Methotrexate vs. methotrexate plus prednisone in patients with alopecia areata totalis, universalis
Authors of a study published in JAMA Dermatology sought to determine the effectiveness of methotrexate as a standalone treatment and in combination with prednisone for the treatment of alopecia areata totalis (AT) or alopecia universalis (AU). The researchers included 89 adult patients with AT or AU who had been diagnosed for over six months despite other topical and systemic treatments having been administered.
[Is low-dose methotrexate associated with a higher risk of melanoma development? Read more inDermWorld.]
The research team treated the participants who had over 25% hair regrowth at six months up until 12 months, and those with less than 25% regrowth were randomized again and then given either methotrexate and a placebo of prednisone or methotrexate and prednisone (20 mg per day for three months and 15 mg per day for three months).
By the end of the study, the team observed complete or almost complete hair regrowth (SALT score of <10) for one participant given methotrexate alone and for seven patients given methotrexate plus prednisone. The near-complete regrowth was reported in five of the seven participants given methotrexate for 12 months and prednisone for six months. The authors conclude that “while methotrexate alone mainly allowed partial hair regrowth in patients with chronic AT or AU, its combination with low-dose prednisone allowed complete hair regrowth in up to 31% of patients. These results seem to be of the same order of magnitude as those recently reported with JAK inhibitors, with a much lower cost.”
DermWorld Insights and Inquiries: Turning a blind eye on second opinions
Whenever I encounter patients who ask for, or are being seen for, second opinions, I silently chuckle at Henny Youngman’s timeless one-liner about the subject (you can Google it). The fact is that second opinions are no joke. There are innumerable reasons why patients seek them ranging from diagnostic dilemmas to exploring therapeutic options. I encourage my patients to get second opinions when I am unsure of the diagnosis or if my therapeutic interventions have been inadequate. Some patients worry about offending me. Dr. Anees Chagpar states: “People are generally very nice and they don’t want to hurt the first doctor’s feelings.” When I sense this, I immediately dispel it — I tell patients that all I want is for them to get better and the last thing I care about is my ego. I am honored that colleagues will often refer patients to me for my opinion. (Interestingly, I have patients contact me from around the world seeking my advice because of a particular DWI&I column I wrote — I sheepishly inform them that I am not an expert on most of these topics and appropriately refer them elsewhere.) I have basic rules for complex consultations… Keep reading!
Nail clipping histopathology for routine evaluation of melanonychia
Authors of an article published in the Journal of Cutaneous Pathology have called on dermatologists and dermatopathologists to include nail clipping histopathology as an essential component of the routine evaluation of melanonychia. Histopathologic evaluation of nail clippings can result in a diagnosis of nail unit melanoma through the identification of melanocyte remnants. It can also aid in triaging nail unit biopsy and assist in surgical planning. Nail clipping histopathology can provide extensive information in the evaluation of melanonychia with minimal discomfort for a patient and minimal disruption to a physician’s clinic flow.
Risk of infection in children with psoriasis treated with ustekinumab, etanercept, or methotrexate
Authors of a JAMA Dermatology study investigated the rate of serious infections requiring hospitalization and outpatient-treated infections among children with psoriasis treated with ustekinumab, etanercept, or methotrexate.
This cohort study used insurance claims data from clinical practices across the U.S. on children aged 17 years or younger with psoriasis who were receiving treatment with a topical medication for psoriasis and started new treatment with ustekinumab, etanercept, or methotrexate. The analysis was stratified by the time before pediatric labeling (2009-2015) and after pediatric approval (2016-2021). Patient follow-up started one day after initiating treatment and ended at six months.
In this cohort study of 2,338 children, the incidence of serious infection was 18.4 per 1,000 person-years for ustekinumab users, 25.6 per 1,000 person-years for etanercept users, and 14.9 per 1,000 person-years for methotrexate users. Ustekinumab showed no increased rate of outpatient infections compared with etanercept and methotrexate and may suggest a trend toward a decreased risk for ustekinumab.
Dermatology topics tested in question banks for medical students
Authors of a study published in Clinical and Experimental Dermatology examined the content of the United States Medical Licensing Examination online preparatory materials to investigate the dermatology exposure received by most U.S. medical students. A total of 655 dermatology questions were included in the UWorld and AMBOSS Step 1 and Step 2CK question banks, with the latter having a higher proportion of questions that assessed management of dermatologic conditions. The study found an underrepresentation of common skin disorders in the questions. Additionally, the proportion of questions using pictures varied significantly between resources, with AMBOSS using pictures in only 29% of questions. The authors suggest that there is a need and opportunity for standardization of dermatology teaching in the medical school curricula.
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