What's hot?
What's hot
February 26, 2019
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Mallory Abate, MD
Isn’t it interesting how some common warts that we treat seem to go away almost instantly but others persist despite multiple rounds of various treatments? What do we make of this? In the November edition of Dialogues and Dermatology featuring “Molluscum and Warts,” Dr. Tor Shwayder of Henry Ford Health System notes that cure rates might be dependent on the wart’s HPV type. Recent literature out of the Netherlands and Canada demonstrate that some HPVs, like HPV-1, seem to resolve regardless of any treatment, whereas others, like HPV-2, 27, and 57, don’t seem to respond well at all. For example, if a patient has a wart caused by HPV-1, you could put “common household detergent on it, it would get better, and everyone thinks it’s a miracle. But in reality, it was just luck that you had HPV-1.” More research on the relationship between HPV type and wart clearance rate is needed, and it is definitely a hot target for future research.
Rosalie Elenitsas, MD
The “line sign.” When we learn basic dermatopathology as residents, we are often taught to recognize morphea/localized scleroderma by a squared-off biopsy specimen. In his recent manuscript, Max Fung, MD, and his colleagues at UC Davis, analyzed the sensitivity and specificity of the “line sign” (Am J Dermatopathol. 2018; 40:873-878). The line sign was defined as a prominent and straight or linear interface produced by sclerotic reticular dermal collagen or subcutaneous septal collagen with the adjacent subcutaneous fat. They compared cases of morphea, sclerotic graft versus host disease, and necrobiosis lipoidica. They evaluated the cases for “line sign,” “cookie cutter sign,” “square biopsy sign,” high eccrine glands, and presence of mucin. The line sign and high eccrine glands were shown to be the most sensitive histopathologic features for diagnosing morphea. The specificity, however, was not high, likely because it represents a manifestation of collagen thickening. The line sign should be added to our ever-expanding list of clues for assisting in histopathologic diagnoses.
Sylvia Hsu, MD
A retrospective chart review of blood test results of almost 5,000 adults and children taking terbinafine or griseofulvin showed that rates of elevated aspartate aminotransferase levels, anemia, lymphopenia, and neutropenia were comparable to baseline levels (JAMA Dermatol. 2018;154(12):1409-16). When lab abnormalities did occur, they were low grade and did not require additional tests or discontinuation of the medication. Because severe drug-induced liver injury is rare and unpredictable, laboratory tests do not determine whether a patient will develop an idiosyncratic reaction. The authors suggest that monitoring laboratory test results during treatment with terbinafine or griseofulvin should no longer be performed in adults and children who do not have underlying hepatic or hematologic conditions. Instead, physicians should screen for underlying hepatic and hematologic disease, counsel patients on recognizing symptoms of hepatic toxicity (pruritus, jaundice, abdominal pain, flu-like symptoms), and perform a history and review of systems in patients taking longer courses.
Kenneth A. Katz, MD, MSc, MSCE
Like other medical fields, dermatology is no stranger to marketing, including marketing done by dermatologists. Some dermatology practices advertise, as do some of our professional societies. Some dermatologist “thought leaders” lecture on behalf of pharmaceutical companies, and others form their own companies that market dermatology-related products and services to their colleagues or the public.
Social media affords a newer, important channel for dermatology-related marketing. “Influencers” is the term for people, including dermatologists (www.harpersbazaar.com/beauty/health/g10289567/best-plastic-surgeons-on-instagram/), who can influence potential consumers via social media.
In all of the above examples, it’s dermatologists who are doing the marketing — or influencing, in social-media speak. But that’s not always the case. A provocative recent article in Slate (https://slate.com/technology/2018/11/medical-students-instagram-influencers-ethics-debate.html) — written by Vishal Khetpal, a medical student who’s also a freelance writer — describes the rise of medical-student influencers in social media.
Some of those medical-student influencers tout non-medically related goods and services. Others, according to Khetpal, hawk medically related — and sometimes dermatology-related — products. Some of the advice is sound, but some of it is not.
The ethics of influencing, Khetpal writes, are complicated, with the American Medical Association and other organizations lacking specific guidance for medical students moonlighting as influencers. (And what about residents, for that matter?)
Dermatology’s scope includes cosmetic concerns, making our field particularly fertile ground for influencers of all levels of training. To help retain the trust of the public, it’s time our specialty, and others in the house of medicine, start outlining guidelines for prospective social media influencers at all levels of training.
CDR Josephine Nguyen, MD, MHCDS
AADA members are representing dermatologists’ interests with compounding-related policymakers.
Allison Vidimos, MD, RPh, FAAD, and Seemal Desai, MD, FAAD, serve as physician representatives on the U.S. Pharmacopeial Convention (USP) Compounding Expert Committee and U.S. Food and Drug Administration (FDA) Pharmacy Compounding Advisory Committee (PCAC).
Dr. Vidimos is a pharmacist and a dermatologist and, in 2018, was selected to serve as one of three expert physician consultants to the USP Compounding Expert Committee. She has attended meetings and conference calls, providing valuable physician input during the ongoing revision of the 797 chapter on compounded sterile preparations. In her position, she cites and explains the literature on the safety of how dermatologists currently practice in the office setting, and demonstrates the safety, practicality, cost effectiveness, and efficiency of in-office compounding — especially regarding buffering lidocaine for patient comfort.
Dr. Desai is serving his second term on the FDA PCAC as a voting member. As the only dermatologist currently serving on the committee, he established collegial and collaborative relationships with high-level officials at the FDA, bolstering the AADA’s advocacy on compounding, especially with respect to the regulation of in-office preparations. He helped advocate for ingredient access and policies that are meaningful to our board-certified dermatologist family and our patients.
In addition to these current roles, Drs. Desai and Vidimos participated in a critical meeting in November 2018 with USP, FDA, and CDC leadership, making great strides in helping these organizations understand how our practices operate with quality and safety, and reiterating the need for extending the currently proposed one-hour exemption from the chapter’s requirements, which would affect how far ahead buffered lidocaine can be used, for example. The final revised version of chapter 797 will be forthcoming this year.
Simon Ritchie, MD
Most dermatologists are aware that solid organ transplant recipients (SOTRs) are at high risk for the development of cutaneous malignancy, specifically cutaneous squamous cell carcinoma. While there are several reasons why this is the case, the underlying etiology is that immune suppression drives oncogenesis and suppresses the immune system’s ability to detect and eliminate malignant cells. However, translating this basic understanding of risk into enhanced clinical outcomes for SOTRs can be difficult as there are no guidelines on workup and, therefore, it is difficult to know if we are under- or over-treating these patients. Many SOTRs will never develop a SCC, and many who do will go on to have a clinical course resembling that of the general population. So, what features of a SCC in an organ transplant recipient indicate that they are at high risk for poor outcomes? Lanz, et al, in the January edition of JAMA Dermatology retrospectively evaluated 51 SOTRs who experienced nodal or distant metastases, or death due to a SCC and correlated their outcomes to features of the SCC upon initial diagnosis. They found that SCCs that caused these outcomes had a median diameter of 18 mm, a median depth of 6.2 mm, and 41% and 39% demonstrated poor histologic differentiation and perineural invasion, respectively. The five-year survival of this cohort of SOTRs was only 23%. This article provides a general sense of when to consider further evaluation of SCCs in SOTRs, to include either MRI (for perineural invasion), or CT (for bone or nodal involvement), along with a complete and thorough physical examination (JAMA Dermatol. 2019;155(1):66-71).
