Off-label use of calcineurin inhibitors for dermatologic conditions
A review published in JAAD discussed the off-label use of systemic tacrolimus and voclosporin in patients with various dermatologic conditions. Tacrolimus is approximately 100 times more potent than cyclosporine in suppressing T-cell activation and has improved blood pressure and lipid profiles. It also shows improved intestinal absorption and more predictable bioavailability compared with cyclosporine. According to the study authors, tacrolimus has been shown to deliver promising results in the treatment of psoriasis, atopic dermatitis, pyoderma gangrenosum, chronic urticaria, and Behçet’s disease. Voclosporin is the newest calcineurin inhibitor and has improved tolerability and dosing compared with other calcineurin inhibitors. It is FDA-approved for lupus nephritis and has shown efficacy in the treatment of psoriasis.
The authors suggest that dermatologists should consider tacrolimus for patients with treatment-resistant disease, especially patients with cardiovascular risk factors or inflammatory bowel disease. Voclosporin should be considered for treating patients with lupus nephritis; however, more studies are needed to determine the appropriateness for other dermatologic conditions.
DermWorld Insights and Inquiries: Diagnosing nail unit melanomas at a faster clip
Every dermatologist has examined a pigmented nail, wondering if the pathologic process reflects a nail unit melanoma (NUM) or subungual melanoma versus a benign melanocytic lesion (melanocytic activation, lentigo, or nevus), pigmented onychomycosis, or hemorrhage. A definitive diagnosis requires a nail unit biopsy, but patients may be reluctant to have the procedure performed due to the risk of nail dystrophy. Dermatologists may also be leery about the procedure, not only because of the cosmetic concerns but also because of a lack of training on properly performing a soft-tissue specimen from the nail unit, and/or the perceived technical difficulty of a nail unit biopsy. Is there a simple, rapid, painless way to identify patients at risk for NUM? Nail clippings may be the answer. Keep reading!
What are risk factors for developing generalized pustular psoriasis?
A research letter published in JAAD assessed risk factors for development of generalized pustular psoriasis (GPP), including lifestyle factors, psychiatric comorbidities, and systemic corticosteroid exposure. This matched case–control study of 642 patients with GPP and 12,811 controls found that obesity, a history of tobacco smoking, depression, anxiety, and oral steroid prescription within three months of the index incident significantly increased the odds of developing GPP. A history of alcohol use disorder was associated with lower odds of GPP. Black patients had decreased odds of GPP compared with white patients.
AADA urges FDA, manufacturers take more action on lidocaine shortage
The AADA recently urged the FDA to take all possible actions to mitigate the lidocaine shortage as a result of a tornado that caused significant damage to Pfizer’s North Carolina facility that manufactures sterile injections, including lidocaine.
The End Drug Shortages Alliance (EDSA), a coalition of health systems, including suppliers, distributors, clinicians, other stakeholders, and the AADA, released a Supply Chain Disruption Report that evaluated the impact of the supply chain following the tornado that damaged the Pfizer Rock Mount facility. Unfortunately, the report identifies several drugs, including lidocaine and lidocaine with epinephrine, as products that may continue to experience supply disruptions. Pfizer produces only 18% of the market share of lidocaine with epinephrine with Fresenius Kabi holding the remaining market share.
The AADA reached out to Pfizer and Fresenius Kabi for status updates and shared our members’ concerns with the limited supply. The AADA will continue to provide updates as available. In the meantime, members are encouraged to visit Pfizer and Fresenius Kabi for the latest updates on their product availability.
CDC report warns of sexual transmission of tinea
The CDC’s Emerging Infectious Diseases reports 13 cases of Trichophyton mentagrophytes genotype VII (TMVII) in France that appear to have been transmitted through sexual contact, with 12 of the 13 cases involving men who had sex with men. The authors note “a substantial delay in diagnosis” as patients “were initially mistakenly believed to have had bacterial infections.” The necessity of “prolonged systemic antifungal treatments and patient hospitalizations,” they write, indicates “how severe TMVII infections can be” and suggests the need for dermatologists and others to be aware of TMVII when seeing patients with skin infections. However, the authors note that unlike in the recent outbreak of cases of T. indotineae, “no terbinafine resistance has been reported for TMVII.”
[CDC announces first reported U.S. cases of tinea caused by Trichophyton indotineae. Read more.]
Work has begun to make it possible for health care professionals to report tinea cases to the AAD/ILDS shared Dermatology COVID-19, Mpox, and Emerging Infections Registry. Look for an announcement in DermWorld Weekly when this new reporting capability is available.
RNA sampling via tape strips may rule out melanoma in suspicious lesions
Authors of a study in JAAD sought to develop the tape stripping technique and validate if RNA profiles can rule out cutaneous malignant melanoma (CMM) in clinically suspicious lesions with 100% sensitivity. A noninvasive test to improve the clinical accuracy of CMM detection using RNA profiles obtained by tape strips from the lesion surface has been proposed, the researchers wrote, adding that the sensitivity of these tests has raised concerns about the risk of overlooking CMM in suspicious lesions. They assessed 200 CMM lesions using tape strips followed by an investigation of the expression levels of 11 genes using RNA measurement. A total of 74 CMMS and 127 non-CMMs were included.
Results showed that tape-strip–derived RNA testing was able to identify all CMMs demonstrating 100% sensitivity. These findings were due to the elevated expression levels of two oncogenes, PRAME and KIT, compared with housekeeping gene RPL18. The technique also correctly excluded CMM in 32% of non-CMM lesions, demonstrating a 32% specificity. RNA sampled by tape stripping can reduce the number of lesions removed unnecessarily by nearly one-third without missing CMMs, according to the researchers.
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