This month’s news from across the specialty
What’s hot
May 1, 2023
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Despite previously published studies refuting the risk of inflammatory bowel disease with isotretinoin use, patients and families commonly raise this as a concern when considering treatment with either isotretinoin or oral antibiotics for acne. This concern, among others, can cause patients with even severe acne with the potential for permanent scarring to be hesitant to initiate systemic treatment for their disease. A recent paper by Matthew Taylor and colleagues in JAAD titled, “A propensity score matched cohort study identifying an association of acne, but not oral antibiotic or isotretinoin use, with risk of incident inflammatory bowel disease” provided important data exploring this issue further. The study found an association between acne itself and inflammatory bowel disease (odd ratio 1.42, confidence interval 1.23-1.65). Furthermore, the study found no increased risk of inflammatory bowel disease with either isotretinoin or systemic antibiotic use in this patient cohort. The authors hypothesize that the link between acne and inflammatory bowel disease may be secondary to a common TH17-driven inflammatory pathway in both disease states. However, because the absolute risk of IBD was found to be relatively low in the acne patients studied, the authors note that the data does not support population-wide screening for IBD for patients with acne at this point. Rather, the study should provide further reassurance to patients and physicians that the use of isotretinoin and oral tetracyclines does not increase risk for inflammatory bowel disease for patients with acne.
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Although oral isotretinoin has remarkable clinical efficacy in the treatment of patients with severe nodulocystic acne vulgaris, it also has potential for serious adverse reactions. One of the long-debated adverse reactions listed in the ‘Warnings and Precautions’ section of the FDA package insert for isotretinoin is the risk of inflammatory bowel disease. To shed light on this controversy, authors of a recent paper in JAAD conducted an international, population-based, retrospective cohort study of patients with acne initiating isotretinoin (n=77,005 patients) or oral antibiotics (n=77,005) using comprehensive propensity-score matching. Most importantly, no difference in the lifetime risk of Crohn’s disease and ulcerative colitis between the study groups was identified. However, in time-stratified analyses, isotretinoin-related risk of ulcerative colitis, but not Crohn’s disease, was slightly increased during the first six months following drug initiation. In clinical terms, the absolute risk difference was marginal; for every 2,000 patients with acne treated with isotretinoin, one additional case of ulcerative colitis would emerge in the first six months. An alternative explanation for the observed data that the authors did not comment on is the possibility of earlier and more comprehensive diagnostic scrutiny of new gastrointestinal symptoms in patients initiating isotretinoin compared to antibiotics. Although this study is unlikely to definitively settle the controversial association between isotretinoin and inflammatory bowel disease, it provides high-quality data in clinically understandable terms that can be immediately shared with patients.
A recent systematic review and meta-analysis sought to identify the patient risk factors, tumor characteristics, and treatment modalities associated with poor outcomes in cutaneous squamous cell carcinoma (JAMA Dermatol. 2023:159(2):160-171). The highest risks for local recurrence and disease-specific death were associated with tumor invasion beyond subcutaneous fat. The highest risk of any metastasis was associated with perineural invasion. Regarding tumor size, 2 cm in diameter or larger is associated with higher risk. Several other risk factors, including immunosuppression, are related to poor outcomes. This is particularly relevant as it is not a part of the current staging systems for cutaneous squamous cell carcinoma. Other high-risk histopathologic characteristics not in the current staging systems are desmoplastic stroma and lymphovascular invasion. Perineural invasion greater than 0.1 mm, lymphovascular invasion, desmoplastic stroma, and poor differentiation were the most consistently high-risk features that warrant consideration of adjuvant radiation therapy. When assessing treatment modalities, Mohs micrographic surgery was associated with the lowest proportion of poor outcomes.
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We only have limited, suboptimal therapeutic options available for hidradenitis suppurativa (HS). For treatment to be effective, it has to impact specific QoL indices in HS patients. A recent study in the British Journal of Dermatology measured the association between HS-specific QoL with demographic and clinical characteristics. The authors performed a cross-sectional survey of HS patients at 27 institutions, mainly HS referral centers, in 14 countries from October 2017 through July 2018 (Global Survey of Impact and Healthcare Needs (Global VOICE)). The 1,828 patients were mostly young adult, obese/overweight females with nearly half being active smokers. A validated, disease-specific, patient-reported outcome that assesses symptoms, psychosocial impact, and activity restrictions, called the Hidradenitis Suppurativa Quality of Life (HiSQOL), was used to assess the life impact of this disease.
The results showed that patients with HS experienced high life impact related to their disease. Given the challenges of finding optimal treatment for this debilitating disease, new medications, in addition to targeting the pathogenesis of and components of the inflammation in HS, should also directly measure improvement in specific quality of life indices for HS patients. Younger age, active smoking, flares, access to a dermatologist, depression and high morbidity burden, disability, and high BMI were associated with disease-related life impact in this study. With exciting emerging therapeutic options for HS on the horizon, this study further emphasizes the need for patient-centered strategies to optimize outcomes. The authors recommend further studies to explore the finding that Black patients may experience worse, disease-specific life impact compared to white patients.
