This month's news from across the specialty
What's hot
April 1, 2021
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Differentiating BCCs from intradermal nevi (IDN) along the lower eyelid margin can be tricky, but is important for both clinical diagnosis and avoidance of unnecessary biopsies in such a sensitive area. A case series in the January JAAD points out important differentiating features (J Am Acad Dermatol. 2021 Jan;84(1):173-175). The authors found that BCCs were more likely to be located more anteriorly on the lower eyelid margin as compared to IDNs and they were more likely to cause structural changes, both irregular surface change, and importantly, disruption of the eyelashes overlying the lesion. In comparison, IDNs have smooth surfaces and none of the IDNs were found to disrupt the eyelashes. Background color was also significant, and as we know, BCCs were more likely to have a pink background. Notably, although arborizing vessels have a high positive predictive value for BCCs of other sites, they were not a reliable distinguisher for the lower eyelid margin.
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A halo nevus is thought to be of no concern in a child. However, a new-onset halo nevus in an adult over the age of 40 has been suggested to be a harbinger of melanoma in the halo nevus itself, at a different cutaneous site, or at a non-cutaneous site. In an adult with a new-onset halo nevus, several major dermatology textbooks recommend looking for melanoma at cutaneous, oral, ophthalmic, and vaginal sites. A recent study in JAAD evaluated the association between new-onset halo nevus and melanoma in adults. (Article in press.) A multi-center retrospective chart review of clinical and histopathologic records at eight university hospitals included 879 patients with 888 halo nevi. Mean age at halo nevus diagnosis was 36.3 years. Review of clinical records identified 95 cases of melanoma. Only nine halo nevi were diagnosed within one year before the melanoma diagnosis, representing a melanoma incidence rate of 0.01 (95% CI: 0.004-0.017) per person per year. All nine of these melanomas were primary cutaneous melanoma. There were no cases of non-cutaneous melanoma, metastatic melanoma, or melanoma within the halo nevus. None of these nine patients had more than one halo nevus. The other 86 melanomas occurred either before the halo nevus diagnosis (n=78) or more than one year after the halo nevus diagnosis (n=8), mean 5.75 years. This study found that adult-onset halo nevus is associated with a 1% risk of cutaneous melanoma development in the year following the halo nevus diagnosis with no cases of non-cutaneous or metastatic melanoma. This melanoma risk is comparable to patients with a history of dysplastic nevi or personal or family history of melanoma. With these results, the authors recommend an annual total body skin exam in an adult with a new diagnosis of halo nevus. However, given that there were zero non-cutaneous melanomas in patients with a halo nevus, they do not advocate for screening for non-cutaneous melanomas in an adult patient with a halo nevus unless there are other risk factors involved. (Acknowledgment to Gabriel Isaza, MD, for bringing this study to my attention.)
The diagnosis of cutaneous inflammatory processes often requires a skin biopsy followed by clinical pathological correlation. A wise dermatology colleague at my hospital always reminds me that “if the clinical presentation is unclear, then the pathology findings are also unclear.” Hence, clinical-pathologic correlation becomes even more critical. In a recent study in the Journal of Cutaneous Pathology on mycosis fungoides, the authors investigated the use of clinical photographs by dermatopathologists on the accuracy of a diagnosis of cutaneous T-cell lymphoma. They utilized 50 cases of mycosis fungoides and 49 cases of inflammatory dermatoses including spongiotic and lichenoid dermatitis, which can frequently have overlapping features with mycosis fungoides. Their results showed that access to clinical photographs (by the pathologist) improved the diagnostic accuracy of both mycosis fungoides and non-mycosis fungoides cases. While this is a small study, it underscores the importance of taking clinical photographs of undiagnosed rashes and if possible, providing them to the dermatopathology laboratory along with the biopsy. Ultimately, this process will be facilitated when pathologists have universal access to the electronic medical records for the specimens they interpret.
Staying the course
Explore dermatologists’ role in the global treatment of HIV.
On June 11, 1981, the Centers for Disease Control published a report describing increases of Kaposi’s Sarcoma and other opportunistic infections (OIs) in the United States, particularly among men who have sex with men (MSM).
That article and others published around that time heralded the beginning of the ongoing HIV/AIDS epidemic, responsible to date for over 700,000 deaths the United States alone. Over 1.1 million people in America are living with HIV.
Some dermatologists played key roles early in the epidemic, caring for persons living with — and dying from — HIV/AIDS. That history is the subject of a recent JAMA Dermatology article by Dr. Heather Milbar and Dr. William James. It’s accompanied by a fascinating audio interview of Dr. Milbar and Dr. Marcus Conant, a San Francisco-based dermatologist and advocate who has contributed substantially to fighting the epidemic from the start.
The article and interview not only recount the heroic efforts of dermatologists like Dr. Conant, however. They also describe bias and discrimination among other dermatologists who did not want to care for persons living with HIV. “Let the gay doctors worry about the gay patients” is how two doctors quoted in the article characterized many doctors’ attitudes at the time.
Forty years later, another epidemic has arrived, disproportionately affecting racial and ethnic minority communities in the United States. Our specialty’s experience early in the HIV/AIDS epidemic serves as a timely reminder of the need for a diverse work force of dermatologists ready — and willing — to meet the challenges ahead.
