This month’s news from across the specialty

November 1, 2023

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

All medical fields can learn from their past mistakes. The path to modern medical practice was not linear and we often learn more from our mistakes than our successes. Cruz and Baker highlighted selected articles in Pediatrics from the past 75 years that would not fit the conventional narrative of progress (Pediatrics. 2023;152(3): e2023062806). They chose examples to remind us how even our most admired predecessors and institutions embraced ideas and beliefs that would now be considered puzzling, or even disturbing.

In one expert-led roundtable discussion in 1952, the authors classify “defective” children into groups based on IQ ranges as “idiots” (low functioning), “imbeciles” (moderate-grade), and “morons” (mildly impaired). The authors discuss how many neurocutaneous syndromes appear to show signs of evolutionary “reversion” of the fetus from a Caucasian to a less “advanced” ethnicity. A 1961 article on “gender-role disturbance” in young males contains multiple stereotypes about “sissy” boys with emotionally distant fathers who need to “untie the apron strings” of overprotective mothers. One of the lead authors of the paper, John Money, later became pivotal in advocating that infants with ambiguous genitalia be raised based solely on medically or surgically assigned gender. An article from 1980 discusses burnout by pediatric interns at Stanford and how their wives were concerned for their intern and feared that “if they got too angry with their spouses, they would find a comforting nurse.” The authors appear blind to growing number of women who were also interns at that time.

Although the articles were selected for pediatricians, the examples are a reminder for all medical professionals that progress is not linear and we are all limited by the assumptions and biases of our time. The authors recommend that to advance our fields we continuously re-evaluate the knowledge base behind the care we provide to our patients, self-reflect on the societal attitudes and implicit biases that drive our scientific work, and consider what future generations might think about deeply held beliefs in our own professions.

Mohs surgeons are extensively trained in complex cutaneous reconstructive surgeries and perform most reconstructive surgeries on cosmetically and functionally sensitive (CFS) sites. However, dermatologists are still not widely considered to be the experts in cutaneous reconstructive surgery.

In 2013, Medicare data show that Mohs surgeons performed 67.7% of CFS cutaneous reconstructive surgeries; plastic surgeons performed only 10.3%. In 2019, this disparity grew further, with Mohs surgeons performing 75.3% of all CFS reconstructions, non-Mohs dermatologists performing 10.4%, and plastic surgeons performing only 8.4% (Derm Surg. 2023;49(6):539).   

Despite the data, studies have shown that neither the public or non-dermatologist physicians are likely to recognize the surgical expertise of dermatologists. They may mistakenly assume better cosmetic outcomes after plastic surgery compared to those following Mohs or dermatologic surgery. These misperceptions are the result of ongoing, extensive public relations efforts by plastic surgery professional societies as well as the widespread portrayal of cosmetic plastic surgery procedures across the media.

By publicly establishing dermatologists’ expertise in cutaneous surgery, we can help to allay patients’ understandable preoperative concerns regarding surgery in CFS areas. Additionally, ensuring that non-dermatologist physicians recognize dermatologists as the experts in CFS reconstructive surgery may increase the proportion of patients that are appropriately referred for indicated procedures, including Mohs surgery. For the benefit of our patients, it is important that we and our dermatologic specialty societies use data-driven approaches to publicly establish Mohs surgeons as the true experts in cosmetically and functionally sensitive cutaneous reconstructive surgery.

One of my most satisfying achievements as a resident was successfully identifying scabies mites, eggs, or scybala via light microscopic examination of copious amounts of skin scrapings collected with mineral oil. My attending physicians were not willing to let me treat scabies empirically without direct microscopic visualization. Thus, my co-residents and I quickly mastered this time-intensive, and sometimes messy, technique. Post-residency, I have largely shelved mineral oil and microscopy in favor of dermoscopy, which is more time-efficient and, in my personal experience, accurate.

Nonetheless, I am always eager to learn new techniques. Scanni G described using an ultraviolet LED source at 365nm (i.e., our trusty Wood’s lamp) for evaluation of lesions suspicious for scabies (Trop Med Infect Dis. 2022; 7(12): 422). Reach for the Wood’s lamp — who knew? The mite appears as a white or green point-shaped area at the end of a burrow, which appears as a bluish-white linear or serpiginous luminescence. A clear advantage is that no skin-on-skin contact is needed, and large skin surfaces can rapidly be assessed. In addition, Yürekli A reported the application of dermoscopy using ultraviolet light mode to identify the scabies mite. Instead of appearing as the “delta sign,” which is seen with traditional dermoscopy and can be difficult for novices to identify, the entire mite is visualized and appears as a white-green luminescent circle (Skin Res Technol. 2023; (5): e13336). Some may be hesitant of establishing a diagnosis and treating a patient based on these techniques, but they might also be used to target lesions for dermoscopy or expedite collection of skin scrapings for light microscopy or other emerging diagnostic methods, like molecular assays via polymerase chain reaction.

There has been a significant increase in antifungal resistance in invasive fungal disease and mucocutaneous mycoses in the last two decades. Terbinafine-resistant Trichophyton (mostly zoophilic Trichophyton mentagrophytes var. mentagrophytes) has been reported as widespread worldwide. The authors of a paper in Australasian Journal of Dermatology discuss several mechanisms of antifungal drug resistance: alteration of the drug target, increase in efflux of drug/metabolites, inactivation of the drug, bypass mechanisms or substitution of the pathway affected by the drug, stress adaptation mechanisms, and biofilm formation.

Aside from drug resistance, poor drug penetration of hard keratin creates a challenge to treating non-dermatophyte molds that infect damaged nails. In a similar way, psychosocial factors like poor hygiene and overuse of broad-spectrum antifungals in medicine and agriculture also contribute to the development of drug resistance.

A holistic biopsychosocial approach is recommended to address various aspects of antifungal resistance. A thorough understanding of the mechanisms of drug resistance is the crucial first step in the development of new drugs and new ways to overcome or prevent resistance. Novel antifungals such as ibrexafungerp (enfumafungin derivative) and oteseconazole (tetrazole) have different structures, hence different binding sites and more selectivity compared to their respective related drug classes of echinocandins and triazoles. Other potential novel antifungal mechanisms include flavonoids targeting cell efflux, influencers of ergosterol synthesis or ERG11 expression, antibiofilm strategies, targeting alternative essential fungal metabolic pathways, and antifungal vaccines.

Other changes at the individual, institutional, and higher systemic level to match the epidemiologic shift are necessary to help combat the rising antifungal resistance. Antifungal stewardship programs and current teachings aimed at more precise management rather than use of broad-spectrum antifungals is recommended. Ultimately, focusing on patient education regarding the importance of personal hygiene, diligent household fungal eradication protocol, and treatment adherence will lead to more successful initial treatments and avoid risking the consequences of antifungal resistance.

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