This month's news from across the specialty

December 1, 2021

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

Being a fan of the Cleveland Browns football team, I am very familiar with organizational dysfunction. It’s not enough to have eleven players on the field; success requires the correct combination of the best players, strong coaching, and the good fortune of everyone staying healthy. Organizational dysfunction of cutaneous immune surveillance is the primary cause of cutaneous squamous cell carcinoma. Our current understanding of the successful coordination of the immune system in cutaneous carcinogenesis resembles the last 23 years of football losses in Cleveland.

The introduction of immune checkpoint inhibitor therapy has reinforced the importance of immune surveillance. Medications that target checkpoint inhibition have dramatically increased our cure rates for aggressive metastatic cutaneous squamous cell carcinoma. Still, only 10% of patients fully respond and reveal our incomplete ability to restore effective immune function for most patients. Luci et al (J Invest Dermatol. 2021. 141(10): 2369e2379) recently reported their work to better understand the organizational dysfunction of the immune system in cutaneous carcinogenesis. They detail the temporal association of infiltrating natural killer cells (NK cells) and tissue-resident innate lymphoid cells (ILC1) in both mouse models and human cutaneous squamous cell carcinomas.

While NK cells have been assigned the function of destroying variant host cells that have mutated by neoplastic or infectious processes, the roles of ILCs are less understood. The authors focus on NK cells and ILC1 because they share the expression of the activating receptor NKp46. They find that ILC1 express cytokines that might promote tumor growth which is in opposition to the role of NK cells destroying tumor cells. Additionally, ILC1 cells are enriched in early stages of epithelial atypia when NK cells would be most impactful. Finally, they note that the properly positioned NK cells in advanced tumors are frequently ineffective and exhausted. Having the wrong cells in the wrong positions and the right cells injured and exhausted is a familiar story of organizational dysfunction. We will need an expanded playbook beyond targeting the PD1 check point to increase our success against cutaneous squamous cell carcinoma.

It was with interest that I read about adherence to dermatology consultant recommendations (J Am Acad Dermatol. 2021 Oct ;85(4): 1008-10). This was a retrospective study of 417 hospital dermatology consultations from 2012-2017 at the University of Kentucky Medical Center. Adherence with the consulting dermatologist’s recommendations was determined based on orders in the medical record.

Full adherence (all recommendations followed) was achieved in 48.4% of consultations. Factors associated with higher full adherence included a higher number of recommendations per consultation, diagnostic rather than therapeutic recommendations, and recommendations to discontinue or continue therapies. Overall, 67.4% (595 of 883) of recommendations were followed. Topical therapies had lower full adherence rates (54.0% vs. 74.3%), higher rates of modification (18.4% vs. 11.2%), and higher rates of nonadherence (27.7% vs. 14.5%), versus systemic therapies. The reason(s) behind inpatient teams’ non-adherence to topical therapy recommendations, however, is unclear.

This study emphasizes the importance of communication to optimize patient care. Additional challenges in the outpatient practice of dermatology include the coordination of care with primary care physicians and other specialists. My mentors never hesitated to pick up the phone to call their patients’ other physicians, and I hope to also instill this sense of responsibility to every trainee that I have a chance to work with for the rest of my career. Many challenges still exist. I do not have a fail-proof method of making sure that all my recommendations are received, acknowledged, or followed. As frustrating as this may be, oftentimes my patients do not know why they are seeing me, and do not even know their referring physician(s)’ names. I foresee some new quality improvement initiatives to come in my own practice!

In dermatology, the hurdles blocking our patients from accessing needed therapeutics seem to be increasing exponentially by the year. Frustrations around step therapy, prior authorizations, appeals, peer to peers, and navigating complex patient assistance programs have a profound impact on each of us, and most importantly, our patients. A paper published in Health Affairs titled “Quantifying the economic burden of drug utilization management on payers, manufacturers, physicians and patients” compiled estimates of drug utilization management from peer-reviewed and professional articles from 2009-2020 in an effort to put a dollar number on these efforts. From this study, the authors calculated that together physicians, patients, payers, and manufacturers spend approximately $93.3 billion annually on implementing, navigating, and contesting drug utilization management programs. The authors determined that payers spend approximately $6 billion annually on implementing these programs and performing the administrative gymnastics of attempting to prevent prescribers from using medications outside of their formularies. On the flip side, pharmaceutical industries were found to spend $24.8 billion annually on trying to support patients’ and prescribers’ efforts to obtain pharmaceuticals prescribed. Physicians were found to spend $26.7 billion annually on contesting denied medications on behalf of their patients. Despite these efforts, patients were reported to spend $35.8 billion annually in out-of-pocket pharmaceutical cost sharing. These numbers are staggering and speak to the dire need to reform the drug utilization management programs currently in existence in our country. Joining forces with advocacy efforts through the AADA and state dermatology societies around legislation to improve and streamline these processes (i.e., step therapy legislation being considered in multiple states and federally this year) can allow us, as physicians, to play a role in improving and streamlining these programs. The time for change is now, and in advocacy there is always power in numbers.

Chronic hand eczema is a disease process commonly encountered in the dermatology office. Consensus and guidelines have been hard to define across the specialty and there are also many geographic differences. An effort at obtaining guidelines was recently conducted through an expert panel of the International Eczema Council (Dermatitis. 2021. 32(5): 319-26). They found significant differences in agreement across their queries with strong consensus in only 17.3% of their questions, moderate consensus in 44.2%, and low or very low agreement in 38.5%. Those areas that had the highest level of agreement as outlined in the paper included: allergic hand eczema having spreading lesions on adjacent and even distant areas from allergen exposure; irritant hand eczema being secondary to prolonged exposure to primary irritants and dependent on the duration and intensity of exposure; and interaction of the epidermis with the external environment contributing to hand eczema. Hand eczema being polymorphic and an epidermal barrier defect in those with atopic dermatitis predisposing to irritant contact dermatitis, and allergic contact dermatitis being confirmed through positive patch tests were also strongly agreed upon. Those topics with significant disagreement included the value of a skin biopsy, investigation for Type I reactions, the value of fungal culture, the role of relevant allergens and/or irritants in most cases, and whether patch testing should be performed independent of the location and morphology.

Although chronic hand eczema is commonly seen in our practice, consensus even among an expert group only occurred in a small subset of topics. This indicates that more research is needed for consensus to be obtained and guidelines to be developed. There are several presentations of hand eczema, and this may lead to challenges in developing guidelines as varying presentations may lend themselves more readily to different evaluations such as skin biopsy, patch testing, or fungal cultures. The authors also comment on the confusing terminology frequently used in those with chronic hand eczema and point to better diagnosis codes to help with research.

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