What's hot?
What's hot
October 30, 2018
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Mallory Abate, MD
Are you familiar with “fish pedicures” and their risks? Fish pedicures are pedicures in which the feet are immersed in a tub filled with the fish Garra rufa —more commonly known as “doctor fish.” They nibble on human skin and have gained international popularity over the past 10 years due to claims they can make feet smoother, improve circulation, eat away bacteria and fungus, and combat skin diseases like psoriasis. However, a recent and highly publicized JAMA case report by Dr. Shari Lipner examines a patient who developed onychomadesis of her toenails after receiving a fish pedicure and reminds dermatologists of the inherent risks associated with these trendy foot treatments (JAMA Dermatol. 2018 July 3; [Epub ahead of print]).
First, the tubs cannot be cleaned between customers when the fish are present, and the fish cannot be disinfected or sanitized, posing the risk for spreading infection. In fact, pathogenic bacteria have been found in pedicure water and there have been reports of S. aureus and Mycobacterium marinum infections. Further, according to the CDC, Chinese Chinchin is a fish that is often mislabeled as Garra rufa and actually have teeth that can draw blood, increasing the risk of infection. Thus, when it comes to this foot fad, it is best to educate our patients to steer clear!
Rosalie Elenitsas, MD
Atypical intraepidermal melanocytic proliferation (AIMP). Is that really a diagnosis? Getting this diagnosis on your pathology report is frustrating for most dermatologists. It is unclear if it is a benign or malignant diagnosis. In a busy practice, this descriptive diagnosis can be an inevitable event, especially if melanocytic lesions are biopsied at an early stage in their evolution. AIMP describes a proliferation of predominantly single melanocytes in the epidermis without clear development of either a nevus or melanoma in situ.
Dr. Etzkorn and his colleagues recently described their experience of Mohs micrographic surgery for atypical intraepidermal melanocytic proliferation in JAAD (doi:10.1016/j.jaad.2108.06.058). Their retrospective review included 223 such lesions of the head, neck, hand, foot, or pretibial region that were treated with Mohs surgery. Interestingly, 42 (18.8%) lesions upstaged to unequivocal melanoma in situ or invasive melanoma. Subclinical spread was present in approximately 24%. It is important for dermatologists to recognize that this diagnosis may be unavoidable even with the most experienced dermatopathologists. Re-excision of AIMP may be necessary in many cases to exclude malignant melanoma.
Sylvia Hsu, MD
Based on a search in the LiverTox database of the National Institutes of Health, PubMed, and Embase for terbinafine-associated severe drug-induced liver injury, reviewers found that patients who had terbinafine-associated liver injury were always symptomatic (Br J Dermatol. 2017 Nov;177(5):1279-1284). There were 38 papers with 69 symptomatic patients. Most cases of terbinafine-induced liver injury occurred between 4 and 6 weeks after starting the drug. Patients experienced symptoms on average 15-16 days (range 0 to 42 days) until seeking medical attention. No asymptomatic patient was identified by checking liver function tests. There was no time point at which lab monitoring was helpful, and the authors do not recommend monitoring of liver function tests on terbinafine. However, patients should be advised to discontinue treatment and seek medical care when symptoms (jaundice, abdominal pain, flu-like symptoms, dark urine, severe pruritus) of drug-induced liver injury occur.
Kenneth A. Katz, MD, MSc, MSCE
Skin cancer screening by dermatologists is clearly effective at finding skin cancers. In the AAD’s national skin cancer screening program from 1986 to 2014, nearly 2 million screenings yielded clinical diagnoses of over 20,000 melanomas, over 30,000 squamous cell carcinomas, and nearly 130,000 basal cell carcinomas (JAAD, https://doi.org/10.1016/j.jaad.2018.05.1242).
But the point of cancer screening is not to find cancer. Rather, it’s to reduce morbidity and mortality. That’s something skin cancer screening has not been proven to do. Indeed, initial optimism over the SCREEN study, in which melanoma mortality fell nearly 50% after implementation of skin cancer screening in a German state in 2003-2004, has dissipated. Questions arose about attribution of causes of death in the study and about effects of the study’s public education component. Moreover, melanoma mortality reductions did not persist over time. Finally, melanoma mortality in Germany overall actually increased after nationwide rollout of skin cancer screening.
In 2016, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its assessment that current evidence is insufficient to recommend skin cancer screening for asymptomatic adults who are not at high risk. USPSTF called for more research on skin cancer screening, recognizing the challenge of conducting a randomized clinical trial (RCT) given relatively low rates of melanoma mortality, even among those at high risk.
The feasibility of conducting an RCT continues to be hotly debated (BJD, 2018;179:532-533; BJD 2018; Aug 13. doi: 10.1111/bjd.17089). In the meantime, the jury is still out on the effectiveness of skin cancer screening in the general population.
CDR Josephine Nguyen, MD, MHCDS
What is the USP and how does it affect my ability to buffer lidocaine and reconstitute botulinum toxin? The United States Pharmacopeial Convention (USP) is an independent, standard-setting organization that is currently revising its chapter on compounded sterile preparations. This chapter consists of equipment and process requirements that individuals who are performing compounding must follow, should a relevant policymaker (e.g., state board of pharmacy) adopt and enforce this chapter.
USP considers compounding’ as the “process of combining, admixing, diluting, pooling, reconstituting, repackaging, or otherwise altering a drug or bulk drug substance to create a sterile medication.” This definition categorizes low-risk medications that dermatologists prepare daily as compounding.’ Specifically, (1) lidocaine with epinephrine buffered with sodium bicarbonate, and (2) botulinum toxins reconstituted with bacteriostatic saline, are considered compounded medications because they are not mixed according to manufacturers’ labeling. USP is proposing a one-hour exemption from the chapter’s requirements but that is not nearly long enough. This one-hour exemption would potentially disrupt surgical procedures and clinic flow as well as create medical waste.
If dermatologists are subject to this chapter (i.e., having to buffer lidocaine in a laminar airflow system), patient access would be adversely impacted, and dermatologists as well other specialties and health care providers would be subject to an unreasonable burden. For many practices, it is important to have buffered lidocaine syringes and reconstituted botulinum toxins ready ahead of patient visits. The AADA is advocating for increased time and preparation-specific exemptions. Now is the time to advocate for our specialty and our patients.
Simon Ritchie, MD
When should we initiate chemoprevention with topical therapies in our high-risk skin cancer patients? For most of us, it probably comes down to a simple question: Does treatment with these modalities actually decrease the future burden of skin cancer, and does the upfront cost justify any long-term savings that may be gained? While most dermatologists likely agree that these modalities decrease the incidence of AKs and NMSC, the long-term cost savings is likely less obvious.
Yoon, et al, in their recent JAAD article “Impact of topical fluorouracil cream on costs of treating keratinocyte carcinoma (nonmelanoma skin cancer) and actinic keratosis” (Sept. 2018; 79(3):501-7) determined that for high-risk skin cancer patients in their VA population a single course of twice daily use of 5% 5-fluorouracil for up to 4 weeks as tolerated led to an overall cost reduction in AK/NMSC related treatment of $771 per patient over three years. When extrapolated to all VA patients treated for NMSC they estimated that this intervention could save $69 million over 3 years. The comparator group in this study was a placebo cream, so the cost savings of topical therapy versus cryotherapy is not clear. However, a take-home point of this article is that high-risk patients — regardless of their current AK burden — will experience less need for AK/NMSC related treatment (thereby lowering costs) for at least 3 years with just a single course of 5% 5-fluorouracil.
