What's hot?
What's hot
April 26, 2019
In this monthly column, members of the Dermatology World Editorial Advisory Workgroup identify exciting news from across the specialty.
Mallory Abate, MD
Having trouble managing your patients with burning mouth syndrome? In the February edition of Dialogues in Dermatology, Dr. Roy S. Rogers III, professor at the Mayo Clinic in Scottsdale, Arizona, offers some excellent tips on how to approach these patients, as well as his workup and management pearls. Burning mouth syndrome most commonly occurs in women, middle-aged and beyond, and is often multifactorial in etiology. Dr. Rogers first recommends having the patient see the dentist to optimize dental health and rule out any dental trauma and ill-fitting hardware like dentures. Next, he recommends checking basic lab work for things like anemia, nutritional deficiencies, and diabetes. For treatment, he often starts with low-dose amitriptyline and titrates up to 30mg over several months, reminding us that all treatments with burning mouth syndrome take 12 weeks to note improvement. Other treatments include alpha lipoic acid and sublingual clonazepam. For all the details on this challenging disorder, check out the full interview at Dialogues in Dermatology.
Rosalie Elenitsas, MD
A BRCA1-associated protein (BAP1) inactivated melanocytic lesion has also been termed “BAPoma.” The initial description of these lesions included a clinical presentation resembling a dermal nevus and histopathology of a “combined nevus,” displaying a mixture of small nevus cells and large epithelioid/spitzoid cells, both associated with a lymphocytic infiltrate. The cells show loss of immunohistochemical staining with BAP1. In a recent study of 102 such lesions, the mean age of onset of these lesions was 30 years (J Am Acad Dermatol. 2018; 79:525-34). Patients with BAPomas may have germline BAP1 mutations and may be part of an autosomal dominant syndrome that is associated with increased risk of uveal melanoma, cutaneous melanoma, renal cell carcinoma, mesothelioma, meningioma, lung adenocarcinoma, and nonmelanoma skin cancer. At this point, indications for germline testing are not clear, but they should be considered in all these patients, especially if there is a personal or family history of BAP1-associated tumors (excluding nonmelanoma skin cancer). Identification of this population of patients is important, as BAPomas are detected earlier in life than the more life-threatening tumors such as uveal melanoma, mesothelioma, and renal cell carcinoma, which generally present in the fifth and sixth decades. Enhanced cancer screening protocols may benefit this population of patients.
Sylvia Hsu, MD
I love this study (J Am Acad Dermatol. 79(2): 360-61), since it validates what I have been doing for years. In this prospective, randomized study, the authors compared elliptical excision to punch incision in 40 patients with truncal 1-3 cm epidermal inclusion cysts (aka follicular cyst, infundibular type). The primary objective was to compare the two techniques on the basis of recurrence over 16 months. The secondary objectives were to compare scar length, procedure time, postoperative complications, patient satisfaction, and skin-specific quality of life. Compared with elliptical excision, punch incision significantly reduced scar length with no significant difference in recurrence rates. Punch incision has similar rates of postoperative complications and skin-specific quality of life improvements as those of elliptical excision. The authors conclude that punch incision is an effective method to remove epidermal inclusion cysts. The authors do not mention the size of the punch instrument. I most often use 8 mm and 10 mm punches to remove large cysts on the trunk.
Kenneth A. Katz, MD, MSc, MSCE
Cases of primary and secondary (P&S) syphilis in the United States more than quintupled from 1999 (N = 5,979) to 2017 (N = 30,644), with men who have sex with men (MSM) disproportionately affected. However, a recent CDC report documents an alarming increase in syphilis among heterosexuals associated with use of methamphetamine, injection drugs, and heroin (www.cdc.gov/mmwr/volumes/68/wr/mm6806a4.htm).
The CDC report analyzed national disease surveillance data, including behavioral risk factors of persons diagnosed with P&S syphilis, from 2013 to 2017. During those years, P&S syphilis rates among women and men increased 156% and 66%, respectively.
Increases in drug-related behaviors, however, occurred only among women and men who have sex with women (MSW). Reported methamphetamine use more than doubled from 2013 to 2017 among women (from 6.2% to 16.6%) and MSW (from 5% to 13.3%). Similar increases occurred with injection drug use, heroin use, and having sex with a person who injects drugs. Drug-related behaviors were more common in the West and less common in the Northeast.
Heterosexual transmission of syphilis has previously been linked to drug use (crack cocaine in the late 1980s and early 1990s). Drug use is associated with sexual behaviors that increase risk for sexually transmitted diseases and with decreased access to health care.
From a public health perspective, CDC recommends integrating substance abuse and STD programs. In the meantime, dermatologists should be aware of evolving trends in syphilis epidemiology and be vigilant for increases in syphilis among heterosexuals.
CDR Josephine Nguyen, MD, MHCDS
Trouble getting off-label meds? Flawed compendia are causing coverage denials for dermatologic conditions. A group of researchers reviewed two compendia used to make Medicare Part D coverage determinations for off-label prescribing in JAMA Dermatology, and found the compendia “incomplete, outdated, idiosyncratic, and unpredictable” for some chronic dermatologic conditions (doi:10.1001/jamadermatol.2018.5052).
When making coverage determinations for off-label prescribing, Medicare Part D recognizes two compendia: the American Hospital Formulary Service (AHFS) Drug Information and the DRUGDEX Information System. Deficiencies in the accuracy and completeness of these compendia could result in coverage denials for necessary, effective, evidence-based treatments leading to worse outcomes for patients. Off-label use is common in dermatology for both common and rare skin conditions. Evidence and FDA approvals for rare or refractory skin diseases are limited.
To assess the magnitude of the problem, Barbieri and his colleagues evaluated a list of 238 accepted treatments for 22 chronic, noninfectious, nonneoplastic dermatologic conditions that had at least four systemic therapies, including one considered first-line, but many not approved by the FDA. Only 73 treatments were listed in either compendium. Additionally, the literature used was often based on decades-old sources from the early Reagan area of 1984.
Researchers found the compendia disagreed with each other almost a quarter of the time, which suggests the approach used to develop them is incomplete and inconsistent. Additionally, more than two-thirds of the medications evaluated were not included in these compendia, including half of the medications with the highest evidence grade (double-blind clinical trial).
The researchers recommend new policies be put in place to better serve patients with rare diseases and diseases with few FDA-approved therapies. These policies should aim to reduce reliance on the compendia so that patients can access much-needed treatments.
The AADA’s Drug Pricing Task Force plans to submit a letter to CMS highlighting several cases of this coverage issue with potential recommendations. If you have experienced adverse coverage determinations due to the compendia, please contact ajohn@aad.org.
Christen Mowad, MD
When prescribing isotretinoin to adolescents, a common concern among patients and parents is the risk of depression or suicidal behavior with the use of this medication. If patients and parents were not already aware of this association, they are after signing the standard iPLEDGE consent form, which specifically comments on this risk. The first report of depressive symptoms with isotretinoin use was in 1983, and since then several studies have tried to elucidate the real relationship with various results. Huang, et al, in their article “Isotretinoin treatment for acne and risk of depression: A systematic review and meta-analysis,” sought to clarify this relationship by collating 31 previous studies on the matter. Their conclusion was that depression scores were no different for acne patients treated with isotretinoin versus alternative treatments (J Am Acad Dermatol. 2017 Jun;76(6):1068-1076.e9). In addition, the overall prevalence of depression decreased in patients treated with isotretinoin which indicates a protective effect. As dermatologists, we understand better than anyone the psychological impact that acne has on our patients, especially adolescents. To find that the presence of depression is more likely due to the acne itself instead of the treatment seems reasonable, as does the apparent protective effect of isotretinoin which we see when our acne patients respond to this medication. Although there were no randomized clinical trials in this analysis, it should prove useful in providing more context to our patients.
