This month’s news from across the specialty
What’s hot
February 1, 2025
In this monthly column, members of the DermWorld Editorial Advisory Workgroup identify exciting news from across the specialty.
The Nation’s Health by the American Public Health Association published a special report on improving health of people with intellectual and developmental disabilities (IDD). People with IDD experience disparate health outcomes in areas such as having fewer preventive screenings, more complications during pregnancy, lower life expectancy, a higher risk of chronic diseases, discrimination, and maltreatment in health care.
We are likely to see these patients daily in our practices as about 8 million Americans have IDD. Unfortunately, research shows that only 40% of physicians feel very confident in their ability to provide the same quality of care to individuals with disabilities and fewer than 57% strongly agree that their practices welcome patients with disabilities. Our lack of confidence may be related to the 11 minutes of IDD education that most medical schools average over the course of four years.
The series provides resources and advocacy strategies for dermatologists who want to go beyond being ADA-compliant to create clinics that are fully inclusive and close these gaps.
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A retrospective study investigated skin cancer risk in a large cohort of patients treated with ultraviolet light therapy between May 1977 and November 2018 (J Am Acad Dermatol. 2024; 90: 759-66). Patients were treated with narrowband UVB (NB-UVB), broadband UVB (BB-UVB), and combined UVAB. All skin cancers occurring after initiation of phototherapy were included. Records for 3,506 patients were reviewed. Most patients had psoriasis (60.9%) or eczema (26.4%). The median number of treatments was 43 (range 1-3,598). Mean follow-up was 7.3 years. Overall, 170 tumors (120 BCCs, 33 SCCs, 17 melanomas) were identified in 79 patients. The mean age of patients with skin cancer was 66. Fifteen of these patients had a history of skin cancer prior to initiating phototherapy. Two patients were on concurrent immunosuppressive medications (methotrexate and cyclosporine). Skin phototype profiles of these 79 patients were: skin type I(n=4), II(n=24), III(n=34), IV (n=10), and V(n=2).
The authors found no increased risk of melanoma, SCC, or BCC when compared to the general population. Skin cancer incidence increased with age and decreased with higher Fitzpatrick skin phototypes. These factors suggest that the profile of skin cancers seen in phototherapy patients is similar to that of the general population, consistent with natural sun exposure as a primary causal factor. In addition, no correlation between skin cancer risk and total number of treatment sessions or cumulative UV dosage was found. This suggests ultraviolet phototherapy can be considered a relatively safe treatment option. The limitations of this study include the low median number of treatments and the follow-up duration.
Few rashes are morphologically as distinctive to the trained eye of a dermatologist as pityriasis rubra pilaris (PRP), which is classically characterized by hyperkeratotic follicular papules, orange-red scaly plaques, and palmoplantar keratosis. The pathogenesis of sporadic PRP, however, remains poorly understood (unlike familial cases of PRP, which have been associated with mutations in the CARD14 gene). Recently, Shi P et al conducted a case-control study of 102 patients with sporadic PRP and 800 healthy controls of the Han Chinese population and identified significant associations with heterozygous loss-of-function mutations involving the Keratin 32 gene (KRT32). Although we typically think of keratin proteins as providing structural support to keratinocytes and helping maintain skin integrity and barrier, the authors instead identified that KRT32 functions to maintain skin immune homeostasis by regulating the NF-κB pathway. Normally KRT32 binds to NEMO and promotes its degradation. Loss-of-function mutations in KRT32 result in NF-κB over-activation and generation of pro-inflammatory cytokines. KRT32 knockout mice exhibited a PRP-like rash phenotype, further supporting their findings. This study suggests that variants of KRT32 are important drivers in PRP development and help regulate skin inflammation. It may further offer important insights into future novel therapeutic targets for PRP.
More What’s Hot!
Check out more What’s Hot columns from the DermWorld Editorial Advisory Workgroup.
It has become widely accepted that sentinel lymph node biopsy (SLNB) must be performed prior to, or simultaneously with, wide local excision (WLE) of melanoma (doi.org/10.1016/j.jaad.2018.08.055). The concern was that performing WLE prior to SLNB could affect afferent lymphatic drainage, leading to misidentification of sentinel lymph nodes, inaccurate staging, and potential inappropriate prognostication or further workup/treatment.
Interestingly, at least one study has shown that repeat lymphoscintigraphy 2 cm away from the original site found the same SLN in 84% of cases (PMID 11337518). In the remaining 16% of cases, both the original LN and additional LNs were highlighted. This indicates that lymphatic drainage — and therefore corresponding SLNB — from any one anatomic area is unlikely to be affected by melanoma excisions performed following standard-of-care margins.
Recently, Tassavor et al reviewed 13 articles published between 1999 and 2022. Based on false-negative rates, disease recurrence, relapse-free survival, overall survival, and changes in lymphatic mapping on repeat lymphoscintigraphy, the authors found no evidence that prior WLE negatively impacts SLNB accuracy or disease recurrence rates (doi.org/10.1097/DSS.0000000000004261). This is important because WLE of melanoma can often be performed more quickly than SLNB or simultaneous WLE+SLNB. Although delay of SLNB has not been shown to adversely affect melanoma survival, delay of >30 days from diagnosis to WLE has been shown to worsen mortality, while WLE performed <30 days after diagnosis seems to confer a survival benefit.
