This month's news from across the specialty
What's hot
November 1, 2021
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Health care support workers (phlebotomists, medical assistants, licensed practical nurses, nursing aides, and medical secretaries) are essential coworkers in all medical practices. It would not be possible to run an efficient dermatology clinic without support staff. Little is known about the financial hardships that these health workers might face. Health Affairs recently published the first study on food insecurity (lack of access to an adequate supply of nutritious food) in health workers in the United States (2021;40(9):1449-1456). Srinivasan et al found that health workers experience food insecurity just like other Americans, but the likelihood of experiencing food insecurity varies substantially based on occupational category — food insecurity rates ranged from 1.7% for practitioners (physicians, nurses, etc.) to 19.7% for health support workers. These numbers were consistent across private and public hospitals and ambulatory care facilities. This means that it is likely that many of our coworkers are currently experiencing food insecurity. Health care support workers who are women, minorities, or have children are the most likely to be experiencing food insecurity.
The World Health Organization notes that health care support workers have helped keep our practices and hospitals open and helped protect the world during COVID-19. In return, everyone has a moral obligation to protect and invest in these members of our health care team. Srinivasan et al suggest that nationally implementing a $15 minimum wage could be a significant long-term strategy that would decrease poverty among female health care workers by as much as 50% (Am J Public Health. 2019;109(2):198-205). Other strategies employers might consider to reduce the risk of food insecurity include improving benefit packages to maximize take-home pay, providing nontraditional benefits such as transportation assistance, childcare, and meal stipends, and considering employee housing assistance. A good starting point might be anonymously surveying employees to see if any coworkers might be at risk for food insecurity.
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A person’s skin color has a significant biological and social impact on their lives. Previously, it was well-known that the processes affecting the pigments in our skin (i.e., eumelanin and pheomelanin) were important determinants of skin color. Recently, a novel mechanism that contributes to skin color was identified (Cell. 2021; 184: 4268-83). This newly identified pathway involves an enzyme called nicotinamide nucleotide transhydrogenase (NNT), which is located in our mitochondria. NNT was known to regulate mitochondrial redox levels (i.e., the propensity to gain or lose electrons through ionization). In this paper, NNT’s regulation of cellular redox levels was found to affect tyrosinase degradation (i.e., an enzyme involved in the production of melanin) and ultimately melanosome maturation. Additionally, they demonstrated that topical application of small-molecular inhibitors of NNT leads to darkening of human skin. They also found that various single-nucleotide polymorphisms within NNT are associated with skin color, tanning, and sun protection use in diverse human cohorts, further supporting their empirical data. Based on these findings, the authors speculated that use of NNT modifiers may someday have a role in the treatment of pigmentation disorders and in skin cancer prevention.
Certain patient and tumor characteristics can predict tumor upgrading of cutaneous squamous cell carcinoma during Mohs surgery (J Am Acad Dermatol. 2021; 85:923-30). Initial biopsies of cutaneous squamous cell carcinomas may not always note aggressive histologic features. What can help preoperatively to determine a patient’s risk of having an upgraded squamous cell carcinoma intraoperatively? In this retrospective cohort, 1,558 squamous cell carcinomas were reviewed, and 115 were upgraded at the time of Mohs surgery. The majority of the these were noted to be less well differentiated at the time of surgery. Upgrading from well to moderate occurred in 82 cases and well to poor in 16 cases. Perineural invasion of nerves > 0.1mm was noted in 10 cases. Utilizing the Brigham and Women’s criteria, a total of 28 patients were upstaged. Regarding specific staging, 16 of these were upstaged from T1 to T2a, and 12 were upstaged from T2a to T2b. In multivariate logistic regression analysis, male sex, prior field treatment, location on the ear/lip, rapid growth, and tumor diameter >2cm were significant predictors of tumor upgrading. Being aware of these characteristics can help prepare patients preoperatively and guide management.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
Granuloma annulare (GA) is one of the more challenging diagnoses to explain to patients due to the poorly understood pathogenesis. In addition to wanting to know how to treat or “get rid of it,” as my patients would say, most patients wonder why they have it, and how the condition might impact their overall health.
Possible association of GA and baseline comorbidities have been described in smaller studies and reports, without significant associations. A large, population-based, retrospective, cohort study from the University of Pennsylvania (JAMA Dermatol. 2021;157(7):817-23) evaluated whether there is indeed an association between GA and baseline and incidental type 2 diabetes, hyperlipidemia, autoimmune diseases, and hematologic malignant neoplasms.
The results showed a significant association between GA and baseline diabetes, hyperlipidemia, as well as autoimmune diseases like hypothyroidism and RA. Those with GA are also more likely to have incidental type 2 diabetes and autoimmune conditions, including systemic lupus. This confirms that both diabetes and dyslipidemia may be risk factors for the development of GA, possibly through dysregulated T-cell activity. It also concludes that autoimmunity may be an important factor in the pathogenesis of GA. There were no associations between GA and increased risk of hematologic malignant neoplasms, as was consistent with other studies.
In clinical practice, in addition to discussing these associations, it may be prudent to take a step further and screen patients with GA for diabetes and hyperlipidemia. It may also be of value to explore the role of statins as potential treatment for GA.
