What's hot?
What's hot
January 2, 2019
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Mallory Abate, MD
Many dermatologists still check baseline labs prior to prescribing oral terbinafine or griseofulvin for adults and children with dermatophyte infections, and then check again at a later point or periodically throughout therapy. However, results from a recent large retrospective study in JAMA Dermatology demonstrate that CBC and LFT lab monitoring for terbinafine and griseofulvin is unnecessary in adults and children without underlying hepatic or hematologic disease (doi:10.1001/jamadermatol.2018.3578).
In this study, which included laboratory data from 4,985 patients, the rates of AST/ALT elevations, anemia, lymphopenia, and neutropenia were low and equal to the baseline rates of abnormalities in the adult and pediatric populations. By forgoing unnecessary lab monitoring for these frequently prescribed medications, we can significantly decrease health care spending. As an example, according to the Centers for Medicare and Medicaid Services, the cost of a single ALT or AST test ranges from $7.20 to $7.40. A serum LFT panel costing $54.91 is often ordered with an additional venipuncture cost of $18.82. When applied to this study, the latter panel equals up to $325,296.76 in unnecessary LFT monitoring.
Rosalie Elenitsas, MD
Endocrine mucin producing sweat gland carcinoma. Are you familiar with this diagnosis? This neoplasm is a low-grade adnexal tumor that usually presents on or near the eyelid in elderly patients. It exhibits histopathological features similar to those seen in solid papillary carcinoma of the breast. Immunohistochemically, these tumors express epithelial markers (keratins) as well as neuroendocrine markers (chromogranin, synaptophysin, neuron specific enolase, CD56), but not CK20. Early tumors may be bland in appearance and easily misdiagnosed by pathologists, especially if mucin production is subtle. There is debate in the literature if the tumor represents a precursor to mucinous eccrine carcinoma, a lesion that is indistinguishable from metastatic mucinous carcinoma from the breast or gastrointestinal tract. In a recent issue of the Journal of Cutaneous Pathology, there are two articles on this topic. One article supports this stepwise progression utilizing array comparative genomic hybridization and BRAF pyrosequencing (2018; 45(9): 681-687), and in contrast, a second article suggests the two entities may not be related based on MYC expression (2018; 45(9):674-680). While more investigate work is needed on this topic, dermatologists should be familiar with this diagnosis.
Sylvia Hsu, MD
Pyoderma gangrenosum (PG) is not a diagnosis of exclusion. Through a Delphi consensus exercise, Maverakis et al (JAMA Dermatol. 2018; 154(4): 461-466) came up with one major criterion and eight minor criteria to diagnose PG. The histopathology is the one major criterion — a biopsy from the ulcer edge MUST show neutrophilic infiltrates. Histopathology stains and tissue cultures are not required to exclude the diagnosis of PG, since superinfection is possible. Exclusion of infection is best done through histopathology. If the one major criterion is not fulfilled, all the minor criteria do not count. The eight minor criteria are: (1) exclusion of infection, (2) pathergy, (3) history of inflammatory bowel disease or inflammatory arthritis, (4) history of papule, vesicle, or pustule ulcerating within four days, (5) peripheral erythema, undermining border, tenderness at ulcer site, (6) multiple ulcers, at least one on anterior lower leg, (7) cribiform or wrinkled paper scars at site of healed ulcer, and (8) decreased size of ulcer within one month of initiating immunosuppressive medication. To have the highest yield on histopathology, the biopsy should be taken during a flare before immunosuppressive medications are initiated.
Kenneth A. Katz, MD, MSc, MSCE
A Rocky lesson.
It was his very first day of residency, the doctor recalled (N Engl J Med. 2018 Oct 4;379(14):1299-1301. doi: 10.1056/NEJMp1806388), and he couldn’t answer his attending’s question during morning rounds. The newly minted doctor had, in fact, adequately presented the clinical details of a patient admitted for chest pain while walking his dog, but the resident had come up short when the attending asked, “What was the name of the dog?”
“I was stumped,” the doctor wrote. “Worse, I didn’t know why we needed to know. Nowhere in the books or the studies I’d read had a dog’s name contributed to the differential. But the attending took us back to the patient’s bedside and asked. Rocky,’ the patient said. And there followed a brief conversation that was more colorful than any other I’d had with a patient that day. It led to a transformation I did not fully appreciate at the time: there was an actual person behind that hospital-issued gown.”
It’s a wise lesson. The demands on doctors’ time are legion, from managing short appointments to mastering electronic health records, from documenting visits to dealing with prior authorizations. Those are critical tasks, of course, but they don’t necessarily help us find joy in the practice of medicine or stave off burnout. Knowing Rocky’s name, by contrast, just might.
Moving forward, I’ll try to remember to ask the name of the dog. And, when I know I have a real connection with a patient, I’ll even share the name of mine.
CDR Josephine Nguyen, MD, MHCDS
Dermatologists continue to be adversely impacted by drug shortages. The AADA is aware of the issue and is engaged with stakeholders, including manufacturers, suppliers, the U.S. Food and Drug Administration (FDA), and Congress to facilitate access to patient care. Many of these medications are sterile injectables including, but not limited to, lidocaine, lidocaine with epinephrine, sodium bicarbonate, and bacteriostatic saline.
How has the AADA addressed the drug shortages?
Recently, the FDA created a Drug Shortages Task Force to come up with long-term solutions to drug shortages. This announcement highlighted the issues with sterile injectables — namely the consolidation in industry and the need to produce large volumes to be profitable. In October 2018, the Drug Shortages Task Force met with the AADA in a listening session with other medical specialties on the clinical and economic impact of drug shortages. The AADA shared the difficulties dermatologists are having getting access to sterile injectables.
The AADA also conducted a survey of the general membership to see how drug shortages are affecting patient access and dermatologists’ ability to treat patients. The AADA presented results of the survey and emphasized the impact of the drug shortages at a public hearing with the FDA in November.
The AADA is also working in collaboration with many other medical associations on an ongoing basis to emphasize the impact of local anesthetic shortages with FDA staff.
What can you do?
Physicians are encouraged to stay informed on all drug shortages that are reported to the FDA and plan accordingly. The AADA has a drug shortages website where you can write to your members of Congress about the issue, and get resources on how to handle current shortages. The FDA and the American Society for Health-system Pharmacists also have websites with current shortage information available at www.fda.gov/Drugs/DrugSafety/DrugShortages/default.htm and www.ashp.org/Drug-Shortages.
Simon Ritchie, MD
The association between atopic dermatitis and allergic contact dermatitis has been difficult to prove in the past because several studies used different inclusion criteria and various strategies for performing patch testing of the patients. There has also been confusion over whether the patients had a current or past history of atopic dermatitis. In their recent article, “Allergic contact dermatitis to personal care products and topical medications in adults with atopic dermatitis,” in the December JAAD, Rastogi, et al sought to clarify the presence or absence of an association between atopic dermatitis and allergic contact dermatitis by attempting to control for the previously mentioned factors (doi: 10.1016/j.jaad.2018.07.017). They reviewed 502 charts of patients who had undergone patch testing with at least the North American Contact Dermatitis Group standard series and found that overall there was no difference between the rates of positive patch test reactions between patients with either a current or past history of atopic dermatitis and patients with no history of AD. However, when they evaluated specific allergens they did find significant differences in the rates of positive patch test reactions to personal care product ingredients and topical antibiotics (bacitracin, fragrance mix II, lanolin, cinnamal, chlorhexidine, tixocortal, and budesonide) between patients that currently have atopic dermatitis versus those without. Among patients with a past history of AD, they had significantly more reactions to cinnamal, cyanoacrylate, quarternium-15, and lanolin. More than 90% of these reactions were relevant for the patients with atopic dermatitis, reinforcing the idea that we should be considering allergic contact dermatitis as a potential exacerbating factor in atopic dermatitis patients with refractory disease.
