This month's news from across the specialty
What's hot
August 1, 2020
In this monthly column, members of Dermatology World's Editorial Advisory Workgroup identify exciting news from across the specialty.
Mortality associated with the COVID-19 pandemic has varied between countries. Among the population-based factors that may account for these differences (e.g., access to health care, age of population), low vitamin D has been proposed as a potential risk factor. Many Northern Hemisphere countries have been severely impacted by COVID (during winter months), and a recent European cross-sectional study demonstrated an apparent correlation between COVID-19 mortality and country-wide mean 25-hydroxyvitamin D levels. In addition, a 2017 meta-analysis found an association between very low vitamin D status and risk of respiratory infection (BMJ. 2017; 356: i6583). Proposed mechanisms for vitamin D protective effects include production of respiratory tract anti-microbial peptides and anti-inflammatory properties. This preliminary data need to be confirmed, but the UK is already recommending vitamin D supplementation until the fall during the COVID pandemic. Given the particular risk of COVID-19 to the nursing home population and high likelihood of vitamin D deficiency in this setting, it may be prudent to consider vitamin D supplementation for this particularly vulnerable population.
Amidst an acute public health crisis that is transforming medicine a more chronic festering public health crisis has come to light: Structural racism and its effect on access to care, quality of care, and resultant health disparities (doi:10.1056/NEJMe2021693). Discrimination and racism have long-term effects of health and mortality and are important social determinants of health. They have shown to act through biologic pathways that accelerate aging, impede vascular and renal function, and promote cerebrovascular disease.
We see the effects of racial biases evident within our own literature with pictures of COVID toes being predominantly pink and white even though it’s a disease which disproportionately affects Black Americans. Structural racism has significant effects on atopic dermatitis severity (Ped Derm. 2020;37:142–146), and melanoma in patients with skin of color (Cancer Cytopathol. 2020 Jan;128(1):7-8). Dermatology is one of the least diverse specialties and there are perceived barriers among minority medical students when considering careers in dermatology (JAMA Dermatol. 2019 Feb 1;155(2):252-254). Racial biases have also had effects on health care spending, access to care, and increasing mortality gap between black and white patients.
What can we do as individuals and as a specialty?
Be aware of the effects of health disparities and structural racism on our patients and their disease manifestations.
Become more conscious of our biases when we care for minority patients and tailor the patient’s care accordingly.
Develop a more diverse workforce in our residency programs and on our medical faculty.
Acknowledge past injustices and the persistent pain experienced by minority trainees and faculty by listening and openly discussing racism and its health effects in lectures, grand rounds, and at conferences.
Broaden medical school curricula to include cultural sensitivity, cultural humility, and upstander training.
Improve access to care and help provide an avenue to health equity for all.
Though the task at hand may seem daunting, together we can stand to be a voice to enact change and continue the momentum of this moment.
Can selfies help induce photoprotection behavior especially in younger individuals? The answer may be "yes" when they are combined with an app that demonstrates the effects of UV photoaging on the skin. A recent study from Brazil targeted 1,573 high school students with a mean age of 15.9 years (JAMA Dermatol. doi:10.1001/jamadermatol.2020.0511). There were an approximately equal number of males and females in both the intervention and control groups. The females were more likely at baseline to engage in regular sunscreen use with 19.8% of females in the intervention group utilizing daily sunscreen versus 9.2% of males. Conversely, prior to the intervention, female students were more likely to partake in tanning — 24.4% of females versus 12.2% of males.
During a seminar, the student’s selfies were altered in an app to demonstrate UV effects on their future faces, and the altered selfies were shown to the entire class. The high school students were then lectured by medical students regarding UV protection. At six months follow up, the difference in change between intervention and control groups regarding daily sunscreen use was 8.8% in favor of the intervention with more impact on the female students — 12.8% behavioral change in females versus 3.3% in males. More studies are needed to demonstrate generalizability, but face-altering apps may be useful in the dermatologist’s armamentarium to impact behavior at a young age.
What’s happening with hydroxychloroquine (HCQ)? In late March 2020, the FDA issued an Emergency Use Authorization (EUA) for HCQ, allowing it to be used to treat certain hospitalized patients with COVID-19. However, on June 15, the FDA revoked the EUA stating that HCQ is unlikely to be effective in treating COVID-19. The former action has resulted in difficulties filling prescriptions for some patients with lupus and rheumatoid arthritis (RA). The AADA, Lupus Foundation of America, Arthritis Foundation, and American College of Rheumatology sent a joint letter to the Administration and congressional leaders to highlight the need for action, advocating for uninterrupted access to HCQ for lupus and RA patients.
The AADA has taken immediate action to help ensure our lupus patients, who have been prescribed HCQ, continue to have access to the medication. Actions taken include: (1) The AADA worked with the compounding pharmacy community to facilitate access to compounded HCQ once the FDA added it to its drug shortages list. This meant a copy of the manufactured product could be compounded since it is on shortage; (2) The AADA also worked with the Alliance for Pharmacy Compounding to urge them to create a resource with real-time listings of compounding pharmacies that have supply of the bulk drug ingredient that can be compounded into tablets for dispensing to patients with lupus and RA; (3) To help ensure our patients should not have to pay more out of pocket for compounded medications where the manufactured versions are on shortage, the AADA signed onto a letter to HHS, FDA, and CMS asking for coverage of compounded medications during a public health emergency, such as the COVID-19 pandemic. The AADA will continue to monitor access to HCQ.
