This month’s news from across the specialty
What’s hot
April 1, 2024
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Melasma is a phenotype of photodamage with a complex and multifaceted etiology involving UV radiation, visible light, hormones, and genetics, with UV radiation being the major driver. Its refractory and recurrent nature, as well as patient nonadherence to photoprotection, can make treatment challenging for dermatologists. In February’s JAAD, some of the nation’s top experts in melasma provide readers with a flexible and focused treatment algorithm.
The authors first recommend counseling on the importance of photoprotection, which involves a broad-brimmed hat, sun avoidance, and a broad-spectrum sunscreen containing iron oxide. Tinted sunscreens and those with antioxidants may also be beneficial. Topical treatment should begin with FDA-approved, fixed-dose hydroquinone-containing triple combination cream (TCC) (4% HQ, 0.05% tretinoin, and 0.01% fluocinolone acetonide) for two to six months at which time (if improved) the patient should be started on a non-hydroquinone maintenance treatment for three to six months before cycling back onto the TCC (if needed). Maintenance topicals may include vitamin C, kojic acid, niacinamide, and azelaic acid, and maintenance orals may include tranexamic acid (TA) or Heliocare (Polypodium leucotomos). If a reduction in hyperpigmentation does not occur with two to six months of TCC, the authors recommend adding oral TA and/or mechanical procedures, with using caution with the latter.
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Pathology reports provide an abundance of information regarding the prognosis for malignant melanoma. This information can be used for patient education and to guide treatment such as surgical margins, sentinel lymph node biopsy, and adjuvant systemic therapy. Two recent articles in the JAAD provide new information about melanoma histopathologic attributes/reporting.
In the current literature, there is conflicting data on the prognostic significance of regression in primary melanomas. Wagner and colleagues studied histopathologic regression in melanoma using retrospective data from 1,179 patients. They found that the presence of regression in melanoma was associated with a favorable relapse-free survival and a negative sentinel lymph node biopsy. Interestingly, regression was associated with favorable survival in patients who had immune checkpoint inhibition therapy, but not those who had targeted therapy.
A separate paper by Hoang et al evaluated the histopathological margin status of lentigo maligna melanoma excisions, and the effect on relapse. A total of 268 cases were studied. They found that patients with a melanoma excision showing either positive or “close” margins were associated with a worse progression-free survival. Close margins were defined as less than 3 mm from the surgical edge. The current standard of care recommends surgical margins based on clinical (not pathology) measurements, but perhaps incorporation of detailed pathological margins would provide important information. Close attention to pathology details may be useful for our melanoma patients.
Seborrheic dermatitis most commonly affects the face and scalp — areas of high sebaceous gland concentration. Seborrheic dermatitis is linked to Malassezia colonization and skin surface lipids. First-line treatments include topical antifungals or corticosteroids. A systematic review found six studies that evaluated low-dose isotretinoin (i.e., ≤ 0.5 mg/kg/d) for the treatment of moderate-to-severe seborrheic dermatitis. The average duration of treatment was four months. Isotretinoin treatment resulted in greater improvements in seborrheic dermatitis symptoms when compared to oral itraconazole, anti-fungal shampoo, or salicylic acid-containing soap. Of three studies totaling 104 patients reporting seborrheic dermatitis severity on validated scales, 100 patients (96%) had at least some improvement in seborrheic dermatitis with isotretinoin, and 47 patients (45%) had complete/excellent clearance. Truncal seborrheic dermatitis had the greatest improvement, followed by the face, then scalp. Relapse rate following isotretinoin cessation was 11.1% at three months.
The mechanism of isotretinoin efficacy in seborrheic dermatitis is likely due to a reduction in sebocyte differentiation and sebaceous gland size, thereby reducing sebum production, Malassezia colonization, and resulting inflammation and scaling. This systematic review supports that isotretinoin, even at low doses, is a potentially effective treatment for moderate-to-severe seborrheic dermatitis.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup.
t’s not the first, and, unfortunately, it likely won’t be the last outbreak of its kind. Yet, a recent report from the CDC and the Florida Department of Health (FDOH) about nontuberculous mycobacteria (NTM) wound infections in cosmetic-surgery patients has important lessons.
In February 2023, CDC notified FDOH regarding a wound infection with Mycobacterium abscessus — a multidrug-resistant, rapidly growing NTM previously associated with health care infections — in a non-Florida resident who had had a cosmetic procedure done by a plastic surgeon in solo practice in Florida. A national investigation subsequently identified 15 confirmed similar infections — and four additional possible infections — in other patients treated by the same surgeon.
Among the 15 patients, all were women, ranging in age from 24 to 51 years. Post-procedural onset of symptoms, including swelling, purulent draining, redness, and/or pain at surgical sites, occurred after a range of 33 to 119 days (median, 69 days). Treatments included oral and intravenous antibiotic courses of up to six months as well as incision, drainage, and debridement. An assessment of a surgical facility operated by the surgeon identified deficiencies in environmental and surgical-device cleaning and in personal protective equipment (PPE) use.
Dermatologists should remain vigilant for NTM infections, especially in patients who have undergone cosmetic surgery procedures. Although public health agencies do not require reporting of NTM infections, dermatologists should notify their local health jurisdiction if they suspect an infection — including from NTM — might be outbreak-related. Appropriate cleaning and PPE use in procedural facilities might help prevent future outbreaks.
