This month’s news from across the specialty

June 1, 2023

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

The American Academy of Dermatology SPOT Skin Cancer™ program has been very well received and provides a community service providing free skin cancer screenings. This program — the AAD’s longest-standing community outreach program of the AAD — started in 1985 and has resulted in over 2.8 million free skin cancer screenings detecting more than 288,000 suspicious lesions. The most common time for these screenings is upon us. Our department does this each May. The authors of a recent article highlight some of the demographics of the patients being screened as well as some of the motivations for individuals who choose to get screened. Most of the participants who were screened were white (86%), college educated (70%), and female (62%). The most common screening motivation for the visit was a spot of concern (36% of the time) followed by no dermatologist (26%). Both of these groups were more likely to be diagnosed with a suspected skin cancer than those without a concerning lesion or with a dermatologist. Although lack of insurance or inability to afford care were low reasons cited for motivation to get screened, both of these groups were associated with higher a likelihood of skin cancer. The statistics tell us that we need to be better at advertising to a broader group of potential screenees, especially those in minority groups and those of lower socioeconomic status.

This patient group often has delayed melanoma diagnosis and thus poorer outcomes. With SPOT season upon us, let us aim to reach those most in need of skin screenings.

In a recent British Journal of Dermatology study, the authors performed a systematic PubMed search from origin of isotretinoin 40 years ago to May 2021. Study selection inclusion criteria were any description of clinical symptoms, lab abnormalities, physical findings, and any paper that described patients as asymptomatic during treatment with isotretinoin. The authors could not identify a single blood test that seems reasonable to perform routinely, given the rarity of adverse outcomes identified in the literature in healthy young patients. They suggest that in healthy young people, lab monitoring for isotretinoin is unnecessary and risks detecting nonserious lab abnormalities. Adverse events were very rare (<1 in 10,000) and were either idiosyncratic or not preventable by lab monitoring, accompanied by symptoms, or seen in identifiable predisposed individuals who might benefit from monitoring because of pre-existing conditions.

Liver function tests (LFTs) will frequently be elevated on isotretinoin, but the risk of drug-induced liver injury (DILI) is negligible, if it even exists and routine monitoring is not helpful. Instead, informing the patient about the symptoms of DILI (dark urine, abdominal pain, generalized pruritus, jaundice) would be more appropriate. If symptoms of DILI arise, LFTs should be checked, and isotretinoin withheld until investigations have been done.

Isotretinoin increases triglyceride levels by 20–40%. Due to the short treatment course for acne, this elevation is unlikely to increase cardiovascular risk. Hypertriglyceridemia-associated pancreatitis is an exceedingly rare adverse event with isotretinoin, which is now thought not to occur in patients with fasting triglycerides <2000 mg/dL. Patients with obesity, acanthosis nigricans, diabetes mellitus, or a history of hypertriglyceridemia may benefit from measurement of baseline triglycerides, but the overwhelming majority will never reach the fasting 2000 mg/dL.

The authors suggest that routine monitoring may be falsely reassuring without improving safety. It is likely to be driving over-investigation of spurious results. (Acknowledgment to Adam Rees, MD, for sending me this study.) 

As a vasculitis involving medium-sized arteries, about 10% of polyarteritis nodosa cases are limited to the skin (cPAN). Extracutaneous complications affect ~50% of cPAN cases and are localized to areas of cutaneous involvement. cPAN has a chronic relapsing course and poses diagnostic and therapeutic dilemmas, oftentimes requiring serial sections or repeat biopsies. Optimal treatment of extracutaneous complications has yet to be clearly delineated.

It is with interest that I reviewed a JAAD study by Bertuzzi et al regarding the efficacy and safety of treatments in cPAN. This was a multicenter retrospective observational study in France that included 68 patients. Median time to diagnosis was 12 months, underscoring cPAN’s diagnostic challenge.

The primary outcome was the rate of complete response (CR) at month three. CR was highest for glucocorticoids (GCs) combined with azathioprine (84%, 11/13 patients). CR was 47% (7/15 patients) and 44% (11/25 patients) for GCs + methotrexate and GCs alone, respectively. CR was lowest for colchicine (31%, 13/42 patients), dapsone (23%, 4/17 patients), and NSAIDs (11%, 1/9 patients). Peripheral neuropathy was a predictor of poor response — CR for colchicine and dapsone would have been higher if patients with neuropathy were excluded.

Take-home points: There is limited utility for hydroxychloroquine and NSAIDs. For mild disease, colchicine and dapsone are great starting points. For severe disease, especially in the setting of neuropathy, consider more aggressive therapy. This study did not include treatments with mycophenolate mofetil or rituximab which have been increasingly reported. As always, we have much more to learn.   

The future of electronic medical records (EMRs), well the one that we expected 20 years ago, has arrived, almost. Take a pause from your overflowing inbox and think back to why we wanted EMRs — to share patient notes. After an epic wait, the Office of the National Coordinator for Health Information Technology (ONC) and CMS issued final rules under the Cares Act that aim to improve patient data access, expand interoperability, and prevent information blocking. Now any EMR certified by ONC or serving CMS patients must adopt a foundational language that eliminates proprietary hurdles for data sharing. This is the year that CMS will require Fast Healthcare Interoperability Resources (FHIR) to be implemented.

Unlike the conversion from ICD-9 to ICD-10, it’s happening behind the scenes and doesn’t require you to learn a new language. Our computers will be able to compute this revolution without us changing our clinical flow. At the core of computer coding is the freedom to give an object any name and multiple names. An actinic keratosis on the left cheek can be labeled “an actinic keratosis on the left cheek” AND “L57” AND “702.0” AND “My company’s code makes up names so that you can’t leave our proprietary software if you wanted to know what this thing on the thing was.” Implementing FHIR adds one more name to any object to establish a standard language that is very easy to incorporate into new code. So why does it matter? FHIR will improve the electronic referral loop by allowing you to import and export outside records. This common language is for the common good of our patients. (Acknowledgement to Dustin Demeo for co-authoring this article.) 

Additional DermWorld Resources