What's hot?
What's hot
August 23, 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 over-checking labs for your acne patients on isotretinoin? An article from the JAAD’s Best of Acne Reprint Collection, June 2018, provides us with an evidence-based approach (Reprinted from J Am Acad Dermatol. 2016;75:323-328). The study reviewed 8 years of laboratory data from 515 acne patients undergoing 574 courses of isotretinoin and determined the frequency, timing, and severity of lab abnormalities. Clinically insignificant leukopenia or thrombocytopenia occurred in 1.4% and 0.9% of patients, respectively. Abnormal values tend to resolve or remain stable throughout therapy. Thus, routine monitoring of CBC is unwarranted, which is in agreement with a JAMA meta-analysis on appropriate isotretinoin lab monitoring (JAMA Dermatol. 2016;152(1):35-44). The JAAD study found a low prevalence of clinically significant liver and lipid abnormalities. Further, most lab abnormalities developed after the first month of therapy (few developed at 30 days from baseline testing). Keeping in mind the overall cost savings that would result from eliminating unnecessary lab monitoring, the authors urge us to re-examine our laboratory monitoring practices for our patients on isotretinoin. They conclude that in healthy patients with no significant personal or family history and normal baseline liver function and lipid panel results, repeated testing can be deferred until after 2 months of therapy and future labs may not be necessary if previous labs are normal. Routine CBC monitoring is not recommended.
Rosalie Elenitsas, MD
The American Society of Dermatopathology recently published the first appropriate use criteria in dermatopathology. This was a joint publication in both the Journal of Cutaneous Pathology (doi: 10.1111/cup.13142) and the Journal of the American Academy of Dermatology (doi: 10.1016/j.jaad.2018.04.033). These criteria were developed using the RAND/UCLA appropriateness methodology for 211 clinical scenarios. This methodology included detailed literature review in combination with opinions by expert pathologists and dermatologists. The group evaluated the following: gene rearrangement clonality studies in cutaneous lymphoid infiltrates; the use of FISH, CGH, and RT-PCR in atypical melanocytic lesions; staining for human papillomavirus, immunohistochemistry for Muir-Torre mismatch repair; and FISH for dermatofibrosarcoma protuberans and clear cell sarcoma. Important points to remember are that these ancillary studies were not compared with one another but were graded alone, and recommendations were made without cost considerations and coverage by insurance. Additionally, it is always important to know that utilization decisions about a particular test must be made for each individual patient and their particular clinical scenario despite these recommendations. The paper also reminds us that these recommendations may be refined as new information and studies become available.
Sylvia Hsu, MD
The AAD endorsed the final guideline on the management of chronic urticaria, published this year (Allergy. doi:10.1111/all.13397). Recently, chronic urticaria has been divided into two categories: chronic spontaneous urticaria (CSU) and chronic inducible urticaria. The term chronic spontaneous urticaria is used to indicate chronic urticaria that is endogenous, and independent of any external physical stimulus, which does not imply knowing or not knowing the cause. Chronic inducible urticaria includes cold, pressure, solar, heat, aquagenic, and contact urticaria. The guideline recommends a limited workup for CSU (e.g., thyroid function tests). Non-sedating H1-antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine) are first-line treatment for chronic urticaria. If the patient does not respond, then the dosage can be increased up to 4 times the recommended dose. Omalizumab is recommended for patients who fail the increased dose of H1-antihistamines. Cyclosporine is recommended for patients who have failed both antihistamines and omalizumab. The guideline recommends against the long-term use of systemic corticosteroids in treating chronic urticaria, although a short course (10 days) may be used, if necessary. The guideline states that the following drugs do not have proven benefit for chronic urticaria: H2-antihistamines, dapsone, and leukotriene receptor antagonists (e.g., montelukast).
Kenneth A. Katz, MD, MSc, MSCE
The United States is grappling with an opioid epidemic involving both prescription and illicit opioids. The data are startling. Opioid overdose deaths quintupled from 1999 to 2016, when over 42,000 opioid overdose deaths occurred. Even short opioid courses can lead to long-term use, with probabilities sharply increasing after five days of treatment (Morb Mortal Wkly Rep. 2017;66:265-269).
Dermatologists’ opioid prescribing patterns were investigated in a study of Medicare data from 2014 (JAMA Dermatol. 2018;154:317-322). Among over 12,000 dermatologists, 42% wrote no opioid prescriptions, 43% wrote 110 opioid prescriptions, and 15% wrote > 10 opioid prescriptions. Dermatologists writing > 10 opioid prescriptions prescribed, on average, 1 prescription lasting 4.4 days for each beneficiary. Dermatologists in surgical practices accounted for nearly 95% of the top 1% of opioid-prescribing dermatologists.
The authors then projected adverse effects of dermatologists’ opioid prescribing on Medicare beneficiaries. Those findings are also startling. They include continued opioid use at 1 and 3 years by up to approximately 7,600 persons and up to approximately 4,000 persons, respectively; gastrointestinal and central nervous system adverse effects in up to approximately 23,000 persons; and fractures suffered by up to approximately 1,000 persons.
To minimize opioid prescribing, the authors suggest following a dermatology-specific algorithm for acute postsurgical pain management (J Am Acad Dermatol. 2015;73:543-60) in which acetaminophen and NSAIDs are first-line, with opioids in combination with NSAIDS considered only in high-risk cases. That’s sound advice for dermatologists as we do our part to combat the opioid epidemic.
Conflict of interest disclosure: I am associate editor of JAMA Dermatology.
CDR Josephine Nguyen, MD, MHCDS
What’s happening to my sunscreen? In July 2018, Hawaii’s governor signed into law a prohibition on the sale and distribution of sunscreens containing oxybenzone and octinoxate, citing environmental concerns (it will take effect in 2021). Although evidence does not definitively implicate oxybenzone or octinoxate, they may be one of many factors adversely impacting marine life. News reports suggest similar legislation may be introduced in other states.
The Center for Biological Diversity, a non-profit environmental organization, brought this to the federal arena by petitioning the U.S. Food and Drug Administration (FDA) to ban oxybenzone and octinoxate in sunscreens and other personal care products. If the ingredients are not banned, they asked for an environmental impact assessment of these ingredients.
Given the mounting concerns about two widely used ingredients, the AADA is increasingly focused on advocating for the FDA and industry to agree upon required safety testing so new sunscreen ingredients can be used in formulations in the U.S. Currently, eight sunscreen active ingredient applications are pending because FDA determined there was insufficient safety data. This safety data includes human clinical safety studies, human safety data, and nonclinical animal studies. Notably, in May 2018, FDA Commissioner Scott Gottlieb, MD, called on industry to perform additional safety studies.
As the AADA continues advocating for new safe and effective sunscreen ingredients, the Academy recommends a comprehensive sun protection plan that includes applying sunscreen, seeking shade, and wearing protective clothing. Those who are concerned about certain sunscreen ingredients can choose physical sunscreens containing the active ingredients zinc oxide or titanium dioxide.
Simon Ritchie, MD
It is well established that patients with psoriasis have an increased risk of several metabolic conditions such as diabetes, obesity, hypertension, etc. In addition, we know that their risk of cardiovascular events such as MI and CVA are higher than matched controls. Even though the link between psoriasis and these comorbidities has not been fully elucidated, over the past several years there has been a growing body of evidence to suggest that treating psoriasis with certain classes of medications (such as TNF-alpha inhibitors and methotrexate) can lower this risk. Adding to this body of evidence is an article by Wu, et al (The risk of cardiovascular events in psoriasis patients treated with tumor necrosis factor-a inhibitors versus phototherapy: An observational cohort study. J Am Acad Dermatol. July 2018;79(1):60-68) that retrospectively compared two large groups of psoriatics treated with either TNF-alpha inhibitors or phototherapy. They found that psoriatics treated with TNF-alpha inhibitors had a decreased risk of cardiovascular events compared to those treated with phototherapy (HR 0.77, p=.046). Although not conclusive given the study design, this study is an important addition to the growing body of evidence that shows when we consider therapeutic options for psoriasis we may need to also consider the differing cardiovascular protective effects of the various options.
