This month's news from across the specialty

December 1, 2020

In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.  

Choice and transparency dominate our landscape. It is hard to believe that it was only 2013 when the FDA issued a final rule defining "gluten-free" for food labeling so that consumers knew if a defined standard was met. It was also only in August 2020 that a final rule was issued regarding gluten-free labeling of fermented or hydrolyzed foods such as yogurt, cheese, and FDA-regulated alcoholic products.

This same spirit of choice and transparency was also evoked by a survey study of dermatology patient perspectives regarding animal product use in suture materials (J Am Acad Dermatol. 2020;83(3):907-908). Surveyed patients were recruited from the waiting room at UConn Health Dermatology in July 2019, and 102 out of 136 patients participated. About 80% of patients had received stitches in the past. 33% of patients reported that they would decline the use of animal-based material used in sutures, and about half of those patients declining would still decline even if they knew they had to return for suture removal. Interestingly, responses were not statistically different between vegetarians and non-vegetarians.

These results are thought provoking. Closure options are always thoroughly discussed in my practice whereas choice of sutures is clouded in secrecy. With COVID-19, we have increased the use of chromic gut sutures to “help” our patients decrease trips away from home, but this study has made me think twice about my practice. One thing remains constant, though, and that is the importance of shared decision making utilizing open and honest communication. Thank you to the authors of this study for bringing this subject to my attention.

Since the first injectable hyaluronic acid (HA) was FDA approved in 2003, there have been new HA formulations and expanded indications. Physicians can now select from a large portfolio of HA fillers with different features including HA molecular weight and concentration and degree of crosslinking (also referred to as degree of modification). Physicians using these devices must be familiar not only with anatomical age-related volume loss, but the different rheological properties of each HA filler.

There is a new addition to the HA class of dermal fillers. The FDA has approved monophasic HA fillers RHA2, RHA3, and RHA4. As with all HA fillers, they are approved for the correction of moderate to severe dynamic wrinkles, such as the nasolabial fold. Designed to be malleable to address facial changes associated with senescence, all three have an HA concentration of 23 mg/ml. RHA4 belongs to a new generation of HA fillers with a unique technology that preserves high molecular weight HA chains and decreases their BDDE crosslinking. This characteristic confers mechanical resilience and durability. It is implanted deeper into the dermis or superficial subcutaneous fat and is indicated for the correction of deep wrinkles and volume loss. Restylane^® Kysse was also recently granted FDA approval. This 20 mg/ml HA filler is injected into the submucosal layer for lip augmentation and into the mid-dermis to the subcutaneous layer for the correction of perioral rhytids and philtral column improvement.

All HA fillers are of bacterial origin (NASHA: nonanimal streptococcus hyaluronic acid), sterile, biodegradable, non-pyrogenic, clear, colorless, flexible, and viscoelastic. They are dispensed in single-use, pre-loaded syringes containing phosphate buffered saline and 3 mg/ml of lidocaine hydrochloride to diminish injection discomfort. Despite the plethora of HA fillers and growth in demand, their design, safety profile, and diverse applications, there are few robust randomized studies directly comparing HA fillers, and selection is often dependent on physician preference and information provided by manufacturers.

A recent study by Tang et al (Nature, Oct. 7, 2020) provides genomic characterization of individual melanocyte cells. The data supplements our existing understanding that the epidermis and keratinocytes carry a higher mutational burden than any other tissue type. Isolating the individual melanocytes gives insights into the progression of melanoma. The novel approach combines clonal expansion of individual melanocytes with DNA amplification techniques. This process was repeated at multiple anatomic sites with a subset of specimens collected adjacent to basal cell carcinoma and melanoma.

Interestingly, the mutational burden of melanoma matched the mutational burden of the melanocytes in surrounding skin. Despite the similar total number of mutations, the neighboring melanocytes contained distinct signature mutations which argue against a clonal association with the melanoma. The comparable mutational burdens support a theory in which the field of melanocytes individually collect similar actinic damage and differ only in a few unfortunate neoplastic combinations of mutations.

The authors also identified unique mutational signatures for anatomic sites with three classifications of UV exposure: chronic on the face, intermittent on the trunk and extremities, and sun-shielded on the soles of the foot. As expected, the lowest mutational burden was seen on the feet. Surprisingly, and contrasting the mutational patterns in keratinocytes, the highest mutational burden was seen in the intermittent sun-exposed sites of the trunk and extremities and not the chronically sun-exposed area of the face. This distinction may be associated with the distinct anatomic distribution of melanomas which more commonly arise on intermittently sun-exposed sites relative to keratinocytic carcinomas.

Although many of us have returned to some type of in-person practice, COVID still looms large in our personal lives and in our patient care. Teledermatology has been used primarily in the outpatient setting and has shown to improve access, reduce wait times, and have good accuracy and agreement when compared to in-person evaluation. Inpatient teledermatology does not appear to be as widely used. Many of us used some form of teledermatology in our outpatient practices prior to 2020, and this has significantly increased in our current world. I wrote back in April how so many of us had rapidly adopted televideo and telephonic visits to accommodate our patients and provide them with care during this public health emergency (PHE). Our own institution did it with remarkable speed despite prior hesitation.

A recent JAAD study demonstrates that inpatient teledermatology can increase access to dermatology care and improve patient care in the inpatient setting (2020; 83: 797-802). Although this article surveyed a group regarding the use of inpatient teledermatology prior to COVID, it is perhaps a more pertinent discussion now in our COVID world. The authors reviewed the literature and surveyed physicians at the Society for Dermatology Hospitalists in 2017. Although a small sample size, they found that 80% of the respondents used some form of teledermatology — a little more than half used teledermatology for both inpatient and outpatient consultations while the remainder focused primarily on outpatient teledermatology. Dermatology evaluation of inpatients has been shown to have a significant positive impact on patient care. Many providers highlight the cost effectiveness of teledermatology and, as many providers cover more than one hospital, the increased utilization and the standardization of inpatient teledermatology could enhance the ability to triage patients, reduce wait times, and improve care. The authors believe that the three practice gaps in the use of inpatient teledermatology are: 1) optimizing use of teledermatology for triaging, 2) increasing inpatient dermatology care with teledermatology, and 3) standardizing reimbursement for inpatient teledermatology. As we continue to forge ahead during a PHE, the optimization and expansion of teledermatology into the inpatient setting will help us provide better care to patients in a timelier manner and is something we should continue to work toward.

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