This month’s news from across the specialty
What’s hot
April 1, 2025
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
Kaiser Family Foundation Health News reported on the very large and growing advertising spending by direct-to-consumer health companies while they also expand in scope to take on complex medical conditions. For example, publicly traded telehealth companies spent over $1.4 billion on marketing in 2023. Cable TV advertising spending by telehealth entities more than doubled from 2019 to 2023 to $111 million. Initially, companies emphasized cost, convenience, and judgment-free care for traditionally stigmatized conditions such as birth control, hair loss, or erectile dysfunction. However, recent ads have focused on more complex conditions such as mental health and obesity. The 2025 Hims & Hers Super Bowl ad, for example, focused on weight loss through direct prescribing of compounded GLP-1 medications that have not undergone the FDA’s drug approval process and don’t require the standardized FDA labeling that applies to branded medications.
The article points out that the expansion of scope for direct-to-consumer telehealth could be troublesome for patients due to limited ability for follow-up, inconsistent care from constantly changing clinicians, and the separation of prescribing from diagnosis and therapy. Clinicians who participate in these services are reduced to screeners who work to ensure that a patient’s requested medication is safe, rather than a collaborator who helps to figure out a diagnosis and treatment plan — that may or may not involve a medication.
Dermatologists may see patients who are on unusual therapeutic plans, inappropriate doses of medications, or experiencing avoidable side effects as patients increasingly choose direct-to-consumer prescription services over collaborative and integrated care.
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The diagnosis of dermatomyositis can be difficult, especially since amyopathic variants exist. Clinical symptoms and skin lesions are not always characteristic. Similarly, the histopathology may be subtle. A typical skin biopsy of dermatomyositis shows an interface dermatitis characterized by vacuolar alteration and dyskeratosis, a lymphocytic infiltrate and dermal mucinous ground substance. A recent study analyzed the histopathology of acral skin biopsies in dermatomyositis. They reviewed 50 skin biopsies from acral surfaces of dermatomyositis patients and compared them to 197 biopsies from non-acral lesions. Their study found that all the characteristic histopathological features are less likely to be seen in acral surfaces (which includes elbows and knees) in comparison to non-acral surfaces. The study serves as a reminder to both dermatologists and dermatopathologists that if an acral biopsy does not show the characteristic interface dermatitis with mucin, the possibility of dermatomyositis cannot be excluded. Additionally, if truncal lesions are present, choosing that site for biopsy is preferred over an acral surface.
A 17-year-old girl presented with a rapid onset, diffuse, vesiculobullous, targetoid eruption on her extremities (including palms and soles), trunk, and face — including her lips. The patient had started lamotrigine four weeks prior to the onset of her rash. A punch biopsy revealed pustules and neutrophils in all layers of the epidermis and some eosinophils. The patient had fever, leukocytosis (neutrophilia), atypical lymphocytes, transaminitis, and eosinophilia. Mycoplasma pneumoniae IgG and IgM antibodies were both elevated. The patient was then presented at a teaching conference as a case of reactive infectious mucocutaneous eruption (RIME).
What is the lesson here? The skin manifestations of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) are polymorphic and may be vesiculobullous (as in this case), targetoid (as in this case), or pustular (as in the histopathology of this case) (J Am Acad Dermatol 2024;90:885-908). The diagnosis of RIME requires that there is no recent history of “a highly worrisome medication” (JAMA Dermatol 2020; 156(2): 124-125), which in this case, there was a contributory, high-risk medication (lamotrigine). If the skin is involved in RIME, the body surface area (BSA) that is involved is classically minimal (< 10% BSA), not diffuse. This was a case of a severe cutaneous adverse reaction to a high-risk medication. Understanding these nuances is essential for accurate diagnosis and timely intervention. This patient should not take lamotrigine again.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup.
Toxic epidermal necrolysis (TEN), which occurs when ≥ 30% of body surface area detaches, is a severe drug reaction that results in mortality rates of at least 30%. That much is clear. What’s less clear is how it happens, and how to stop it.
A proteomics study published in Nature (2024. Oct. 16;635(8040):1001–9) sheds new light on TEN. (For a useful basic primer on proteomics, try this JAMA Learning article).
The investigators used deep visual proteomics, which characterize single-cell protein expression, to study skin biopsies of patients with maculopapular drug rashes, drug reaction with eosinophilia and systemic symptoms [DRESS], or TEN, and healthy individuals. TEN patients expressed more proteins involved in calcium homeostasis and cellular stress response, especially interferons. The most notable TEN-specific proteins were in the cytokine-activated JAK/STAT pathway, which is also important in DRESS.
The investigators then used in vitro and mouse models to show that various JAK inhibitors effectively inhibited cutaneous drug reactions, including TEN. That data led the investigators to use JAK inhibitors to treat seven human patients with TEN or Stevens Johnson Syndrome-TEN overlap; all patients reportedly survived to day 30 with no side effects.
Those clinical data will need to be studied in larger trials. But this new proteomics-based understanding of TEN pathophysiology is, clearly, promising.
