What's hot?
What's hot
September 18, 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 clock is TICKing on emerging vectorborne diseases. Lyme disease, famously named for its endemicity in Old Lyme, Connecticut in 1975, has extended its geographic reach over the past 40 years to nearly 50% of U.S. counties. The CDC reports that the incidence of tickborne bacterial and protozoal diseases doubled from 2004 to 2016, and the true incidence of Lyme disease may be as much as 10x higher than the 30,000 reported cases each year.
A May 2018 Morbidity and Mortality Weekly Report and July Perspective article in the New England Journal of Medicine put a spotlight on the growing public health concern of tickborne diseases (Morb Mortal Wkly Rep. 2018 May 4;67(17):496-501; N Engl J Med. 2018 Jul 25. doi: 10.1056/NEJMp1807870. [Epub ahead of print]). In addition to the rapid rise in Lyme disease across the U.S., viral tickborne infection with Powassan virus has emerged as a cause of North American tickborne encephalitis. The Powassan virus appears to use the same vector as Lyme disease, Ixodes scapularis, suggesting that the spread of Lyme disease into new areas of the U.S. could portend a similar increase in this tickborne viral infection.
Dermatologists are on the front line of early diagnosis of Lyme disease, but not all patients will manifest erythema migrans, and laboratory confirmation is complicated by the timing of testing after tick exposure, the potential for co-infection with multiple pathogens, and the difficulty of distinguishing between current and past infection. Fortunately, newer assays are in development that may help overcome some of these limitations.
Deepti Gupta, MD
Antihistamines are widely used to treat pruritus in atopic dermatitis despite the lack of evidence for their efficacy. The American Academy of Dermatology guidelines on atopic dermatitis do not recommend the use of non-sedating antihistamines for the management of atopic dermatitis and recommend intermittent use of sedating antihistamines for pruritus-induced insomnia. Both are still widely prescribed across various physician specialties for atopic dermatitis (J Am Acad Dermatol. 2018; 79: 92-6). A common view is that sedating antihistamines are necessary to improve sleep in patients with atopic dermatitis with severe pruritus, but they may reduce sleep quality and rapid eye movement sleep. They may also have a lasting daytime effects on cognition, learning, and productivity. A recent study by Zee et al (J Am Acad Dermatol. 2018; doi: 10.1016/j.jaad.2018.04.020 [Article in press]) showed that patients with atopic dermatitis not only had delayed sleep latency, but also had almost 1,500 more nocturnal movements than case-matched controls clustered between 1 and 6 hours after sleep onset. Analysis of a small subgroup that took nighttime antihistamines showed improved sleep onset, but no difference in total number or timing of nocturnal movements, suggesting antihistamines do not have any effect on nocturnal pruritus. There was also a significant increase in the number of minutes of wake after sleep onset in the patients who took antihistamines at night versus those who did not, adding to mounting evidence that the common practice of using antihistamines to control pruritus associated with atopic dermatitis is not effective.
Corey Hartman, MD
What is the efficacy of microneedling combined with 5-fluorouracil in the treatment of vitiligo compared with tacrolimus? Although there are several treatment modalities that are available to repigment hypopigmented skin in vitiligo, none of the options are reliable or consistent for all patients. Previous procedural treatments such as intralesional triamcinolone injections and suction blister grafting have failed to provide repigmentation in a satisfactory manner.
Twenty-five patients with vitiligo were subjected to microneedling to two patches of vitiligo. One patch had application of 5-flurouracil and the other patch had application of tacrolimus. Subjects underwent treatment every two weeks for six months (total 12 sessions). Excellent improvement (greater than 75% repigmentation) occurred in 48% of 5-flurouracil-treated patches while only in 16% of tacrolimus-treated patches. On acral skin, 40% of the patches treated with 5-flurouracil achieved excellent repigmentation, while none of the tacrolimus-treated patches achieved excellent repigmentation. The 5-flurouracil-treated skin also experienced more inflammation and ulceration (J Cosmet Dermatol. 2018 Mar 12. doi: 10.1111/jocd.12440).
Microneedling combined with 5-flurouracil or tacrolimus is safe and effective for treatment of vitiligo. However, 5-flurouracil achieved a greater percentage of repigmentation than tacrolimus particularly on acral skin.
Michel McDonald, MD
At the most recent meeting of the American Medical Association (AMA) House of Delegates held in June, members of the Dermatology Section Council (DSC) addressed multiple issues relevant to dermatology. Recognizing the trend of consolidation of dermatology practices, the DSC sponsored a resolution which passed asking the AMA to study the positive and negative effects of private equity firms acquiring physician practices. Due to the current regulatory environment regarding compounding, the DSC also supported a resolution which calls on the AMA to work with United States Pharmacopeia to ensure that the requirements regarding compounding are not onerous to physicians and prohibitive to their current ability to provide medications to their patients. Other resolutions that were passed with input from dermatology included: MIPS relief asking the AMA to work with CMS to shorten the yearly data reporting period from one year to a minimum of 90 days (of the physician’s choosing) within the calendar year; drug shortages as a public health crisis; and drug pricing related to the role of pharmacy benefit managers and the need for transparency. The DSC continues to work on these topics throughout the year and at both the annual and interim meetings of the AMA.
Christopher Messana, DO, JD
As dermatologists and Mohs surgeons we are often asked our opinion regarding “alternative” or “natural” remedies for skin cancer. Patients commonly seek alternatives to evidence-based medicine and myriad alternative and herbal remedies for skin cancer can be found on the internet. The FDA does not regulate herbal supplements and a great deal of internet content can be very misleading to our patients.
Dermatologic Surgery published a very helpful “Review of Common Alternative Herbal 'Remedies' for Skin Cancer” that provides useful guidance for these conversations (2018 Aug 9. doi: 10.1097/DSS.0000000000001622 epub ahead of print). The authors reviewed the scientific literature regarding evidence in treating skin cancer for “black salve,” solasidine rhamnosyl glycosides, frankincense, cannabis, black raspberry, milk thistle, St. John’s wort, and turmeric. Each of these botanical compounds was assigned a D grade of recommendation according to the Oxford Center for Evidence-Based Medicine. The authors recommend that physicians should warn their patients that although some encouraging results have been reported with herbal preparations, those positive results have not been reproducible and are not robust enough to replace current standard therapies. Further, when used to treat skin cancer, herbal remedies may produce an incomplete cure and lead to a delay in diagnosis that can lead to exacerbation of disease including metastasis.
Christen Mowad, MD
Cultural practices including complementary and alternative medicine, traditional Chinese medicine, ayurvedic medicine, coining, cupping, acupuncture, and moxibustion are all increasingly being used by patients for the therapeutic management of many disease processes including those involving the skin. Dermatologists need to be familiar with these practices and inquire about them as they can result in cutaneous complications such as contact dermatitis, a range of drug reactions, and skin findings that can be mistaken for abuse as well as systemic toxicities. Additionally, cultural cosmetic practices such as henna, threading, bindi, and hair styling can also result in complications such as allergic contact dermatitis, scarring, keloids, hair loss, and infections. The authors of a recent two-part CME article review many therapeutic and cosmetic cultural practices and reported dermatologic and systemic complications (J Am Acad Dermatol. 79(1):1-29). Familiarity with the vast array of cultural practices — both medical and cosmetic — is important for physicians so as to enhance our ability to communicate with and care for our patients.
