Authors of a study published in JAMA Dermatology developed a consensus statement about the optimal approach to laboratory monitoring for otherwise healthy patients treated with isotretinoin for acne. An electronic survey was distributed to 22 board-certified dermatologist acne experts from five continents to determine whether consensus could be reached (≥70% agreement).
Consensus was achieved for the following statements:
Check alanine aminotransferase within a month prior to initiation (89.5%) and at peak dose (89.5%) but not monthly (76.2%) or after treatment completion (73.7%)
Check triglycerides within a month prior to initiation (89.5%) and at peak dose (78.9%) but not monthly (84.2%) or after treatment completion (73.7%)
Do not check complete blood cell count or basic metabolic panel parameters at any point during isotretinoin treatment (all >70%)
Do not check gamma-glutamyl transferase (78.9%), bilirubin (81.0%), albumin (72.7%), total protein (72.7%), low-density lipoprotein (73.7%), high-density lipoprotein (73.7%), or C-reactive protein (77.3%).
DermWorld Insights and Inquiries: Metformin mania — Is it an adequate chemopreventive agent for skin cancer?
Precisely a century ago (in 1922) metformin was synthesized based on the folk knowledge that the active, but toxic constituent guanidine galegine, (derived from French lilac, Galega officinalis) could treat “sweet urine.” Metformin is now utilized daily by more than 150 million people to treat type 2 diabetes mellitus (T2DM).
In managing diabetes, metformin decreases hepatic glucose output and acts as an insulin sensitizer by increasing glucose utilization by muscles and adipocytes. By improving glycemic control, serum insulin concentrations decline slightly, as do luteinizing hormone and androgen levels, thereby improving hyperinsulinemia and its signs. Additionally, metformin has platelet anti-aggregating and antioxidant effects. These pharmacological properties allow metformin to be effective in myriad disorders including cutaneous diseases such as acne, hirsutism, hidradenitis suppurativa, acanthosis nigricans, psoriasis, skin cancer, and others. Keep reading!
Monkeypox: A dermatologic primer
Authors of a JAAD article review historical outbreaks, modes of transmission, and clinical manifestations of monkeypox as well as the diagnostic methods and treatment options for the virus. Dermatologists will play a key role in recognizing and diagnosing infections and educating and preparing frontline health care workers to detect new cases early, the authors note.
Typically, within one to five days from the onset of fever, a rash evolves and resolves over a two- to four-week period of time. First, the rash appears as macules (1-2 days), then develops into papules (1-2 days), followed by vesicles (1-2 days), and ultimately pea-sized, hard pustules (5-7 days) before crusting, scabbing, and eventually falling off (7-14 days). Once the eschar has fallen off and the wounds have healed with a fresh layer of skin, the patient is no longer considered infectious — about two to four weeks from the first lesion.
Reports from the current outbreak suggest that there may be a less severe prodrome with the characteristic vesicular lesions presenting in the genital and perineal region more frequently and potentially limited to that anatomic site. Monkeypox should be in the differential diagnosis for new genital lesions and evaluation for potential sexually transmitted infections.
The main clinical differential diagnosis is smallpox, although the presence of lymphadenopathy and crop-like, less-centrifugally distributed lesions may indicate monkeypox. Herpes infections (both herpes simplex virus and varicella-zoster virus) tend to have smaller individual lesions and more frequently occur in limited anatomic areas. Herpes-family infections may be reliably diagnosed by rapid polymerase chain reaction testing.
[AMA adds codes for monkeypox testing, vaccination. Learn more in Derm Coding Consult.]
Primary treatments are supportive, although early identified close contacts may benefit from ring vaccination, either with the vaccinia vaccine (replication-competent vaccine, approved for smallpox) or the newer Jynneos’ Imvamune (replication-deficient vaccine, approved for monkeypox). The replication-competent vaccinia vaccine has a considerable adverse event profile with many contraindications. For individuals with a history of atopic dermatitis, a rare and potentially lethal complication known as eczema vaccinatum can occur with vaccination by replication-competent vaccinia vaccine. Read more about other potential treatments, and infection control and public health guidelines.
AADA, sister societies address drug shortage with FDA
Last week, the AADA, the American College of Mohs Surgery (ACMS), the American Society for Dermatologic Surgery Association (ASDSA), and the American Society for Mohs Surgery (ASMS) expressed strong shared concerns about the critical national shortage of lidocaine with epinephrine, lidocaine, and other local anesthetics and its impact on patient care in a letter to the FDA Office on Drug Shortage. The societies urged the FDA to take immediate action by adding lidocaine and lidocaine with epinephrine to the “List of Extended Use Dates to Assist with Drug Shortages.” The societies further requested that FDA engage with stakeholders to find a long-term solution.
This most recent letter is just the latest AADA action addressing drug shortage concerns with the FDA. In June, AADA Compounding Workgroup Chair Seemal Desai, MD, FAAD, and AADA Past President George Hruza, MD, FAAD, representing ASDSA, participated in an FDA compounding workgroup listening session and clearly outlined the consequences for patients of the escalating problem with shortage of generic injectable medication.
Characterizing three profiles for bullous pemphigoid
A retrospective analysis published in JAAD identified 279 patients with bullous pemphigoid (BP) and described three separate phenotypes. The first cluster of patients (56%) were older than the other clusters. These patients were more likely to have pauci-bullous BP and anti-BP230 autoantibodies in 87% of the cases. The second cluster of patients (32%) were more likely to have more than 100 blisters. The third group of patients (12%) were more likely to report mucosal involvement (91%). The patients in this cluster required more treatment modalities and experienced more relapses. The majority of patients in the second and third clusters were positive for only anti-BP180 autoantibodies (79% and 74%, respectively).
What are the latest advances in the diagnosis of autoimmune bullous dermatoses? Find out inDermWorld.
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