What's hot?
What's hot
May 31, 2019
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Edward W. Cowen, MD, MHSc
There are several FDA-approved options available for field therapy for the treatment of multiple actinic keratoses, including photodynamic therapy, ingenol mebutate, imiquimod, and 5-flourouracil. In a recent study from the Netherlands, investigators compared each of these options head-to-head in 624 patients with five or more actinic keratoses of the head and neck area (N Eng J Med. 2019; 380(10): 935-46). The treatment duration differed for each agent based on current recommended course, and patients could be re-treated with the same regimen once, if they did not meet the criterion of 75% clearance. All patients also received superficial curettage of lesions prior to therapy.
At 12 months after the end of the first treatment, 75% of patients treated with 5% 5-fluorouracil cream maintained a 75% reduction in the number of actinic keratoses (primary outcome), compared to 54% of patients receiving imiquimod, 38% receiving MAL-PDT, and 29% receiving ingenol mebutate. Additionally, patients receiving 5-flourouracil were least likely to require a second course of treatment at follow-up after completion of initial therapy. Among patients treated with 5-flourouracil, 15% required a second course of treatment, which was superior to MAL-PDT, imiquimod, and ingenol mebutate (35%, 37%, and 48% respectively).
As might be expected, compliance was greatest for those receiving one-time treatment (MAL-PDT; 97%) and a three-day course of therapy (ingenol mebutate; 99%), compared to four weeks of treatment with imiquimod (88%) or 5-flourouracil (89%). In addition, compliance with four weeks of treatment could be expected to be even lower in the real-world setting. Nonetheless, these data suggest that 5% 5-flourouracil cream provides superior long-term clearance of actinic keratosis in comparison to more recently approved field therapies.
Deepti Gupta, MD
Oral tofacitinib, a Janus kinase (JAK) inhibitor, is an emerging pathogenesis-directed treatment for alopecia areata (AA), and can be a promising therapeutic option for children. A case series in 13 adolescents (J Am Acad Dermatol. 2017; 76:29-32) receiving oral tofacitinib showed 70% of patients experiencing regrowth over a median of five months (range 2-16 months), and a more recent case series of four preadolescent patients (https://doi.org/10.1016/j.jaad.2018.08.041), ages 8-10, demonstrated regrowth in 75% of patients between three and six months on treatment. In both studies, dosing of 5mg BID was used and well tolerated. In the adolescent study, one non-responsive patient had AA for >12 years, mirroring data in adults where it has been observed that those with >10 years of disease were less responsive to oral tofacitinib. This could support the argument for early treatment of alopecia areata during onset in childhood and adolescence to prevent potentially irreversible hair loss. Though the sample sizes were small, oral JAK inhibitors should be considered, especially in patients experiencing psychologic impairment and negative effect on quality of life. Currently there are no long-term safety data in the pediatric population with oral JAK inhibitors and proper counseling regarding the risks, including severe infection and malignancy, should be had with patients and families.
Michel McDonald, MD
What dermatology content are your patients accessing on YouTube most frequently and how have trends changed? According to Dermatology Online Journal, about 93 million Americans have searched for health-related topics online. In September 2018, the primary type of dermatology content accessed under the search term dermatology’ was clinical demonstration (https://escholarship.org/uc/item/512863fv). This differed from a 2014 study of the same dermatology’ search term where the primary content accessed was educational. According to the article, clinical demonstration videos have blossomed since 2015 — especially after the popularity of Dr. Sandra Lee’s (Dr. Pimple Popper) YouTube channel. Overall, 42% of educational videos involved a medical professional. That is an increase from 2014 where 35% featured medical personnel. Interestingly, there is also a proliferation of medical student videos giving advice on rotations and the Match process. In contrast to some previous reports, thankfully, the search term tanning’ resulted in a majority of anti-tanning videos versus portraying it favorably. Search terms sun safety’ and sun protection’ saw increases in videos targeting sporting and occupational sun safety and sun-protective clothing. Finally, it is good for dermatologists to be aware that the search term skin cancer treatment’ showed that videos promoting alternative medicine therapies, especially black salve, are growing in popularity.
Christen Mowad, MD
Allergic contact dermatitis is a common dermatologic problem that we all encounter on a routine basis. Patch testing is the criterion standard for diagnosing this condition. A recent Dermatitis study evaluates the effectiveness of patch testing on improving allergic contact dermatitis and looks at prognostic factors that affect the clinical outcome and ability of patients to recall detected allergens (2019. 30(2): 135-141). The authors looked at 111 patients who were evaluated with Investigator Global Assessment (IGA) scores and Dermatology Quality of Life Index (DQLI) pre and post patch testing. They were divided into two groups: those that had relevant positive allergens detected, and the control group that did not have any relevant allergens. The authors found that in patients where allergens were found and avoidance instruction was provided, there was improvement in IGA and DQLI six months after testing. They also found that 75% of patients correctly remembered their allergens. This percentage was higher and more significant in patients who were female and who had higher baseline IGA and DLQI. Recollection of allergens was lower in those with greater than one allergen. More positive reactions to allergens also resulted in less improvement of IGA and DLQI, underscoring the difficulty associated with high number of allergens — given the need for more extensive lifestyle changes and difficulty in compliance.
This study reinforces the benefits of patch testing on the clinical course of contact dermatitis. It also highlights the necessary role of education in the management of ACD patients. Patients who made lifestyle changes and remembered and avoided allergens had the most significant improvements in IGA and DLQI. This study reminds us that we can significantly impact our patients with ACD, their clinical involvement, and quality of life through patch testing, education regarding allergen avoidance, and follow up.
