.54 (p = 0.028) for the development of lung cancer within the TNF-alpha treatment group. This was a relatively small study of psoriatics with malignancies, and the wide confidence intervals associated with the findings imply that further, larger studies should be conducted to validate this data. However, until then it is reasonable to take this data into account when treating psoriasis patients with systemic therapies, especially those with a history of malignancy.
