This month’s news from across the specialty

May 1, 2022

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

Prior authorization (PA) is purportedly designed to promote evidence-based care and prevent overuse of health services that patients may not need. However, what will insurers do when evidence shows that PA does not promote evidence-based care and it actually increases the risk of hospitalizations, surgeries, and emergency department use?

Researchers at Children’s Hospital Colorado assessed the initiation of antitumor-necrosis factor alpha biologics in children at their institution with inflammatory bowel disease between 2010 to 2020 and found that almost three-fourths of children experienced a PA for use of a biologic and 13% experienced a complicated PA (peer-to-peer review, letter of appeal, and/or step therapy). Upon completion of the PA process, biologic medications were approved for all children suggesting that no inappropriate prescribing occurred. On the other hand, PA significantly delayed biologic initiation by weeks leading to emergency department use, hospitalization, and corticosteroid dependence — one in eight children had a potentially avoidable health care utilization outcome associated with PA (Pediatrics. 2022;149(3): e2021052501).

Studies in multiple specialties have shown that PA did not alter the prescribed medicine in 79-99% of cases after provider appeal, but universally delayed medication initiation. There is ample evidence showing that PA increases clinical burden, delays care, and worsens clinical outcomes while having no effect on its reported goal — altering the medication or service that is ultimately prescribed. The authors suggest legislative regulations of the PA process are needed if payers are unwilling to follow evidence-based guidelines that prioritize patient care.

Hark! There is a new immune checkpoint inhibitor for treatment of patients with metastatic or unresectable melanoma. Relatlimab, a lymphocyte-activation gene 3 (LAG-3)-blocking antibody, was recently studied in combination with nivolumab, a programmed death 1 (PD-1)-blocking antibody. In a randomized trial, progression-free survival at 12 months was 48% (95% CI: 42-53%) with combination relatlimab-nivolumab as compared with 36% (95: CI: 31-42%) with nivolumab monotherapy (N Engl J Med. 2022; 386:24-34). On the other hand, grade 3 or 4 treatment-related adverse events were more common with relatlimab-nivolumab than nivolumab (19% vs. 10%). Data on overall survival differences are not yet available.

Like PD-1 and CTLA-4, LAG-3 is a cell surface molecule expressed on immune cells that suppresses T-cells; these inhibitory co-receptors normally serve as critical checkpoints in preventing autoimmunity. Their expression, however, also dampens the ability of the immune system to kill cancer cells. Relatlimab binds to and blocks LAG-3, restoring the function of exhausted T-cells. Combination relatlimab-nivolumab was approved by the FDA in March 2022, and is anticipated to play an important role in the management of patients with advanced melanoma. Although the survival efficacy of relatlimab-nivolumab compared to the current standard-of-care ipilimumab-nivolumab remains unknown, the safety profile of relatlimab-nivolumab appears relatively more favorable.

What are some of the most common reasons that Mohs surgeons do not follow the appropriate use criteria and what can that tell us about potential future versions? A retrospective review of 1,000 consecutive patients who underwent Mohs micrographic surgery at a single institution with a total of 1,318 biopsy-proven nonmelanoma skin cancers were classified as appropriate, uncertain, or inappropriate based on the AUC (Dermatol Surg. 2022. 48(3): 290-2). The vast majority (93.9%) were categorized as appropriate. Of the remaining reviewed cases based on the criteria, 4.5% were uncertain and 1.7% were not appropriate. The most common reason for performing Mohs surgery on an inappropriate lesion was treatment of adjacent lesions in one session. The second most-common reason for appropriate use criteria nonadherence was Mohs surgery for lower leg lesions. The third most-common reason was subcentimeter nonaggressive skin cancer on a low-risk site, encased in an ill-defined field of actinic changes. Combined Mohs surgery on an appropriate skin cancer and an adjacent skin cancer as well as Mohs surgery on all areas on the lower extremities can efficiently spare local tissue. Especially on the lower leg, this allows for shorter granulation time or a higher potential of primary closure. Per the authors, these clinical scenarios deserve consideration in future versions of the appropriate use criteria.

Occupational skin disease (OSD) is the second most-common occupational illness in the United States. Occupational contact dermatitis (OCD) makes up the majority of all OSD and can have significant economic consequences and negative impact on quality of life. A retrospective study by the North American Contact Dermatitis Group (NACDG) provides a comprehensive review/update on OCD in North America (J Am Acad Dermatol. 2022; 86:782-90). The study describes the characteristic and patch test results of workers included in the NACDG database between 2001-2016. About 12% (4,471) of workers tested were found to have OSD, of which about 71% were diagnosed with occupational allergic contact dermatitis (ACD) using NACDG standards.

The most affected occupations in this study were service occupations, including personal service workers (hairdressers/cosmetologists), cleaning/building service workers, and food service workers. Overall, hospitals had the greatest number of OSD, with sources of occupational ACD like nickel, components of disinfectants, and rubber accelerators in latex/nitrile gloves. The highest percentage of occupationally relevant reactions was noted with bisphenol A epoxy resin, thiuram mix, and carba mix — with carba mix showing the sharpest increase in prevalence across the study period. Gloves were the most common source of occupational ACD.

This study, spanning a 16-year period, is the largest reported, detailed analysis of OSD from North America. It emphasizes the importance of knowing the common occupational allergens, their sources, and most common at-risk occupations/industries for thorough clinical assessment, diagnosis, and treatment of OCD. It also highlights the importance of comprehensive patch testing with the NACDG plus supplemental allergens as indicated. About 20% of patients with occupationally relevant ACD would have been inadequately assessed if supplemental, occupation-specific allergens were not included.

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