This month’s news from across the specialty

March 1, 2024

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

Palliative medicine assists patients with balancing their goals of care with multiple physicians. The shared decision-making with patients can help them avoid treatments that fail to match a patient’s preferred levels of predicted cure and burdens of discomfort.

Important inpatient palliative care consultations may not be happening for your seriously ill patients who have been recently discharged from the hospital. A large study of 34,239 patients across 11 U.S. hospitals found only 16.6% of seriously ill patients in the control group received palliative care consultations during their admission (JAMA. 2024; 331(3):224-232). The intervention in this study was a default order for a palliative care consultation that was added on admission for patients older than 65 years with chronic obstructive pulmonary disease, dementia, or kidney failure. The intervention improved the rate of consultations to 43.9%. Considering these hurdles to inpatient palliative care discussions and the nationwide shortage of palliative care services, we dermatologists could consider leaning into these important discussions with our long-established patients to help guide them through this complicated chapter of their lives. The next time that your patient shares the details about a recent admission for serious illness, ask them for their thoughts about the experience and their care goals for when the situation next occurs. Our listening may help fill a void in their care.

It can be defeating for a patient with atopic dermatitis (AD) to fail years of inadequate therapies. It can be outright devastating to then subsequently fail a highly promised therapy such as dupilumab. Then, fear sets in when the dermatologist offers a Janus kinase (JAK) inhibitor such as upadacitinib or abrocitinib. Even though upadacitinib has reported superior efficacy to dupilumab in a prior head-to-head clinical trial, there are black box warnings to consider.

It is with interest that I read about a Canadian multicenter retrospective study regarding the real-world effectiveness and safety of upadacitinib for the treatment of adult AD in patients who failed or did not tolerate dupilumab. Treatment success was defined as 75% improvement in the Eczema Area and Severity Index (EASI 75), or Investigator Global Assessment of 0 (clear) or 1 (almost clear). Of the 39 dupilumab non-responders, upadacitinib treatment yielded response in 75% (21/28) with the 15mg dose, and in 81.8% (9/11) with the 30mg dose. EASI 100 or IGA 0 was achieved by 56.4% (22/39), and mean EASI improvement was 91.6% (range 60%-100%) in this cohort as well. These findings were like those achieved in the phase 3 clinical trials involving dupilumab-naïve patients.

Adverse events through 16 weeks in this cohort (30.7%) were less commonly experienced than the rate in the upadacitinib phase 3 RCT (44%). Of note, one patient in this study cohort with severe dupilumab-induced conjunctivitis resolved following the switch to upadacitinib.

Failing dupilumab certainly is not the end of the road for our patients, and we must guide them through this understandably stress-provoking medical decision-making process. Though this study is too small to let us make definitive recommendations, it will prove useful to me when counseling my patients.

In today’s social media-centric age, patients are developing an interest in skin care at markedly younger ages. Requests for skin care consultations from teens and tweens have risen exponentially, and many arrive to these visits armed with multi-step skin care routines — often based solely on advice from influencers. For example, a recent JAAD cross-sectional analysis of acne treatments on YouTube found that up to 91% of teens report using social media to access health information. However, the study found that 65.6% of acne videos on YouTube featured the perspective of a patient or blogger, while only 14.6% featured the perspective of a dermatologist.

As board-certified dermatologists (and for many of us, as parents) this is truly alarming. We know that good skin care in young people without specific concerns such as acne or dermatitis should be very simple — gentle cleansers, non-comedogenic moisturizers, and rigorous sun protection is all that is needed. Yet, the rise of the “skin care guru” has convinced these children that they should be using anti-aging, brightening, and firming products that we know are not only unnecessary, but potentially quite harmful to developing skin. This is a major success for the cosmetic sales industry and an epic failure for dermatologists and patients alike. As the true experts in this field, it is crucial that we as a community educate patients and their families regarding proper skin care techniques for younger patients and actively dispel the myth that more is better.

The 2024 allergen of the year honor goes to: sulfites (Dermatitis. 35(1): 2024). This distinction was made by the American Contact Dermatitis Society (ACDS) to highlight an often missed and infrequently tested-for allergen. Sodium disulfite, also known as sodium metabisulfite or sodium pyrosulfite, can serve as an antioxidant to extend shelf life and as a preservative to prevent bacterial overgrowth and is commonly found in personal care products (PCP), foods, beverages, and pharmaceuticals. Sulfites do not cross-react with sulfates, a different chemical category. A recent North American Contact Dermatitis Group (NACDG) study found 2.7-3.3% of routinely patch tested patients tested positive to sulfites. Clinically, this allergen presents with facial dermatitis 28.8% of the time followed by hands 20.5%, and then scattered/generalized distribution in 13.6% of patients. Clinical relevance appears to be high with the NACDG group, reporting 65.2% of patients demonstrating current relevance.

Personal care products and topical medications are common sources of exposure — one study revealed hair dye accounted for 44% of exposures. A search of the ACDS Contact Allergen Management Program Database found 90.1% of hair dye kits and 90% of depigmenting agents contained sulfites. Occupational sources include wine making and brewing, photographic chemicals, leather, and rubber manufacturing. Gloves also contain sulfites added for their preservative properties. Glove dermatitis may be secondary to sulfites added for their preservative function and as such they are not commonly tested for. Therefore, they may be missed as a causative allergen. Common ingestible sources are apricots and dried fruits, avocados, baked products, and beer. High sulfite consumption through diet has been reported to cause systemic contact dermatitis.

Designating sulfites as allergen of the year will help raise awareness of this often missed and under-recognized allergen and may encourage increased testing and enhanced identification of this allergen.

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