This month’s news from across the specialty

December 1, 2022

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

One advantage of working in the same practice as your surgeons is the ability to quickly confirm biopsy site location when any doubt exists. My practice has changed over time as I did not initially have a standard workflow nor the tools to integrate photos easily into the chart. I remember searching for imperceptible scars to confirm biopsy sites. Even my own patients would forget the laterality of their biopsy!

It was with great interest that I read about a quality improvement project done at the University of California, San Francisco, after two episodes of wrong-site surgery occurred between 2016-2018 (J Am Acad Dermatol. 2022 Aug;87(2):467-9). This prompted an initiative, Better Lesional Site Identification, to improve the rate of helpful biopsy-site photographs. Three criteria determined whether photos were high-quality: 1) marked lesion 2) magnifying photo, and 3) mapping photo (includes at least one anatomic landmark). During the study, it was determined that for the “special sites” that included the face, hands, feet, and genitalia, only one photo was sufficient to both magnify and map. A workflow was developed in which physicians marked biopsy sites, and medical assistants photographed the lesions. 3,284 biopsies were analyzed between April 2019 and August 2020. Random sampling was determined to be accurate, and a randomized sample of 20% of biopsies was analyzed monthly. The median high-quality biopsy-site photo rate increased from 59% to 83% post-intervention. This improvement was sustained over the succeeding year.

Difficulties confirming biopsy sites are compounded when the patient is referred from an outside practice — we are sometimes lucky to even receive a blurry black and white faxed photograph, if anything at all! I fear that the incidence of wrong-site surgery is higher than anyone can ever grasp. I will surely be sharing this article with my team to emphasize the importance of the photographs we take!

When a clinician suspects bullous pemphigoid (BP), is enzyme-linked immunosorbent assay (ELISA) detection of antibodies to BP180 and BP230 a good screening test?

A paired, multivariable, diagnostic accuracy study analyzed data from 1,125 patients with suspected pemphigoid. Eligible participants were patients with paired data on at least, 1. DIF test; 2. Indirect immunofluorescence on a human salt-split skin substrate (IIF SSS) test; and/or 3. One or more routine immunoserologic tests (JAMA Dermatology. 2019;155(2):158-165).

Of the 1,125 patients analyzed, 343 patients received a diagnosis of BP. DIF was the most sensitive diagnostic test (88.3% [n = 303]; 95% CI, 84.5%-91.3%), whereas IIF SSS was less sensitive (77.0% [n = 263]; 95% CI, 72.2%-81.1%), but was highly specific (99.9%; 95% CI, 99.3%-100%) and complemented most cases with negative DIF findings. The sensitivity of BP180 NC16A ELISA was 70.0% (95% CI, 64.9%-74.6%) and BP230 ELISA was 44.6% (95% CI, 39.9%- 49.9%). Performance of combined ELISAs BP180 NC16A and BP230 had a sensitivity of 79.0% (95% CI, 74.4%-82.9%) with a specificity of 83.6% (95% CI, 79.8%-86.8%).

Use of ELISA for BP180 and BP230 for suspected cases of BP is an inadequate standalone test and is helpful in making the diagnosis only when the test result is positive. However, ELISA for BP180 and BP230 appears to miss about one-fifth of cases of BP.

As a field, we are in an exciting time where we are seeing an explosion of new therapeutics coming to market and receiving approval for inflammatory skin disease. Namely, the Janus kinase (JAK) inhibitors are being used with increased frequency and notable success in a wide range of our inflammatory disease states. With the uptick of JAK inhibitor use, we’ve also seen increasing discussion around the side effect profiles of these medications. While some of the more serious potential complications of JAK inhibitors ranging from thromboembolism to malignancy have captured most of the spotlight, it is also crucial that as dermatologists, we familiarize ourselves with the potential cutaneous complications of these newer agents.

A paper published in October 2022 evaluated the rate, severity, and treatment approaches for patients who developed acne while on upadacitinib (or placebo) for atopic dermatitis (J Am Acad Dermatol. 2022 Oct;87(4):784-91). The study found that 9.8%, 15.2%, and 2.2% of patients receiving updatacitinib 15 mg daily, 30 mg daily, and placebo respectively developed acne over a 16-week period. Acne was reportedly mild to moderate in severity for all, but led to discontinuation of treatment in two patients. In addition to the increased risk of acne at higher doses of upadacitinib, acne was also reported with increased frequency in younger, female, and non-white patients. For patients who pursued treatment for acne, most cases were able to be managed with topical agents for acne including topical benzoyl peroxide, topical antibiotics, and/or retinoids. Overall, it is crucial that dermatologists familiarize ourselves with the potential for, rate of, and treatment approaches to acne as a potential side effect of upadacitinib and other JAK inhibitors. Doing so will allow us to best counsel and provide comprehensive dermatologic care for our patients starting on JAK inhibitors both in our clinics and beyond in the years to come.

The COVID pandemic has heightened our awareness of hand hygiene. As a result, hand sanitizers have become commonplace in the work and home environments and have remained a staple in many people’s lives. Individuals are more frequently using hand sanitizers numerous times a day, both in our personal lives and in certain industries including health care. Contact dermatitis has been found to be more common as a result. Many hand sanitizers have contact allergens even in those with marketing claims of “dermatologist recommended,” “fragrance free,” or “hypoallergenic.”

A recent study in JAAD looked at 160 commercial hand sanitizers and evaluated the ingredient list for allergens that are contained in the North American Contact Dermatitis Group (NACDG) 2017-2018 standard series. All sanitizers did have appropriate legally marketed active ingredients, most commonly ethyl alcohol in 81.9% of products, benzalkonium chloride in 9.4%, and isopropyl alcohol in 8.8%. When reviewing products 71.3% had at least one NACDG allergen. The most common allergens were tocopherol, fragrance, propylene glycol, and phenoxyethanol. 84% of products had some of the above marketing claims. Yet, of those listed as “fragrance free,” 39.1% contained a fragrance or cross reactor. Of those listed as “hypoallergenic,” 70% had an NACDG allergen, and among those 60% had at least one ingredient with a sensitization rate over 1%. Marketing claims have been the subject of previous studies and this article supports that there are discrepancies that sometimes exist between personal product claims and their composition.

This study points out that in our current world with a focus on increased hand hygiene, dermatologists are well positioned to recommend low-allergen hand sanitizers. The authors list in their article several hand sanitizers that lack common allergens. This is practical information for the dermatologist as our patients frequently look to us for products that may help limit exposure to potential allergens.

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