This month's news from across the specialty
What's hot
October 1, 2021
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
We all know how frustrating it can be when a patient’s acne returns after isotretinoin, requiring them to undergo a second course. A better understanding of why this occurs could be very beneficial for prescribers. So, what are the risk factors for acne relapse in patients who then undergo a second course of isotretinoin? Prior studies have identified factors such as cumulative dose, male sex, younger age, and severity and treatment duration to be associated with acne recurrence. A more recent retrospective review published in JAAD (2021. Mar; 84(3): 856-9) found two main risk factors. Compared with control patients who only had to undergo one course of isotretinoin, patients who relapsed were more likely to have received a lower cumulative dose (128.1 vs. 159mg/kg p< .005) and to have a shorter duration of treatment continuation after acne clearance (32 vs. 65.4 days p< .005). The authors note that the latter finding of extending the isotretinoin treatment well beyond the clearance date is a relatively new concept. These results support that extending isotretinoin treatment at least two months beyond acne clearance is important to prevent relapse.
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The MEDLINE database was searched to identify data on risks associated with adalimumab, etanercept, infliximab, and ustekinumab. Articles were reviewed and graded according to methods developed by the U.S. Preventative Services Task Force (J Am Acad Dermatol. 2015;73(3):420-8.e1).
The highest evidence grade for screening studies was B, seen in the use of tuberculin skin testing (TST) and interferon-gamma release assay (IGRA). Based on the USPSTF grading system, it is recommended this screen be provided because there is high certainty that the net benefit is moderate, or medium certainty that the net benefit is moderate to substantial. IGRA is preferred over TST because of IGRA’s higher sensitivity and specificity.
Although HBV screening with triple serology — hepatitis surface antigen (HBsAg), hepatitis surface antibody (HBsAb), and hepatitis core antibody (HBcAb) — is recommended, this is supported by only grade C evidence. The evidence supporting HCV screening is also grade C, indicating that there is moderate certainty that the net benefit of routine screening for HBV and HCV is small. Therefore, screening for HBV or HCV can be performed based on professional judgment and/or prior authorization requirement. There is also insufficient evidence to recommend these routine screening tests: HIV, ANA, CBC, LFTs, skin cancer screening, renal studies, pregnancy testing, dsDNA, CRP.
Baseline tuberculosis testing is the only screening test with strong evidence to support its practice. Other screening and monitoring tests that are often performed in patients who are taking biologic agents lack evidence to support their use.
Have you ever received a phone call from your laboratory that a biopsy bottle was empty? This is not as rare as one may think. In a recent study, the authors reviewed all the empty specimen bottles received in a dermatopathology laboratory over 10 years (J Cutan Pathol. June 2, 2021; 1-6). Of 270,754 specimens, 83 empty specimen containers were received. Analysis of the cases revealed that 14 (17%) of these patients had one empty specimen container and a second bottle for that patient contained two specimens (in other words, two biopsies were put in the same container, and one was left empty).
This problem creates inconvenience and discomfort for both patients and dermatologists. Patients may question the quality of their dermatologist, their support staff, and the laboratory itself. Legal issues also enter the picture. The authors of this paper offer suggestions for standardized procedures in the office as well as in the laboratory. Examples include creating a procedure confirming that the specimen is in the formalin/bottle with every biopsy, and standardizing the preparation for transport. Laboratories may employ double confirmation by two individuals that a specimen bottle is indeed empty.
Implementation of some of these suggestions can hopefully decrease the risk of the empty bottle problem.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
Count on a new generation of cicadas every 17 years, like clockwork. For updates to the Sexually Transmitted Infection (STI) Treatment Guidelines from the Centers for Disease Control and Prevention (CDC), the interval is more variable. This year has seen both. CDC published its Sexually Transmitted Infections (STI) Treatment Guidelines in July 2021. Although there had been interim changes to the most recent guidelines, released in 2015, the 2021 guidelines provide comprehensive updated recommendations for diagnosis and management of STIs (including sex-partner management and information related to HIV infection) and promotion of sexual and reproductive health.
Highlights from the updated guidelines include guidance on STI prevention; information relevant to special populations (pregnant women; adolescents; children; men who have sex with men; women who have sex with women and women who have sex with women and men; transgender and gender diverse persons; and persons in correctional facilities); and STI-specific sections, including — but not limited to — ulcerative diseases, including chancroid, genital herpes, granuloma inguinale, and lymphogranuloma venereum; syphilis; chlamydia; gonorrhea; human papillomavirus infection; and ectoparasitic infections.
Notably, for the first time, the updated guidelines use the term STI rather than sexually transmitted diseases. They also include changes to some STI screening and treatment regimens.
As always, the guidelines are clearly written and easily accessible on the web (and a forthcoming app). Dermatologists caring for patients with (or concerned about) STIs can look to the guidelines to find authoritative, clinically focused, and dermatologically relevant STI-related information. Count on that!
