This month’s news from across the specialty

September 1, 2023

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

The HPV vaccine is a safe and effective method of preventing cancer, but parental hesitancy toward vaccine safety is limiting vaccination coverage among adolescents. A study in Pediatrics analyzed data from the 2010-2020 National Immunization Survey — Teen that included 119,695 unvaccinated adolescents and identified the five main causes of hesitancy among parents as: “not necessary,” “safety concerns,” “lack of recommendation,” “lack of knowledge,” and “not sexually active”. From 2010 through 2018 the proportion of parents citing “safety or side effects” increased by 15.6% annually becoming the most common reason given by parents for not intending to vaccinate adolescents against HPV infection. Internet misinformation is likely playing a significant role in promoting these fears. The authors note that social media accounts run by antivaccination groups were rapidly growing in number and influence before 2019 — spreading scientifically debunked myths about vaccines causing autism, multiple sclerosis, autoimmune diseases, ovarian failure, and death. The authors expect HPV vaccination safety concerns to increase even more in parallel with misinformation surrounding coronavirus vaccinations. The authors encourage efforts to accurately inform parents of the risks and benefits of HPV vaccination for cancer prevention.

During the summer, many of our patients ask questions about sunscreen usage and which type of sunscreen they should use. Despite recommending sunscreens year-round, summer is the time of year that our patients focus most on these products. Patients may not be aware that in addition to their intentional use of sunscreens, many personal care products contain sunscreen ingredients and therefore patients also have unintentional exposure to UV filters all year. A recent review of sunscreens and their allergic potential provides some timely factors to consider.

Oxybenzone (benzophenone-3), a chemical/organic filter, is the most common ingredient to cause allergic contact dermatitis and photoallergic contact dermatitis compared to other sunscreens. It is used in sunscreens and personal care products. The physical/inorganic sunscreens, titanium dioxide and zinc oxide, have not been reported to cause allergic or photoallergic contact dermatitis. These are safe alternatives for patients with suspected allergies to sunscreens. In addition to the active sunscreen ingredients, there are many inactive ingredients in sunscreens that have been identified as causing allergic contact dermatitis with fragrances, vitamin E, cetyl stearyl alcohol derivatives, and triethanolamine being the most common cited by the authors.

With the increase in awareness for sun safety and the use of UV filters in personal care products, clinicians should be aware of the potential allergens patients are exposed to from UV filters. If there is concern for allergy to a specific sunscreen, patch testing and photopatch testing should be considered. Physical blockers, zinc oxide, and titanium dioxide may be appropriate alternatives. We should also consider inactive ingredients as potential allergens in sunscreen-containing products.

Even though rosacea is one of the most prevalent inflammatory skin diseases for which patients seek care in dermatology clinics, treatment options for the erythema and flushing associated with rosacea remain extremely limited. Additionally, topical treatment options that do exist are fraught with two major issues. First, patients often report significant rebound phenomenon associated with available topical therapies. Second, topicals for rosacea are often not covered by insurance given cost and the fact that many insurers consider rosacea to be a “cosmetic” issue for patients regardless of the prominent impact this disease has on patients’ quality of life.

Consequently, additional treatment options for the erythema associated with rosacea are necessary. A recent paper introduced paroxetine 25 mg daily as a new treatment option for rosacea-associated erythema. The study enrolled 97 patients with refractory erythema and demonstrated statistically significant improvements in the Clinical Erythema Assessment in patients receiving paroxetine (n = 49) over placebo (n = 48) over the 12-week study period. Additionally, the study demonstrated improvements in flushing, burning, and depression in the paroxetine-treated group. While side effects associated with paroxetine included dizziness, lethargy, nausea, dyspepsia, and muscle tremors, these were experienced by a minority of patients and the medication was well tolerated overall. While additional research should include larger study populations and examine optimal dosing regimens of paroxetine, the study introduces a new treatment option to consider for our rosacea treatment algorithm.

Baricitinib’s groundbreaking FDA approval for alopecia areata (AA) in 2022 was the bright point in an area devoid of recent significant advances. However, I found myself in the clinic oftentimes telling some of my patients that I wished they were just a handful of years older so that I could offer them other options.

It is with great interest that I heard about ritlecitinib’s recent FDA approval for AA in patients 12 years of age and older. Ritlecitinib is an oral, selective dual inhibitor of Janus kinase 3 (JAK 3) and the tyrosine kinase expressed in hepatocellular carcinoma (TEC) family of kinases.

The approval was based on the ALLEGRO Phase 2b/3 trial that was conducted at 118 sites in 18 countries (Lancet. 2023. May 6;401(10387): 1518-29). 718 patients with at least 50% scalp hair loss (SALT 50) were randomly assigned to receive oral ritlecitinib (with or without a loading dose), or placebo once daily for 24 weeks. Subsequently, there was a 24-week extension period during which the placebo group switched to ritlecitinib treatment.

At week 24, 23% of ritlecitinib patients achieved SALT 20 (e.g., 80% or more scalp hair present), versus only 1.5% of those receiving placebo. The incidence of adverse events (AE) was similar between treatment groups; within the placebo-controlled period, 73% of ritlecitinib patients versus 71% of the placebo group had AE. Most AE were mild to moderate in severity.

I am excited, to say the least. Time will tell how effective ritlecitinib is in real-world use, and how insurance companies decide to cover this new treatment.

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