This month’s news from across the specialty
What’s hot
May 1, 2024
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Researchers at the University of Virginia showed that utilization of telemedicine by pediatric specialists in one children’s hospital center eliminated 1.56 million miles roundtrip (and 69,454 gallons of fuel) by patients and families from August 2019 through February 2022. This is important, as an estimated 10% of the carbon emissions created by health care delivery are due to patient travel. Studies have shown similar reductions in carbon emissions in adult clinics. However, pediatric specialists (like pediatric dermatologists) are unique in the United States as most pediatric specialists are limited in supply and in large children’s centers — forcing many patients to travel considerable distances to receive care. Thus, the use of telemedicine by pediatric specialists saves considerable amounts of greenhouse gases and decreases time away from school, work for parents, cost, and time for travel. The authors of the article note that the use of telemedicine in their center was sustained by pediatric specialists after lifting the COVID-19 restrictions, showing its acceptance, importance, and permanence in pediatric specialty care.
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Recent findings suggest that there may be little evidence supporting frequent routine monitoring for isotretinoin. Abnormalities identified on routine tests are rare, and for most cases, they are mild and transient. Pancreatitis in the setting of isotretinoin for acne is rare, and many cases are not associated with hypertriglyceridemia. There is limited evidence that isotretinoin is associated with hepatic injury and one study found liver function testing abnormalities are just as common prior to initiation of isotretinoin as they are on therapy.
In a recent study, a modified electronic Delphi process was used to establish a consensus for isotretinoin laboratory monitoring among an international cohort of experts in acne. The only tests that reached consensus for inclusion were alanine aminotransferase (ALT) and triglycerides, which should both be tested once within a month of starting isotretinoin treatment and a second time at peak dose (JAMA Dermatol. 2022; 158(8): 942-8). These tests should not be performed at the completion of treatment.
The inconvenience of frequent blood draws may dissuade patients from starting or continuing isotretinoin therapy, which can lead to poorer patient outcomes. Moreover, frequent unnecessary monitoring poses a psychosocial burden especially for younger patients, who may experience pain and distress surrounding phlebotomy. By eliminating potentially wasteful testing, the pain, fear, and cost for patients being treated with isotretinoin can be reduced.
I’m sure all of us can recall being challenged by patients with severe prurigo nodularis. This disease is associated with debilitating itching and leads to impaired quality of life. The approval by the FDA of dupilumab in 2022 for the treatment of adults with prurigo nodularis was a watershed moment as it was the first FDA-approved treatment option for these patients. Incredibly, patients may have access to another treatment option only a few years later. Kwatra et al studied the effect of nemolizumab, an interleukin-31 receptor alpha antagonist, on the signs of symptoms of prurigo nodularis (N Engl J Med. 2023. 389; 17:1579-89). Nemolizumab was studied because IL-31 is a neuroimmunologic cytokine that is increased in patients with prurigo nodularis and dermal levels are correlated with itch severity. After 16 weeks of treatment, patients who received nemolizumab (30mg or 60mg subcutaneous injection every four weeks) were significantly more likely than those who received placebo to have clearer skin, a rapid and sustained reduction in their itch, and improved sleep. Nemolizumab was well-tolerated, and the most common adverse events were headache and atopic dermatitis. Although not yet approved in the United States, the FDA recently granted Priority Review for the use of nemolizumab in patients with prurigo nodularis. Stay tuned!
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup.
The two most widely used cSCC staging tools are the American Joint Committee on Cancer 8th Edition (AJCC8) and Brigham and Women’s Hospital (BWH) staging systems. Although both staging systems are commonly utilized to stage cSCC irrespective of anatomic location, the AJCC8 system was developed only for staging of cSCC on the head and neck. The BWH system was developed for staging of cSCC on any anatomic site but lacks high-quality studies evaluating its performance for tumors of the head and neck.
A recent study by Guerra et al evaluated both AJCC8 and BWH cSCC staging systems’ ability to predict poor clinical outcomes of cSCC that are not located on the head and neck. The study included 1,042 cSCC not located on the head or neck. Tumors were defined as either high (BWH T2b/T3, AJCC8 T3/T4a/b) or low (BWH T1/T2a, AJCC8 T1/T2) stage. Tumors were also defined as those with or without poor clinical outcomes (local recurrence, satellite or in-transit metastasis, nodal metastasis, distant metastasis, disease-specific death).
In this retrospective cohort analysis of cSCC off the head/neck, both AJCC8 and BWH staging systems performed well, with non-head/neck cSCC identified as ‘high stage’ by either system having an increased cumulative incidence of poor clinical outcomes. Importantly, both staging systems identified major poor outcomes in non-head/neck cSCC with high specificity (0.99 for BWH and 0.97 for AJCC8), meaning that patients who did not experience poor clinical outcomes were very likely to have low-stage tumors. Despite the limited nature of the analysis, this important study demonstrates that both BWH and AJCC8 staging systems can be used with high accuracy to predict poor clinical outcomes in non-head/neck cSCCs, comparable to their use in the staging of head and neck tumors.
