This month's news from across the specialty
What's hot
October 1, 2020
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Why do a small percentage of young and apparently healthy patients with COVID-19 develop life-threatening infection or a Kawasaki syndrome-like disease after infection? Could one or more genetic polymorphisms confer this risk? Conversely, could a protective polymorphism be responsible for the ‘COVID toes’ phenomenon, which appears to occur in patients who do not develop severe COVID-19 symptoms? The COVID Human Genetic Effort will explore the genetic predisposition that may underlie different COVID-19 sequalae (e.g., cardiomyopathy, encephalitis, Kawasaki-like disease). Understanding the genetic regulation driving the human immune response to SARS-CoV-2 infection could have significant implications, explaining the variability in disease severity, influencing the development of new therapeutic or preventative interventions, and providing insight on predicted performance for potential COVID-19 vaccine candidates.
Lisa Arkin, MD, a pediatric dermatologist at the University of Wisconsin-Madison, and colleagues are specifically investigating the genetic and immune signature in patients with "COVID toes" through a biobank for tissue, blood, and saliva, focusing on the Type I (antiviral) interferon response, which is critical in containing early SARS-CoV-2 infection. Meanwhile, another research group is directly dissecting differences in immune response in patients with moderate vs. severe COVID-19 disease (doi: 10.1038/s41586-020-2588-y). Preliminary evidence suggests that patients with moderate disease manifest a strong early Type I response, followed by a progressive reduction in Type I activation. In contrast, multiple patterns of persistently elevated immune response are detected in severely affected COVID patients, including inflammasome-dependent cytokines and Type II cytokines. The authors theorize that inflammasome activation and sepsis-like cytokine release syndrome may be responsible for the vasculopathy and tissue damage in severely affected COVID patients (doi: 10.1038/s41577-020-0373-7; doi: 10.1038/s41586-020-2588-y).
Congenital syphilis is making a comeback. In the U.S., cases of congenital syphilis — which can result in fetal demise, neonatal death, premature birth, or physical and mental developmental delays — have increased nearly four-fold in less than a decade.
In 2012, 334 congenital syphilis cases were reported in the U.S. In 2018, the last year for which data are available, there were 1,306, including 94 stillbirths or early infant deaths. That increase closely tracks with concerning increases of syphilis among women. Racial and ethnic minorities are disproportionately affected by syphilis, including congenital syphilis.
Early diagnosis and treatment of maternal syphilis during pregnancy can prevent congenital syphilis. CDC and numerous other organizations recommend at least one-time syphilis screening for all pregnant women.
So why is congenital syphilis increasing?
To address that question, CDC researchers reviewed medical records of mothers who gave birth in 2018 to infants with congenital syphilis.
Missed opportunities for prevention include: inadequate maternal treatment for syphilis, despite early diagnosis (31%); lack of timely prenatal care, including syphilis screening (28%); late identification of syphilis infection occurring after initial negative screening (11%); and lack of syphilis screening despite timely prenatal care (9%). In 4% of cases, no missed opportunity was identified; congenital syphilis occurred despite appropriate maternal treatment. Records were not available in 18% of cases.
The CDC and other organizations should redouble efforts to prevent congenital syphilis. Dermatologists can help too, by being vigilant for the mucocutaneous manifestations of congenital and other forms of syphilis.
Shared decision making has always been central to patient relationships with dermatologic surgeons. Recently, there has been innovation in our protocols to structure shared decision making to better facilitate a patient’s understanding of relative risks and potential outcomes. Still, patients frequently struggle to comprehend the balance of morbidity and mortality of cutaneous carcinoma with the efficacy and potential burdens of treatment. Performance status scales are standardly applied in chemotherapy protocols to predict a patient’s ability to tolerate the high morbidity of treatment. With the average morbidity of dermatologic surgery for cutaneous carcinoma being much lower than traditional chemotherapy regimens, assessment of performance status in dermatologic surgery has been traditionally more informal and infrequently documented. As a quantifiable variable in skin cancer research, age has been promoted as a surrogate for performance status in the clinical assessment of performance status. As many older patients can have superior performance status scores relative to younger patients, numerous clinicians are uncomfortable including age within skin cancer treatment algorithms.
To better assess performance status in skin cancer treatments in older patients, Vora et al (J Am Acad Dermatol. 2020; 83(2):463-468) used two easily applied instruments to 238 patients over the age of 84 that presented to a tertiary cancer center department of dermatology for skin cancer care. The ultimate treatments for these patients included Mohs micrographic surgery, excision, nonsurgical treatment, referral, and observation. The Karnofsky Performance Scale and Katz ADL Performance Scale are similar to the Eastern Cooperative Oncology Group (ECOG) Performance Status. These scales evaluate the burden of disability on a patient’s ability to perform self-care. The authors found that the majority of referred patients had high performance status scores. As expected, survival was progressively worse with medium and low performance status scores. This work reinforces the informal assessments performed by many dermatologic surgeons with our older patients that are living independently and seeking our care. Inclusion of these quick and simple standardized assessments of performance status helps identify older patients with skin cancer that may benefit from an expanded conversation about the goals of care that includes an emphasis on palliation.
Can a skin biopsy help you with the diagnosis of COVID-19 infection? In the past few months, we have seen many reports of skin involvement in patients with COVID-19 infection. Clinical lesions have included urticarial lesions, erythema multiforme-like lesions, morbilliform eruptions, chilblains, chickenpox-like lesions, and hemorrhagic rashes. There is very little written about the histopathology. A recent study from northern Italy during a peak phase of COVID-19 infection (Am J Dermatopathol. 2020; 42: 564-570) describes skin biopsies on a cohort of patients. The patients were divided into three categories: confirmed COVID-19 active infection, probable COVID-19 infection with negative PCR test, and cases of highly suspicious COVID-19 infection where PCR testing was not performed due to lack of available testing. The following changes were seen on histopathology: dilated blood vessels with swollen endothelial cells, perivascular inflammation of eosinophils and CD8-positive lymphocytes, Langerhans cells in the epidermis, and rarely vascular clots. While none of these findings are specific to this viral infection, skin biopsies may help identify a coagulopathy in a particular patient. Future work may provide insight into the pathophysiology of this infectious process.
