This month’s news from across the specialty
What’s hot
April 1, 2023
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
The American Academy of Pediatrics (AAP) has released updated guidance on the diagnosis and management of head lice (Pediatrics. 2022. Oct 1;150(4): e2022059282). Despite reportedly high resistance rates, the AAP still recommends topical permethrins/pyrethrins (i.e., Nix/ RID), which are available OTC, as first-line treatments. Notably, these are the drugs of choice during pregnancy. If there is documented community resistance or treatment failure to the pyrethroids, the AAP then recommends using topical ivermectin lotion (OTC), spinosad suspension (rx), or malathion lotion (rx, >6 y/o). If refractory to all topicals, consider oral ivermectin (if wt > 15kg), which is very effective. A review of natural, alternative approaches, including application of topical dimethicone and manual removal of nits, is provided. The AAP stresses that children should NOT be restricted from school because of head lice or nits, and that no-nit policies should be abandoned.
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Medication supply shortages in the United States are common. The COVID-19 pandemic and recent geopolitical challenges have made this problem even more acute (i.e., our current lidocaine shortage). Health Affairs Forefront published a synthesis of reports by experts aiming to identify the underlying causes and solutions to our challenges (doi:10.1377/forefront.20230126.864137).
The article overviews several tensions that make finding a solution challenging. Noting that 78% of active pharmaceutical ingredients are made outside the U.S., many advocate for onshoring manufacturing facilities. However, the most common cause of U.S. shortages is production disruptions within U.S.-based facilities. Most reports advocate for increasing transparency of supply chains — however, universal implementation would be an enormous process as there are more than 13,000 registered facilities making more than 20,000 prescription drug products for the U.S. Finally, the changes required to improve supply chain resiliency (increasing transparency, investing in enhanced manufacturing capacity, carrying emergency inventory, and onshoring manufacturing) will remove important tools used by private companies to maintain financial competitiveness — the needed transformative steps will require more than goodwill from manufacturers.
The authors advocate for federal government involvement to set priorities, provide incentives, and make mandates to steer the industry toward increasing investments in supply chain resilience. Some suggested interventions include executive orders asking companies to report shortages, creating payment models that reward greater transparency, mandating or financially encouraging firms producing critical medicines to hold sufficient inventories, setting up systems for fair allocation when inventory is limited, and using incentives and mandates to improve U.S. production reliability.
The diagnosis and reporting of melanocytic lesions remain a difficult challenge for dermatopathologists. As a practicing dermatologist or treating physician, one desires a pathology report that helps answer the questions, “Does this lesion need to be excised?” and “Is this lesion a threat to the patient’s health?” Terminology, and its reproducibility in melanocytic lesions, is challenging — resulting in confusion for patients and dermatologists. Dr. Raymond Barnhill and expert colleagues recently published the updated version of MPATH-Dx (Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis), which is a reporting system for classification of melanocytic lesions (JAMA Netw Open. 2023; 6(1): e2250613). This version simplifies melanocytic diagnoses into four categories:
Class I is a very low-risk lesion and no further treatment is needed. This category would include a variety of common nevi and low-grade melanocytic dysplasia.
Class II includes lesions that are at low risk for progression to malignancy such as high-grade melanocytic dysplasia, melanoma in situ, and Spitz nevi. Re-excision with clear margins is recommended for class II.
Class III includes lesions that are at low risk for local and regional metastasis and primarily includes thin melanomas (AJCC stage pT1a).
Class IV includes melanomas with moderate or increased risk for metastasis, which would include melanomas that are AJCC stage pT1b or higher.
Importantly, the MPATH-Dx system assumes that the lesion was adequately sampled. Implementation of such a tool could provide a unified understanding and communication of risk assessment in melanocytic lesions.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup at the DermWorld homepage.
Syphilis has continued to increase every year in the United States since 2000. In 2020, 41,655 cases of primary and secondary syphilis and 2,148 cases of congenital syphilis were reported, representing seven-fold and four-fold increases, respectively, compared with 2000.
Nontreponemal and treponemal serologic tests remain the cornerstones of diagnosing syphilis. Additionally, when reactive, nontreponemal tests (such as rapid plasma reagin [RPR] or venereal disease research laboratory [VDRL] assays) are reported in terms of titers, with higher titers representing greater disease activity. Both clinical and serologic follow-up is critical to assessing effectiveness of syphilis treatment. A serologic cure in primary and secondary syphilis is defined as a ≥4-fold decrease in nontreponemal titer within 12 months after treatment.
An accurate nontreponemal test titer, therefore, is critical to determining whether a serologic cure has been achieved. To that end, syphilis guidelines have recommended obtaining “day-of-treatment” titers, based on theoretical concerns that titers might change between initial serologic assessment and treatment.
New data support that recommendation. A recent study compared RPR titers in syphilis patients on initial presentation with titers at time of treatment (≤14 days after presentation; median, 6 days). Among 766 cases, nearly 15% had a substantial (≥ 4-fold increase or decrease) titer change between presentation and treatment, with probability increasing over time. The probability of substantial titer change was not associated with syphilis stage.
Dermatologists diagnosing and treating patients with syphilis should ensure that patients get “day-of-treatment” titers, which will enable accurate interpretation of post-treatment titers and serologic cure status.
