This month’s news from across the specialty

November 1, 2024

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

Researchers in Amsterdam used karaoke to study the well-known, but poorly understood subtype of facial erythema known as blushing. Their results challenge the long-held hypothesis initially put forward by Charles Darwin that blushing is primarily provoked by a fear of being judged by others. The team recruited 40 adolescents to sing: “All I Want for Christmas is You” by Mariah Carey, “All the Things You Said” by t.A.T.u., “Hello” by Adele, and “Let It Go” from Disney’s Frozen on camera. To provoke as much embarrassment as possible, the participants were asked to watch recordings of their karaoke performance along with an audience. Their cerebral activity was analyzed by fMRI and facial flushing was measured while they watched themselves.

Analysis of the fMRI results showed that blushing is associated with regions of the brain associated with emotional excitement and self-awareness, rather than fear of judgement by others. The researchers also found increased activity in the cerebellum, an area of the brain known for controlling movement and coordination, but recently discovered to process emotions. The study shows that thinking about the thoughts of others may not be necessary for blushing to occur and that it may be a spontaneous reaction triggered by a surge of self-awareness in social situations.

Patients with anxiety disorders often develop a fear of blushing and consult dermatologists for their facial erythema. This study opens a new way of thinking about and discussing blushing with our patients that focuses on subconscious arousal and self-awareness rather than embarrassment and social anxiety.

Vitamin B3 (in the form of nicotinamide) has been used in dermatology for decades, including as an oral treatment for bullous pemphigoid (with tetracyclines) and in the chemoprevention of keratinocyte carcinoma. New research, however, suggests that a terminal metabolite of vitamin B3 may have adverse effects on heart health (Nature Medicine 2024; 30(2):424-434). Ferrell et al found that excess vitamin B3 is broken down into a metabolite called 4PY (N1-methyl-4-pyridone-3-carboxamide), and that this breakdown product activates inflammatory pathways that lead to plaque formation in arteries, increasing the risk of myocardial infarction and stroke.

These findings have led to recent editorials questioning the safety of niacin/niacinamide oral supplementation and may also explain the so-called niacin paradox: Although niacin lowers LDL cholesterol, niacin had never been shown to reduce cardiovascular risk. Researchers believe that the potential health benefit of niacin (through lowering cholesterol levels) is likely offset by excess niacin metabolites promoting plaque formation. In my view, these findings raise questions about the use of nicotinamide in dermatology, particularly for the aim of preventing actinic keratoses and keratinocyte carcinoma. Any potential benefit (which remains uncertain in my opinion) could be outweighed by increased cardiovascular and mortality risk. Even a slight increase in heart disease risk would have large effects because of the high baseline prevalence of heart disease, especially in elderly patients. Today, heart disease is the leading cause of death in the United States, accounting for 20% of deaths. Therefore, unless future research suggests otherwise, I carefully consider and individually personalize my recommendations regarding nicotinamide supplementation to patients to reduce their risk of skin cancer.

A recent JAMA review (doi:10.1001/jama.2024.12708) assessed bleeding complications in surgical patients taking direct oral anticoagulants (DOACs), proposing risk-based guidelines for perioperative management of these medications. The authors considered dermatologic surgeries — “excision of basal and squamous cell skin cancers, actinic keratoses, or premalignant or cancerous skin nevi” — to be procedures with minimal risk of bleeding complications; the JAMA guidelines do not recommend perioperative interruption of DOAC therapy. If the surgeon or patient is concerned about excessive bleeding, they may opt to delay their daily DOAC dose until after the surgery or may skip one dose if they normally take the DOAC twice daily.

Further, a 2021 research letter (doi:10.1016/j.jaad.2020.06.011) analyzed 2,732 Mohs surgery cases, 48.9% of which were anticoagulated. Only 1% of all patients and only 0.9% of patients taking a DOAC had a bleeding complication after Mohs. Similarly, a 2024 chart review (doi:10.1097/DSS.0000000000003967) of 2,181 Mohs surgeries found that continuation of DOAC use during Mohs surgery was not associated with an increased postoperative bleeding risk. The authors did find that the combination of a DOAC with aspirin resulted in a higher risk of postoperative bleeding, but that did not result in adverse patient outcomes.

These findings support the perioperative continuation of DOACs in dermatologic surgeries. The data highlight the minimal risk of perioperative bleeding in patients taking DOACs and reinforce that, even when bleeding occurs, it does not cause poor outcomes. Conversely, the potential consequences of DOAC interruption — such as thromboembolic events — can result in devastating, long-term adverse outcomes for patients.

There has been a significant increase in the popularity of permanent makeup (PMU)/cosmetic tattooing in recent years for aesthetic purposes or to camouflage pathological skin conditions such as scars, dyspigmentation, birthmarks, alopecia, and nipple-areola complex reconstruction after breast surgery. A literature review from Northwestern University provides a detailed overview of PMU, focusing on its use, regulation, and potential complications (J Am Acad Dermatol. 2024. 91: 690-8).

PMU artists come from various backgrounds and include estheticians, nurses, tattoo artists, cosmetologists, and physicians, and training duration can range from four hours to 24 months. There is no uniformity in training, and there are limited federal and state regulations for the tattoo industry. The FDA does not regulate or control the additives in PMU ink, and there are little to no guidelines from national medical organizations.

The most common complications of PMU are patient dissatisfaction, pigment misapplication, migration, and fanning. Other complications include pain, bleeding, infections (localized and systemic), non-infectious inflammatory reactions (allergic, granulomatous/lichenoid reaction). Drug reactions with bisphosphonates and alkaline local anesthetics have been reported.

Streamlined regulations pertaining to PMU and the development of patient-centered content by reputable, national organizations may protect and help consumers and dermatologists better understand the benefits and complications of PMU.

Additional DermWorld Resources