Dermatology

In addition to the patient’s SK, the second finding was diagnosed as a thin melanoma. The clinical appearance of SKs and nevi or melanoma can overlap. Dermoscopy is a helpful tool in distinguishing between them, even when juxtaposed in a collision lesion such as this.¹

Dermoscopy of the superior portion of the lesion demonstrated a well-demarcated brown, waxy papule with milia-like cysts, consistent with an SK. Inferiorly, the dermoscopic features included atypical pigment network, asymmetrical streaks, and blue-white veil, suggestive of melanoma or an atypical melanocytic neoplasm. A deep-shave biopsy was performed of the lower section, aiming for a narrow margin (1-3 mm) of normal skin. The biopsy confirmed a superficial spreading melanoma with a Breslow depth of 0.5 mm with 0 mitoses per high-power field.

A deep-shave biopsy was chosen over a punch biopsy because the latter would be unlikely to sample the entire lesion.

One month after the initial biopsy, a wide local excision with a 1-cm margin was performed. The planned follow-up for the patient was skin exams every 3 months for the first year, every 6 months for the next 4 years, and then annually for life.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

In addition to the patient’s SK, the second finding was diagnosed as a thin melanoma. The clinical appearance of SKs and nevi or melanoma can overlap. Dermoscopy is a helpful tool in distinguishing between them, even when juxtaposed in a collision lesion such as this.¹

Dermoscopy of the superior portion of the lesion demonstrated a well-demarcated brown, waxy papule with milia-like cysts, consistent with an SK. Inferiorly, the dermoscopic features included atypical pigment network, asymmetrical streaks, and blue-white veil, suggestive of melanoma or an atypical melanocytic neoplasm. A deep-shave biopsy was performed of the lower section, aiming for a narrow margin (1-3 mm) of normal skin. The biopsy confirmed a superficial spreading melanoma with a Breslow depth of 0.5 mm with 0 mitoses per high-power field.

A deep-shave biopsy was chosen over a punch biopsy because the latter would be unlikely to sample the entire lesion.

One month after the initial biopsy, a wide local excision with a 1-cm margin was performed. The planned follow-up for the patient was skin exams every 3 months for the first year, every 6 months for the next 4 years, and then annually for life.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

In addition to the patient’s SK, the second finding was diagnosed as a thin melanoma. The clinical appearance of SKs and nevi or melanoma can overlap. Dermoscopy is a helpful tool in distinguishing between them, even when juxtaposed in a collision lesion such as this.¹

Dermoscopy of the superior portion of the lesion demonstrated a well-demarcated brown, waxy papule with milia-like cysts, consistent with an SK. Inferiorly, the dermoscopic features included atypical pigment network, asymmetrical streaks, and blue-white veil, suggestive of melanoma or an atypical melanocytic neoplasm. A deep-shave biopsy was performed of the lower section, aiming for a narrow margin (1-3 mm) of normal skin. The biopsy confirmed a superficial spreading melanoma with a Breslow depth of 0.5 mm with 0 mitoses per high-power field.

A deep-shave biopsy was chosen over a punch biopsy because the latter would be unlikely to sample the entire lesion.

One month after the initial biopsy, a wide local excision with a 1-cm margin was performed. The planned follow-up for the patient was skin exams every 3 months for the first year, every 6 months for the next 4 years, and then annually for life.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

An exploratory analysis recently published in the Journal of the American Academy of Dermatology examines whether it is possible to classify dermatologists and internists into different patterns of prescribing behavior for patients with acne.

“Prior research has highlighted that prescribing for acne may not be aligned with guideline recommendations, including the overuse of oral antibiotics and lack of use of concomitant topical medications such as topical retinoids,” the study’s corresponding author, John S. Barbieri, MD, MBA, of the department of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

“In addition, there is substantial variation in prescribing practices among clinicians. We were interested in examining whether it is possible to identify different prescribing phenotypes among dermatologists and internists who care for patients with acne. By identifying such groups, it would facilitate future qualitative interviews to understand factors that might contribute to clinicians having certain prescribing patterns, which could help guide implementation science work to better align practices with evidence and guidelines.”

For the study, which appeared online on March 1, Dr. Barbieri and colleague David J. Margolis, MD, PhD, professor of dermatology and epidemiology at the University of Pennsylvania, evaluated all clinical encounters associated with an ICD-9 or ICD-10 code for acne that occurred in the university’s departments of dermatology and internal medicine between Jan. 1, 2011, and Dec. 31, 2019. They used a machine-learning method known as k-means clustering to cluster clinicians based on their relative use of acne medications, as well as the ratio of spironolactone versus tetracycline use among female patients and stratified their analyses by specialty.

Of the 116 dermatologists included in the analysis, the researchers identified three clusters. The first cluster included 17 dermatologists (14.7%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and low use of spironolactone, compared with oral antibiotics, among women with acne. Physicians in this cluster were more likely to be male and to have more years in practice.

The second cluster included 46 dermatologists (39.6%) and was marked by high use of spironolactone and low use of isotretinoin. The third cluster included 53 dermatologists (45.7%) and was characterized by high use of topical retinoids and frequent use of systemic medications.

Of the 86 internists included in the study, the researchers identified three clusters. The first cluster included 39 internists (45.4%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and limited use of spironolactone. The second cluster included 34 internists (39.5%) and was marked by low use of topical retinoids and systemic medications. The third cluster included 13 clinicians (15.1%), most of whom were nurse practitioners, physician assistants, and other advanced practice providers. This cluster was characterized by high use of topical retinoids and relatively high use of spironolactone.

“There are likely opportunities to improve the use of topical retinoids by internists caring for patients with acne, since these are a first-line treatment option that may be underutilized by internists,” Dr. Barbieri said in the interview. “Future work is needed to identify underlying factors associated with different prescribing phenotypes among both dermatologists and internists. By understanding these factors, we can develop implementation science efforts to align prescribing behavior with best practices based on the guidelines and available evidence.”

He acknowledged certain limitations of the analysis, including its single-center design and the lack of data on patient characteristics. “Future studies are needed to examine whether our results generalize to other settings,” he said.

Dr. Barbieri disclosed that he receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania. The authors had no other disclosures.

dbrunk@mdedge.com

An exploratory analysis recently published in the Journal of the American Academy of Dermatology examines whether it is possible to classify dermatologists and internists into different patterns of prescribing behavior for patients with acne.

“Prior research has highlighted that prescribing for acne may not be aligned with guideline recommendations, including the overuse of oral antibiotics and lack of use of concomitant topical medications such as topical retinoids,” the study’s corresponding author, John S. Barbieri, MD, MBA, of the department of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

“In addition, there is substantial variation in prescribing practices among clinicians. We were interested in examining whether it is possible to identify different prescribing phenotypes among dermatologists and internists who care for patients with acne. By identifying such groups, it would facilitate future qualitative interviews to understand factors that might contribute to clinicians having certain prescribing patterns, which could help guide implementation science work to better align practices with evidence and guidelines.”

For the study, which appeared online on March 1, Dr. Barbieri and colleague David J. Margolis, MD, PhD, professor of dermatology and epidemiology at the University of Pennsylvania, evaluated all clinical encounters associated with an ICD-9 or ICD-10 code for acne that occurred in the university’s departments of dermatology and internal medicine between Jan. 1, 2011, and Dec. 31, 2019. They used a machine-learning method known as k-means clustering to cluster clinicians based on their relative use of acne medications, as well as the ratio of spironolactone versus tetracycline use among female patients and stratified their analyses by specialty.

Of the 116 dermatologists included in the analysis, the researchers identified three clusters. The first cluster included 17 dermatologists (14.7%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and low use of spironolactone, compared with oral antibiotics, among women with acne. Physicians in this cluster were more likely to be male and to have more years in practice.

The second cluster included 46 dermatologists (39.6%) and was marked by high use of spironolactone and low use of isotretinoin. The third cluster included 53 dermatologists (45.7%) and was characterized by high use of topical retinoids and frequent use of systemic medications.

Of the 86 internists included in the study, the researchers identified three clusters. The first cluster included 39 internists (45.4%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and limited use of spironolactone. The second cluster included 34 internists (39.5%) and was marked by low use of topical retinoids and systemic medications. The third cluster included 13 clinicians (15.1%), most of whom were nurse practitioners, physician assistants, and other advanced practice providers. This cluster was characterized by high use of topical retinoids and relatively high use of spironolactone.

“There are likely opportunities to improve the use of topical retinoids by internists caring for patients with acne, since these are a first-line treatment option that may be underutilized by internists,” Dr. Barbieri said in the interview. “Future work is needed to identify underlying factors associated with different prescribing phenotypes among both dermatologists and internists. By understanding these factors, we can develop implementation science efforts to align prescribing behavior with best practices based on the guidelines and available evidence.”

He acknowledged certain limitations of the analysis, including its single-center design and the lack of data on patient characteristics. “Future studies are needed to examine whether our results generalize to other settings,” he said.

Dr. Barbieri disclosed that he receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania. The authors had no other disclosures.

dbrunk@mdedge.com

An exploratory analysis recently published in the Journal of the American Academy of Dermatology examines whether it is possible to classify dermatologists and internists into different patterns of prescribing behavior for patients with acne.

“Prior research has highlighted that prescribing for acne may not be aligned with guideline recommendations, including the overuse of oral antibiotics and lack of use of concomitant topical medications such as topical retinoids,” the study’s corresponding author, John S. Barbieri, MD, MBA, of the department of dermatology at the University of Pennsylvania, Philadelphia, said in an interview.

“In addition, there is substantial variation in prescribing practices among clinicians. We were interested in examining whether it is possible to identify different prescribing phenotypes among dermatologists and internists who care for patients with acne. By identifying such groups, it would facilitate future qualitative interviews to understand factors that might contribute to clinicians having certain prescribing patterns, which could help guide implementation science work to better align practices with evidence and guidelines.”

For the study, which appeared online on March 1, Dr. Barbieri and colleague David J. Margolis, MD, PhD, professor of dermatology and epidemiology at the University of Pennsylvania, evaluated all clinical encounters associated with an ICD-9 or ICD-10 code for acne that occurred in the university’s departments of dermatology and internal medicine between Jan. 1, 2011, and Dec. 31, 2019. They used a machine-learning method known as k-means clustering to cluster clinicians based on their relative use of acne medications, as well as the ratio of spironolactone versus tetracycline use among female patients and stratified their analyses by specialty.

Of the 116 dermatologists included in the analysis, the researchers identified three clusters. The first cluster included 17 dermatologists (14.7%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and low use of spironolactone, compared with oral antibiotics, among women with acne. Physicians in this cluster were more likely to be male and to have more years in practice.

The second cluster included 46 dermatologists (39.6%) and was marked by high use of spironolactone and low use of isotretinoin. The third cluster included 53 dermatologists (45.7%) and was characterized by high use of topical retinoids and frequent use of systemic medications.

Of the 86 internists included in the study, the researchers identified three clusters. The first cluster included 39 internists (45.4%) and was characterized by low use of topical retinoids, high use of oral tetracycline, and limited use of spironolactone. The second cluster included 34 internists (39.5%) and was marked by low use of topical retinoids and systemic medications. The third cluster included 13 clinicians (15.1%), most of whom were nurse practitioners, physician assistants, and other advanced practice providers. This cluster was characterized by high use of topical retinoids and relatively high use of spironolactone.

“There are likely opportunities to improve the use of topical retinoids by internists caring for patients with acne, since these are a first-line treatment option that may be underutilized by internists,” Dr. Barbieri said in the interview. “Future work is needed to identify underlying factors associated with different prescribing phenotypes among both dermatologists and internists. By understanding these factors, we can develop implementation science efforts to align prescribing behavior with best practices based on the guidelines and available evidence.”

He acknowledged certain limitations of the analysis, including its single-center design and the lack of data on patient characteristics. “Future studies are needed to examine whether our results generalize to other settings,” he said.

Dr. Barbieri disclosed that he receives partial salary support through a Pfizer Fellowship in Dermatology Patient Oriented Research grant to the Trustees of the University of Pennsylvania. The authors had no other disclosures.

dbrunk@mdedge.com

Skin microbiome therapy to protect against Staphylococcus aureus in patients with atopic dermatitis (AD) proved safe in a phase 1 randomized clinical trial that also demonstrated “encouraging clinical and mechanistic results,” Richard L. Gallo, MD, PhD, and his coinvestigators have reported in Nature Medicine.

Findings from the 1-week, 54-patient trial of a topical formulation containing Staphylococcus hominis A9 (ShA9) offer evidence that the strain directly kills S. aureus, inhibits the production of S. aureus–generated toxins, and enables expansion of a healthy bacterial community, “allowing the rest of the microbiome to start to recover to normal,” Dr. Gallo, professor and chairman of the department of dermatology at the University of California, San Diego, said in an interview.

“And perhaps most exciting,” Dr. Gallo added, is the finding that the subset of patients with AD who were most responsive to the ShA9 compound – approximately two-thirds of the participants who were randomized to receive it – showed improvement in local EASI (Eczema Area and Severity Index) and SCORAD (Scoring Atopic Dermatitis) scores used to assess inflammation. Plans are underway for a larger and longer trial, he said.

S. aureus commonly colonizes patients with AD and exacerbates disease by causing inflammation. In recent years, Dr. Gallo and other investigators have come to believe that AD is a cyclic disease in which the skin’s microbiome affects the host, and the host affects the microbiome. The goal of bacteriotherapy is to break the cycle of S. aureus colonization and improve the skin immune and barrier dysfunction characteristics of AD, Dr. Gallo said.

ShA9, a bacterium isolated from healthy human skin, was chosen as a potential topical therapy for AD based on its capacity both to selectively kill S. aureus and to inhibit toxin production by S. aureus. Dr. Gallo’s team’s preclinical work involved screening thousands of isolates of coagulase-negative staphylococci for gene products that perform these two functions by expressing both antimicrobial peptides (AMPs) and autoinducing peptides (AIPs), the latter of which inhibit the S. aureus quorum-sending system that leads to toxin production. Most patients with AD lack protective strains of coagulase-negative staphylococci, including S. hominis, prior research has found.

The double-blind phase 1 trial randomized 54 adults with moderate-severe AD affecting the ventral forearms in a 2:1 fashion to receive the proprietary lyophilized preparation of ShA9 or an ShA9-free formulation twice daily for 1 week. All participants were culture positive for S. aureus.

Clinical assessments and skin swabs were obtained before and within an hour after the first application of day 1, and swabs were collected on days 4 and 7 within 4 hours of the first application.

Blinded physician assessments and skin swabs were also obtained at 24, 48, and 96 hours after the final dose on day 7.

Based on structured daily diaries, there were no serious adverse events, and significantly fewer adverse events in those treated with ShA9, compared with the vehicle alone; 55.6% versus 83.3%, respectively, were considered to have adverse events.

The adverse event–reporting system captured the normal fluctuation of eczema and considered any report of fluctuation above baseline to be an adverse event. “Patients treated with the [placebo formulation] had the expected high frequency of itching, burning, and pain that you see with AD but it was encouraging that the frequency of reporting these events was significantly less in those treated with the active [formulation],” Dr. Gallo said in the interview.

Their report describes a decrease in S. aureus in participants treated with ShA9, and increases in ShA9 DNA. Not all S. aureus strains were directly killed by ShA9, but all strains had reduced expression of mRNA for psm-alpha, an important virulence factor. That reduced expression correlated with ShA9 AIPs and improved EASI scores, the latter of which was observed in a post-hoc analysis. “Participants with S. aureus not killed by ShA9 were still sensitive to inhibition of toxin production, a mechanistic outcome that predicted clinical improvement in mice and may require longer therapy to observe clinical improvement in humans,” the investigators wrote.

Local eczema severity was not significantly different between the bacteriotherapy and control groups. But the post-hoc analysis showed that after 7 days of treatment, and up to 4 days after treatment was discontinued, the patients with S. aureus that was sensitive to killing by ShA9 (21 out of 35 total who received the bacteriotherapy) showed improvement in EASI and SCORAD scores, compared with control patients.

Future research will assess the compound in both S. aureus culture-positive and culture-negative patients, and in patients with mild disease, Dr. Gallo said.

The trial was conducted at USCD and the National Jewish Health General Clinical Research Center in Denver, and was sponsored by the National Institute of Allergy and Infectious Diseases. The ShA9 formulation and related technology are licensed to MatriSys Bioscience, of which Dr. Gallo is the cofounder and an advisory board member. Dr. Gallo holds equity interest in the company.

Skin microbiome therapy to protect against Staphylococcus aureus in patients with atopic dermatitis (AD) proved safe in a phase 1 randomized clinical trial that also demonstrated “encouraging clinical and mechanistic results,” Richard L. Gallo, MD, PhD, and his coinvestigators have reported in Nature Medicine.

Findings from the 1-week, 54-patient trial of a topical formulation containing Staphylococcus hominis A9 (ShA9) offer evidence that the strain directly kills S. aureus, inhibits the production of S. aureus–generated toxins, and enables expansion of a healthy bacterial community, “allowing the rest of the microbiome to start to recover to normal,” Dr. Gallo, professor and chairman of the department of dermatology at the University of California, San Diego, said in an interview.

“And perhaps most exciting,” Dr. Gallo added, is the finding that the subset of patients with AD who were most responsive to the ShA9 compound – approximately two-thirds of the participants who were randomized to receive it – showed improvement in local EASI (Eczema Area and Severity Index) and SCORAD (Scoring Atopic Dermatitis) scores used to assess inflammation. Plans are underway for a larger and longer trial, he said.

S. aureus commonly colonizes patients with AD and exacerbates disease by causing inflammation. In recent years, Dr. Gallo and other investigators have come to believe that AD is a cyclic disease in which the skin’s microbiome affects the host, and the host affects the microbiome. The goal of bacteriotherapy is to break the cycle of S. aureus colonization and improve the skin immune and barrier dysfunction characteristics of AD, Dr. Gallo said.

ShA9, a bacterium isolated from healthy human skin, was chosen as a potential topical therapy for AD based on its capacity both to selectively kill S. aureus and to inhibit toxin production by S. aureus. Dr. Gallo’s team’s preclinical work involved screening thousands of isolates of coagulase-negative staphylococci for gene products that perform these two functions by expressing both antimicrobial peptides (AMPs) and autoinducing peptides (AIPs), the latter of which inhibit the S. aureus quorum-sending system that leads to toxin production. Most patients with AD lack protective strains of coagulase-negative staphylococci, including S. hominis, prior research has found.

The double-blind phase 1 trial randomized 54 adults with moderate-severe AD affecting the ventral forearms in a 2:1 fashion to receive the proprietary lyophilized preparation of ShA9 or an ShA9-free formulation twice daily for 1 week. All participants were culture positive for S. aureus.

Clinical assessments and skin swabs were obtained before and within an hour after the first application of day 1, and swabs were collected on days 4 and 7 within 4 hours of the first application.

Blinded physician assessments and skin swabs were also obtained at 24, 48, and 96 hours after the final dose on day 7.

Based on structured daily diaries, there were no serious adverse events, and significantly fewer adverse events in those treated with ShA9, compared with the vehicle alone; 55.6% versus 83.3%, respectively, were considered to have adverse events.

The adverse event–reporting system captured the normal fluctuation of eczema and considered any report of fluctuation above baseline to be an adverse event. “Patients treated with the [placebo formulation] had the expected high frequency of itching, burning, and pain that you see with AD but it was encouraging that the frequency of reporting these events was significantly less in those treated with the active [formulation],” Dr. Gallo said in the interview.

Their report describes a decrease in S. aureus in participants treated with ShA9, and increases in ShA9 DNA. Not all S. aureus strains were directly killed by ShA9, but all strains had reduced expression of mRNA for psm-alpha, an important virulence factor. That reduced expression correlated with ShA9 AIPs and improved EASI scores, the latter of which was observed in a post-hoc analysis. “Participants with S. aureus not killed by ShA9 were still sensitive to inhibition of toxin production, a mechanistic outcome that predicted clinical improvement in mice and may require longer therapy to observe clinical improvement in humans,” the investigators wrote.

Local eczema severity was not significantly different between the bacteriotherapy and control groups. But the post-hoc analysis showed that after 7 days of treatment, and up to 4 days after treatment was discontinued, the patients with S. aureus that was sensitive to killing by ShA9 (21 out of 35 total who received the bacteriotherapy) showed improvement in EASI and SCORAD scores, compared with control patients.

Future research will assess the compound in both S. aureus culture-positive and culture-negative patients, and in patients with mild disease, Dr. Gallo said.

The trial was conducted at USCD and the National Jewish Health General Clinical Research Center in Denver, and was sponsored by the National Institute of Allergy and Infectious Diseases. The ShA9 formulation and related technology are licensed to MatriSys Bioscience, of which Dr. Gallo is the cofounder and an advisory board member. Dr. Gallo holds equity interest in the company.

Skin microbiome therapy to protect against Staphylococcus aureus in patients with atopic dermatitis (AD) proved safe in a phase 1 randomized clinical trial that also demonstrated “encouraging clinical and mechanistic results,” Richard L. Gallo, MD, PhD, and his coinvestigators have reported in Nature Medicine.

Findings from the 1-week, 54-patient trial of a topical formulation containing Staphylococcus hominis A9 (ShA9) offer evidence that the strain directly kills S. aureus, inhibits the production of S. aureus–generated toxins, and enables expansion of a healthy bacterial community, “allowing the rest of the microbiome to start to recover to normal,” Dr. Gallo, professor and chairman of the department of dermatology at the University of California, San Diego, said in an interview.

“And perhaps most exciting,” Dr. Gallo added, is the finding that the subset of patients with AD who were most responsive to the ShA9 compound – approximately two-thirds of the participants who were randomized to receive it – showed improvement in local EASI (Eczema Area and Severity Index) and SCORAD (Scoring Atopic Dermatitis) scores used to assess inflammation. Plans are underway for a larger and longer trial, he said.

S. aureus commonly colonizes patients with AD and exacerbates disease by causing inflammation. In recent years, Dr. Gallo and other investigators have come to believe that AD is a cyclic disease in which the skin’s microbiome affects the host, and the host affects the microbiome. The goal of bacteriotherapy is to break the cycle of S. aureus colonization and improve the skin immune and barrier dysfunction characteristics of AD, Dr. Gallo said.

ShA9, a bacterium isolated from healthy human skin, was chosen as a potential topical therapy for AD based on its capacity both to selectively kill S. aureus and to inhibit toxin production by S. aureus. Dr. Gallo’s team’s preclinical work involved screening thousands of isolates of coagulase-negative staphylococci for gene products that perform these two functions by expressing both antimicrobial peptides (AMPs) and autoinducing peptides (AIPs), the latter of which inhibit the S. aureus quorum-sending system that leads to toxin production. Most patients with AD lack protective strains of coagulase-negative staphylococci, including S. hominis, prior research has found.

The double-blind phase 1 trial randomized 54 adults with moderate-severe AD affecting the ventral forearms in a 2:1 fashion to receive the proprietary lyophilized preparation of ShA9 or an ShA9-free formulation twice daily for 1 week. All participants were culture positive for S. aureus.

Clinical assessments and skin swabs were obtained before and within an hour after the first application of day 1, and swabs were collected on days 4 and 7 within 4 hours of the first application.

Blinded physician assessments and skin swabs were also obtained at 24, 48, and 96 hours after the final dose on day 7.

Based on structured daily diaries, there were no serious adverse events, and significantly fewer adverse events in those treated with ShA9, compared with the vehicle alone; 55.6% versus 83.3%, respectively, were considered to have adverse events.

The adverse event–reporting system captured the normal fluctuation of eczema and considered any report of fluctuation above baseline to be an adverse event. “Patients treated with the [placebo formulation] had the expected high frequency of itching, burning, and pain that you see with AD but it was encouraging that the frequency of reporting these events was significantly less in those treated with the active [formulation],” Dr. Gallo said in the interview.

Their report describes a decrease in S. aureus in participants treated with ShA9, and increases in ShA9 DNA. Not all S. aureus strains were directly killed by ShA9, but all strains had reduced expression of mRNA for psm-alpha, an important virulence factor. That reduced expression correlated with ShA9 AIPs and improved EASI scores, the latter of which was observed in a post-hoc analysis. “Participants with S. aureus not killed by ShA9 were still sensitive to inhibition of toxin production, a mechanistic outcome that predicted clinical improvement in mice and may require longer therapy to observe clinical improvement in humans,” the investigators wrote.

Local eczema severity was not significantly different between the bacteriotherapy and control groups. But the post-hoc analysis showed that after 7 days of treatment, and up to 4 days after treatment was discontinued, the patients with S. aureus that was sensitive to killing by ShA9 (21 out of 35 total who received the bacteriotherapy) showed improvement in EASI and SCORAD scores, compared with control patients.

Future research will assess the compound in both S. aureus culture-positive and culture-negative patients, and in patients with mild disease, Dr. Gallo said.

The trial was conducted at USCD and the National Jewish Health General Clinical Research Center in Denver, and was sponsored by the National Institute of Allergy and Infectious Diseases. The ShA9 formulation and related technology are licensed to MatriSys Bioscience, of which Dr. Gallo is the cofounder and an advisory board member. Dr. Gallo holds equity interest in the company.

Children with atopic dermatitis (AD) face a significantly greater risk of chronic school absenteeism compared with their peers with psoriasis and without AD or psoriasis.

In addition, parents of children with AD have significantly increased absenteeism from work compared with parents of children without AD.

Those are among key findings from a cross-sectional analysis of data from the Medical Expenditure Panel Surveys (MEPS), reported by Brian T. Cheng and Jonathan I. Silverberg, MD, PhD, MPH. The results were published online March 1 in the Journal of the American Academy of Dermatology.

“Atopic dermatitis is a debilitating disease that profoundly impacts children and their ability to attend school,” the study’s senior author, Dr. Silverberg, director of clinical research in the department of dermatology at George Washington University, Washington, said in an interview. “This is clinically relevant because school absenteeism is a sign of poorly controlled disease and should prompt clinicians to step up their game and aim for tighter control of the child’s atopic dermatitis.”

In an effort to determine the burden and predictors of chronic school absenteeism in children with AD, Mr. Cheng, a medical student at Northwestern University, Chicago, and Dr. Silverberg conducted a cross-sectional retrospective analysis of 124,267 children, adolescents, and young adults between the ages of 3 and 22 years from the 2000-2015 MEPS, which are representative surveys of the U.S. noninstitutionalized population conducted by the Agency for Healthcare Research and Quality. They used ICD-9 codes to determine a diagnosis of AD, psoriasis, and comorbidities; the primary outcome was chronic school absenteeism, defined as missing 15 or more days per year in the United States. MEPS also recorded the number of workdays that parents missed to care for their children or a relative.

The 124,267 individuals evaluated ranged in age between 3 and 22 years. Of these, 3,132 had AD and 200 had psoriasis. In the full cohort, chronic school absenteeism was higher among females, younger children, and those with lower household incomes, and public insurance.

Among children with AD, and those with psoriasis, 68% and 63% missed one or more day of school due to illness, respectively, while 4% in each group missed 15 days or more. Logistic regression analysis revealed that AD was associated with chronic absenteeism overall (adjusted odds ratio, 1.42), and with more severe disease (aOR, 1.33 for mild to moderate disease; aOR, 2.00 for severe disease).

On the other hand, the researchers did not observe any statistical difference in chronic absenteeism among children with versus those without psoriasis (aOR, 1.26).

The researchers also found that parents of children with versus parents of children without AD had a higher prevalence of absenteeism from work (an aOR of 1.28 among fathers, P = .009; and an aOR of 1.24 among mothers, P = .003).

In other findings, chronic absenteeism among children with AD was associated with poor/near poor/low income (aOR, 4.61) and comorbid disease (aOR, 3.35 for depression and aOR, 3.83 for asthma).

The investigators recommend that clinicians screen for and aim to reduce school absenteeism and parental work absenteeism in children with AD.

“I typically ask ‘Has (child’s name) missed any school because of their eczema?’ and follow-up with ‘What about from asthma or allergies?’ ” Dr. Silverberg said. “If the parent’s answer is yes to the first question, then I follow-up with more open-ended probing questions to understand why. Is it from all the doctor visits? Not sleeping well? Severe itch or pain? Poor sleep? Feeling sad or depressed? An answer of yes to each of these would prompt a potentially different treatment decision.”

The study received financial support from the Dermatology Foundation. The authors reported having no financial disclosures.

dbrunk@mdedge.com

Children with atopic dermatitis (AD) face a significantly greater risk of chronic school absenteeism compared with their peers with psoriasis and without AD or psoriasis.

In addition, parents of children with AD have significantly increased absenteeism from work compared with parents of children without AD.

Those are among key findings from a cross-sectional analysis of data from the Medical Expenditure Panel Surveys (MEPS), reported by Brian T. Cheng and Jonathan I. Silverberg, MD, PhD, MPH. The results were published online March 1 in the Journal of the American Academy of Dermatology.

“Atopic dermatitis is a debilitating disease that profoundly impacts children and their ability to attend school,” the study’s senior author, Dr. Silverberg, director of clinical research in the department of dermatology at George Washington University, Washington, said in an interview. “This is clinically relevant because school absenteeism is a sign of poorly controlled disease and should prompt clinicians to step up their game and aim for tighter control of the child’s atopic dermatitis.”

In an effort to determine the burden and predictors of chronic school absenteeism in children with AD, Mr. Cheng, a medical student at Northwestern University, Chicago, and Dr. Silverberg conducted a cross-sectional retrospective analysis of 124,267 children, adolescents, and young adults between the ages of 3 and 22 years from the 2000-2015 MEPS, which are representative surveys of the U.S. noninstitutionalized population conducted by the Agency for Healthcare Research and Quality. They used ICD-9 codes to determine a diagnosis of AD, psoriasis, and comorbidities; the primary outcome was chronic school absenteeism, defined as missing 15 or more days per year in the United States. MEPS also recorded the number of workdays that parents missed to care for their children or a relative.

The 124,267 individuals evaluated ranged in age between 3 and 22 years. Of these, 3,132 had AD and 200 had psoriasis. In the full cohort, chronic school absenteeism was higher among females, younger children, and those with lower household incomes, and public insurance.

Among children with AD, and those with psoriasis, 68% and 63% missed one or more day of school due to illness, respectively, while 4% in each group missed 15 days or more. Logistic regression analysis revealed that AD was associated with chronic absenteeism overall (adjusted odds ratio, 1.42), and with more severe disease (aOR, 1.33 for mild to moderate disease; aOR, 2.00 for severe disease).

On the other hand, the researchers did not observe any statistical difference in chronic absenteeism among children with versus those without psoriasis (aOR, 1.26).

The researchers also found that parents of children with versus parents of children without AD had a higher prevalence of absenteeism from work (an aOR of 1.28 among fathers, P = .009; and an aOR of 1.24 among mothers, P = .003).

In other findings, chronic absenteeism among children with AD was associated with poor/near poor/low income (aOR, 4.61) and comorbid disease (aOR, 3.35 for depression and aOR, 3.83 for asthma).

The investigators recommend that clinicians screen for and aim to reduce school absenteeism and parental work absenteeism in children with AD.

“I typically ask ‘Has (child’s name) missed any school because of their eczema?’ and follow-up with ‘What about from asthma or allergies?’ ” Dr. Silverberg said. “If the parent’s answer is yes to the first question, then I follow-up with more open-ended probing questions to understand why. Is it from all the doctor visits? Not sleeping well? Severe itch or pain? Poor sleep? Feeling sad or depressed? An answer of yes to each of these would prompt a potentially different treatment decision.”

The study received financial support from the Dermatology Foundation. The authors reported having no financial disclosures.

dbrunk@mdedge.com

Children with atopic dermatitis (AD) face a significantly greater risk of chronic school absenteeism compared with their peers with psoriasis and without AD or psoriasis.

In addition, parents of children with AD have significantly increased absenteeism from work compared with parents of children without AD.

Those are among key findings from a cross-sectional analysis of data from the Medical Expenditure Panel Surveys (MEPS), reported by Brian T. Cheng and Jonathan I. Silverberg, MD, PhD, MPH. The results were published online March 1 in the Journal of the American Academy of Dermatology.

“Atopic dermatitis is a debilitating disease that profoundly impacts children and their ability to attend school,” the study’s senior author, Dr. Silverberg, director of clinical research in the department of dermatology at George Washington University, Washington, said in an interview. “This is clinically relevant because school absenteeism is a sign of poorly controlled disease and should prompt clinicians to step up their game and aim for tighter control of the child’s atopic dermatitis.”

In an effort to determine the burden and predictors of chronic school absenteeism in children with AD, Mr. Cheng, a medical student at Northwestern University, Chicago, and Dr. Silverberg conducted a cross-sectional retrospective analysis of 124,267 children, adolescents, and young adults between the ages of 3 and 22 years from the 2000-2015 MEPS, which are representative surveys of the U.S. noninstitutionalized population conducted by the Agency for Healthcare Research and Quality. They used ICD-9 codes to determine a diagnosis of AD, psoriasis, and comorbidities; the primary outcome was chronic school absenteeism, defined as missing 15 or more days per year in the United States. MEPS also recorded the number of workdays that parents missed to care for their children or a relative.

The 124,267 individuals evaluated ranged in age between 3 and 22 years. Of these, 3,132 had AD and 200 had psoriasis. In the full cohort, chronic school absenteeism was higher among females, younger children, and those with lower household incomes, and public insurance.

Among children with AD, and those with psoriasis, 68% and 63% missed one or more day of school due to illness, respectively, while 4% in each group missed 15 days or more. Logistic regression analysis revealed that AD was associated with chronic absenteeism overall (adjusted odds ratio, 1.42), and with more severe disease (aOR, 1.33 for mild to moderate disease; aOR, 2.00 for severe disease).

On the other hand, the researchers did not observe any statistical difference in chronic absenteeism among children with versus those without psoriasis (aOR, 1.26).

The researchers also found that parents of children with versus parents of children without AD had a higher prevalence of absenteeism from work (an aOR of 1.28 among fathers, P = .009; and an aOR of 1.24 among mothers, P = .003).

In other findings, chronic absenteeism among children with AD was associated with poor/near poor/low income (aOR, 4.61) and comorbid disease (aOR, 3.35 for depression and aOR, 3.83 for asthma).

The investigators recommend that clinicians screen for and aim to reduce school absenteeism and parental work absenteeism in children with AD.

“I typically ask ‘Has (child’s name) missed any school because of their eczema?’ and follow-up with ‘What about from asthma or allergies?’ ” Dr. Silverberg said. “If the parent’s answer is yes to the first question, then I follow-up with more open-ended probing questions to understand why. Is it from all the doctor visits? Not sleeping well? Severe itch or pain? Poor sleep? Feeling sad or depressed? An answer of yes to each of these would prompt a potentially different treatment decision.”

The study received financial support from the Dermatology Foundation. The authors reported having no financial disclosures.

dbrunk@mdedge.com

A bidirectional relationship between sleep and immunity helps explain why patients with atopic dermatitis (AD) often complain of difficulty sleeping.

Courtesy Dr. Phyllis C. Zee

According to Phyllis C. Zee, MD, PhD, proinflammatory cytokines influence neural processes that affect sleep and circadian rhythm. “It’s almost like when you’re most vulnerable, when you’re sleeping, the immune system is kind of poised for attack,” Dr. Zee, chief of the division of sleep medicine at Northwestern University, Chicago, said at the Revolutionizing Atopic Dermatitis symposium. “This is normal, and perhaps in some of these inflammatory disorders, it’s gone a little haywire.”

Circulation of interleukins and cytokines are high in the morning, become lower in the afternoon, and then get higher again in the evening hours and into the night during sleep, she continued. “Whereas if you look at something like blood flow, it increases on a diurnal basis,” she said. “It’s higher during the day and a little bit lower during the mid-day, and a little bit higher during the evening. That parallels changes in the sebum production of the skin and the transepidermal water loss, which has been implicated in some of the symptoms of AD. What’s curious about this is that the transdermal/epidermal water loss is really highest during the sleep period. Some of this is sleep gated, but some of this is circadian gated as well. There’s a bidirectional relationship between sleep and immunity.”

Disturbance of sleep can have multiple consequences. It can activate the hypothalamic-pituitary-adrenal axis through autonomic activation, increase brain metabolic activity, trigger mood disturbances and cognitive impairment, and cause daytime sleepiness and health consequences that affect cardiometabolic and immunologic health.

One study conducted by Anna B. Fishbein, MD, Dr. Zee, and colleagues at Northwestern examined the effects of sleep duration and sleep disruption and movements in 38 children with and without moderate to severe AD. It found that children with AD get about 1 hour less of sleep per night overall, compared with age-matched healthy controls. “It’s not so much difficulty falling asleep, but more difficulty staying asleep as determined by wake after sleep onset,” said Dr. Zee, who is also a professor of neurology at Northwestern.

Tab1962/iStockphoto.com

A study of 34,613 adults who participated in the 2012 National Health and Nutrition Examination Survey found that eczema increased the odds of fatigue (odds ratio, 2.97), daytime sleepiness (OR, 2.66), and regular insomnia (OR, 2.36).

“Very importantly, it predicted poor health,” said Dr. Zee, who was one of the study’s coauthors. “This gives us an opportunity to think about how we can improve sleep to improve outcomes.”

Dr. Zee advises dermatologists and primary care clinicians to ask patients with AD about their sleep health by using a screening tool such as the self-reported STOP questionnaire, which consists of the following questions: “Do you snore loudly?” “Do you often feel tired, fatigued, or sleepy during daytime?” “Has anyone observed you stop breathing during your sleep?” “Do you have or are you being treated for high blood pressure?”

Other clinical indicators of a sleep disorder, such as obstructive sleep apnea (OSA), include having a neck circumference of 17 inches or greater in men and 16 inches or greater in women. “You want to also do a brief upper-airway examination, the Mallampati classification where you say to the patient, ‘open your mouth, don’t stick your mouth out too much,’ and you look at how crowded the upper airway is,” Dr. Zee said . “Someone with a Mallampati score of 3 has a very high risk of having sleep apnea.”

She also recommends asking patients with AD if they have difficulty falling asleep or staying asleep 3 or more nights per week, and about the frequency and duration of awakenings. “Maybe they have insomnia as a disorder,” she said. “If they have trouble falling asleep, maybe they have a circadian rhythm disorder. You want to ask about snoring, choking, and stop breathing episodes, because those are symptoms of sleep apnea. You want to ask about itch, uncomfortable sensations in the limbs during sleep or while trying to get to sleep, because that may be something like restless legs syndrome. Sleep disorder assessment is important because it impair daytime function, cognition, attention, and disruptive behavior, especially in children.”

For the management of insomnia, try behavioral approaches first. “You don’t want to try medications from the get-go,” Dr. Zee advised. Techniques include sleep hygiene and stimulus control therapy, “to make the bedroom a safe place to sleep. Lower the temperature a little bit and get rid of the allergens as much as possible. Relaxation and cognitive-behavioral therapy can also help. If you get a lot of light during the day, structure your physical activity, and watch what and when you eat.”

An OSA diagnosis requires evaluation of objective information from a sleep study. Common treatments of mild to moderate OSA include nasal continuous positive airway pressure and oral appliances.

Dr. Zee disclosed that she had received research funding from the National Institutes of Health, Jazz Pharmaceuticals, Harmony and Apnimed. She also serves on the scientific advisory board of Eisai, Jazz, CVS-Caremark, Takeda, and Sanofi-Aventis, and holds stock in Teva.

dbrunk@mdedge.com

A bidirectional relationship between sleep and immunity helps explain why patients with atopic dermatitis (AD) often complain of difficulty sleeping.

Courtesy Dr. Phyllis C. Zee

According to Phyllis C. Zee, MD, PhD, proinflammatory cytokines influence neural processes that affect sleep and circadian rhythm. “It’s almost like when you’re most vulnerable, when you’re sleeping, the immune system is kind of poised for attack,” Dr. Zee, chief of the division of sleep medicine at Northwestern University, Chicago, said at the Revolutionizing Atopic Dermatitis symposium. “This is normal, and perhaps in some of these inflammatory disorders, it’s gone a little haywire.”

Circulation of interleukins and cytokines are high in the morning, become lower in the afternoon, and then get higher again in the evening hours and into the night during sleep, she continued. “Whereas if you look at something like blood flow, it increases on a diurnal basis,” she said. “It’s higher during the day and a little bit lower during the mid-day, and a little bit higher during the evening. That parallels changes in the sebum production of the skin and the transepidermal water loss, which has been implicated in some of the symptoms of AD. What’s curious about this is that the transdermal/epidermal water loss is really highest during the sleep period. Some of this is sleep gated, but some of this is circadian gated as well. There’s a bidirectional relationship between sleep and immunity.”

Disturbance of sleep can have multiple consequences. It can activate the hypothalamic-pituitary-adrenal axis through autonomic activation, increase brain metabolic activity, trigger mood disturbances and cognitive impairment, and cause daytime sleepiness and health consequences that affect cardiometabolic and immunologic health.

One study conducted by Anna B. Fishbein, MD, Dr. Zee, and colleagues at Northwestern examined the effects of sleep duration and sleep disruption and movements in 38 children with and without moderate to severe AD. It found that children with AD get about 1 hour less of sleep per night overall, compared with age-matched healthy controls. “It’s not so much difficulty falling asleep, but more difficulty staying asleep as determined by wake after sleep onset,” said Dr. Zee, who is also a professor of neurology at Northwestern.

Tab1962/iStockphoto.com

A study of 34,613 adults who participated in the 2012 National Health and Nutrition Examination Survey found that eczema increased the odds of fatigue (odds ratio, 2.97), daytime sleepiness (OR, 2.66), and regular insomnia (OR, 2.36).

“Very importantly, it predicted poor health,” said Dr. Zee, who was one of the study’s coauthors. “This gives us an opportunity to think about how we can improve sleep to improve outcomes.”

Dr. Zee advises dermatologists and primary care clinicians to ask patients with AD about their sleep health by using a screening tool such as the self-reported STOP questionnaire, which consists of the following questions: “Do you snore loudly?” “Do you often feel tired, fatigued, or sleepy during daytime?” “Has anyone observed you stop breathing during your sleep?” “Do you have or are you being treated for high blood pressure?”

Other clinical indicators of a sleep disorder, such as obstructive sleep apnea (OSA), include having a neck circumference of 17 inches or greater in men and 16 inches or greater in women. “You want to also do a brief upper-airway examination, the Mallampati classification where you say to the patient, ‘open your mouth, don’t stick your mouth out too much,’ and you look at how crowded the upper airway is,” Dr. Zee said . “Someone with a Mallampati score of 3 has a very high risk of having sleep apnea.”

She also recommends asking patients with AD if they have difficulty falling asleep or staying asleep 3 or more nights per week, and about the frequency and duration of awakenings. “Maybe they have insomnia as a disorder,” she said. “If they have trouble falling asleep, maybe they have a circadian rhythm disorder. You want to ask about snoring, choking, and stop breathing episodes, because those are symptoms of sleep apnea. You want to ask about itch, uncomfortable sensations in the limbs during sleep or while trying to get to sleep, because that may be something like restless legs syndrome. Sleep disorder assessment is important because it impair daytime function, cognition, attention, and disruptive behavior, especially in children.”

For the management of insomnia, try behavioral approaches first. “You don’t want to try medications from the get-go,” Dr. Zee advised. Techniques include sleep hygiene and stimulus control therapy, “to make the bedroom a safe place to sleep. Lower the temperature a little bit and get rid of the allergens as much as possible. Relaxation and cognitive-behavioral therapy can also help. If you get a lot of light during the day, structure your physical activity, and watch what and when you eat.”

An OSA diagnosis requires evaluation of objective information from a sleep study. Common treatments of mild to moderate OSA include nasal continuous positive airway pressure and oral appliances.

Dr. Zee disclosed that she had received research funding from the National Institutes of Health, Jazz Pharmaceuticals, Harmony and Apnimed. She also serves on the scientific advisory board of Eisai, Jazz, CVS-Caremark, Takeda, and Sanofi-Aventis, and holds stock in Teva.

dbrunk@mdedge.com

A bidirectional relationship between sleep and immunity helps explain why patients with atopic dermatitis (AD) often complain of difficulty sleeping.

Courtesy Dr. Phyllis C. Zee

According to Phyllis C. Zee, MD, PhD, proinflammatory cytokines influence neural processes that affect sleep and circadian rhythm. “It’s almost like when you’re most vulnerable, when you’re sleeping, the immune system is kind of poised for attack,” Dr. Zee, chief of the division of sleep medicine at Northwestern University, Chicago, said at the Revolutionizing Atopic Dermatitis symposium. “This is normal, and perhaps in some of these inflammatory disorders, it’s gone a little haywire.”

Circulation of interleukins and cytokines are high in the morning, become lower in the afternoon, and then get higher again in the evening hours and into the night during sleep, she continued. “Whereas if you look at something like blood flow, it increases on a diurnal basis,” she said. “It’s higher during the day and a little bit lower during the mid-day, and a little bit higher during the evening. That parallels changes in the sebum production of the skin and the transepidermal water loss, which has been implicated in some of the symptoms of AD. What’s curious about this is that the transdermal/epidermal water loss is really highest during the sleep period. Some of this is sleep gated, but some of this is circadian gated as well. There’s a bidirectional relationship between sleep and immunity.”

Disturbance of sleep can have multiple consequences. It can activate the hypothalamic-pituitary-adrenal axis through autonomic activation, increase brain metabolic activity, trigger mood disturbances and cognitive impairment, and cause daytime sleepiness and health consequences that affect cardiometabolic and immunologic health.

One study conducted by Anna B. Fishbein, MD, Dr. Zee, and colleagues at Northwestern examined the effects of sleep duration and sleep disruption and movements in 38 children with and without moderate to severe AD. It found that children with AD get about 1 hour less of sleep per night overall, compared with age-matched healthy controls. “It’s not so much difficulty falling asleep, but more difficulty staying asleep as determined by wake after sleep onset,” said Dr. Zee, who is also a professor of neurology at Northwestern.

Tab1962/iStockphoto.com

A study of 34,613 adults who participated in the 2012 National Health and Nutrition Examination Survey found that eczema increased the odds of fatigue (odds ratio, 2.97), daytime sleepiness (OR, 2.66), and regular insomnia (OR, 2.36).

“Very importantly, it predicted poor health,” said Dr. Zee, who was one of the study’s coauthors. “This gives us an opportunity to think about how we can improve sleep to improve outcomes.”

Dr. Zee advises dermatologists and primary care clinicians to ask patients with AD about their sleep health by using a screening tool such as the self-reported STOP questionnaire, which consists of the following questions: “Do you snore loudly?” “Do you often feel tired, fatigued, or sleepy during daytime?” “Has anyone observed you stop breathing during your sleep?” “Do you have or are you being treated for high blood pressure?”

Other clinical indicators of a sleep disorder, such as obstructive sleep apnea (OSA), include having a neck circumference of 17 inches or greater in men and 16 inches or greater in women. “You want to also do a brief upper-airway examination, the Mallampati classification where you say to the patient, ‘open your mouth, don’t stick your mouth out too much,’ and you look at how crowded the upper airway is,” Dr. Zee said . “Someone with a Mallampati score of 3 has a very high risk of having sleep apnea.”

She also recommends asking patients with AD if they have difficulty falling asleep or staying asleep 3 or more nights per week, and about the frequency and duration of awakenings. “Maybe they have insomnia as a disorder,” she said. “If they have trouble falling asleep, maybe they have a circadian rhythm disorder. You want to ask about snoring, choking, and stop breathing episodes, because those are symptoms of sleep apnea. You want to ask about itch, uncomfortable sensations in the limbs during sleep or while trying to get to sleep, because that may be something like restless legs syndrome. Sleep disorder assessment is important because it impair daytime function, cognition, attention, and disruptive behavior, especially in children.”

For the management of insomnia, try behavioral approaches first. “You don’t want to try medications from the get-go,” Dr. Zee advised. Techniques include sleep hygiene and stimulus control therapy, “to make the bedroom a safe place to sleep. Lower the temperature a little bit and get rid of the allergens as much as possible. Relaxation and cognitive-behavioral therapy can also help. If you get a lot of light during the day, structure your physical activity, and watch what and when you eat.”

An OSA diagnosis requires evaluation of objective information from a sleep study. Common treatments of mild to moderate OSA include nasal continuous positive airway pressure and oral appliances.

Dr. Zee disclosed that she had received research funding from the National Institutes of Health, Jazz Pharmaceuticals, Harmony and Apnimed. She also serves on the scientific advisory board of Eisai, Jazz, CVS-Caremark, Takeda, and Sanofi-Aventis, and holds stock in Teva.

dbrunk@mdedge.com

Atopic dermatitis (AD) is associated with lower patient satisfaction scores in adults, suggesting there are unmet needs in clinical AD management.

Satisfaction scores were higher when specialists prescribed systemic therapy, but were lower when nonspecialists prescribed systemic therapy and when specialists prescribed only topical therapy.

©aniaostudio/Thinkstock.com

Recognizing that treatment regimens are complex and used differently by provider type, the researchers examined interactions between specialists (dermatologists and allergists) and treatment type. “Previous studies found dermatologists treat more severe, chronic AD,” Mr. Cheng said. “We found here that there was lower satisfaction among those treated with topical therapy and by specialists, which may reflect inadequate disease control. We also found lower satisfaction among those treated with systemic therapy by primary care physicians. This may reflect that these patients are not achieving optimal therapy. We found that satisfaction was highest among those treated with systemic therapy and by dermatologists and allergists.”

Socioeconomic, racial/ethnic, and health care disparities were observed in terms of satisfaction among this cohort. The following characteristics were significantly associated with lower patient satisfaction, compared with the general cohort of adults with AD: poor to low income (aOR, –1.82; P less than .0001), multiracial/other race (aOR, –2.34; P = .0001), Hispanic ethnicity (aOR, –1.40; P = .007), and having no insurance coverage (aOR, –4.53; P less than .0001).

“Moreover, those with multimorbidity had even lower satisfaction,” Mr. Cheng said. “In previous studies, AD has been linked with many other comorbidities. This may reflect that these patients are not being adequately managed overall. So, there’s a need here for multidisciplinary care to ensure that all of these comorbidities and the full spectrum of symptoms are being managed adequately.”

He concluded that future research is needed to determine strategies to optimize patient satisfaction in adults with AD.

“I’m not sure how much more provocative you can get in terms of data,” added Dr. Silverberg, director of clinical research and contact dermatitis at George Washington University, Washington. “It’s really eye-opening. I think many clinicians may feel like they’re doing a perfect job in managing this disease. These data suggest that at least at the national level that may not be the case.”

Mr. Cheng reported having no financial disclosures. Dr. Silverberg reported that he is a consultant to and/or an advisory board member for several pharmaceutical companies. He is also a speaker for Regeneron and Sanofi and has received a grant from Galderma.

dbrunk@mdedge.com

Atopic dermatitis (AD) is associated with lower patient satisfaction scores in adults, suggesting there are unmet needs in clinical AD management.

Satisfaction scores were higher when specialists prescribed systemic therapy, but were lower when nonspecialists prescribed systemic therapy and when specialists prescribed only topical therapy.

©aniaostudio/Thinkstock.com

Recognizing that treatment regimens are complex and used differently by provider type, the researchers examined interactions between specialists (dermatologists and allergists) and treatment type. “Previous studies found dermatologists treat more severe, chronic AD,” Mr. Cheng said. “We found here that there was lower satisfaction among those treated with topical therapy and by specialists, which may reflect inadequate disease control. We also found lower satisfaction among those treated with systemic therapy by primary care physicians. This may reflect that these patients are not achieving optimal therapy. We found that satisfaction was highest among those treated with systemic therapy and by dermatologists and allergists.”

Socioeconomic, racial/ethnic, and health care disparities were observed in terms of satisfaction among this cohort. The following characteristics were significantly associated with lower patient satisfaction, compared with the general cohort of adults with AD: poor to low income (aOR, –1.82; P less than .0001), multiracial/other race (aOR, –2.34; P = .0001), Hispanic ethnicity (aOR, –1.40; P = .007), and having no insurance coverage (aOR, –4.53; P less than .0001).

“Moreover, those with multimorbidity had even lower satisfaction,” Mr. Cheng said. “In previous studies, AD has been linked with many other comorbidities. This may reflect that these patients are not being adequately managed overall. So, there’s a need here for multidisciplinary care to ensure that all of these comorbidities and the full spectrum of symptoms are being managed adequately.”

He concluded that future research is needed to determine strategies to optimize patient satisfaction in adults with AD.

“I’m not sure how much more provocative you can get in terms of data,” added Dr. Silverberg, director of clinical research and contact dermatitis at George Washington University, Washington. “It’s really eye-opening. I think many clinicians may feel like they’re doing a perfect job in managing this disease. These data suggest that at least at the national level that may not be the case.”

Mr. Cheng reported having no financial disclosures. Dr. Silverberg reported that he is a consultant to and/or an advisory board member for several pharmaceutical companies. He is also a speaker for Regeneron and Sanofi and has received a grant from Galderma.

dbrunk@mdedge.com

Atopic dermatitis (AD) is associated with lower patient satisfaction scores in adults, suggesting there are unmet needs in clinical AD management.

Satisfaction scores were higher when specialists prescribed systemic therapy, but were lower when nonspecialists prescribed systemic therapy and when specialists prescribed only topical therapy.

©aniaostudio/Thinkstock.com

Recognizing that treatment regimens are complex and used differently by provider type, the researchers examined interactions between specialists (dermatologists and allergists) and treatment type. “Previous studies found dermatologists treat more severe, chronic AD,” Mr. Cheng said. “We found here that there was lower satisfaction among those treated with topical therapy and by specialists, which may reflect inadequate disease control. We also found lower satisfaction among those treated with systemic therapy by primary care physicians. This may reflect that these patients are not achieving optimal therapy. We found that satisfaction was highest among those treated with systemic therapy and by dermatologists and allergists.”

Socioeconomic, racial/ethnic, and health care disparities were observed in terms of satisfaction among this cohort. The following characteristics were significantly associated with lower patient satisfaction, compared with the general cohort of adults with AD: poor to low income (aOR, –1.82; P less than .0001), multiracial/other race (aOR, –2.34; P = .0001), Hispanic ethnicity (aOR, –1.40; P = .007), and having no insurance coverage (aOR, –4.53; P less than .0001).

“Moreover, those with multimorbidity had even lower satisfaction,” Mr. Cheng said. “In previous studies, AD has been linked with many other comorbidities. This may reflect that these patients are not being adequately managed overall. So, there’s a need here for multidisciplinary care to ensure that all of these comorbidities and the full spectrum of symptoms are being managed adequately.”

He concluded that future research is needed to determine strategies to optimize patient satisfaction in adults with AD.

“I’m not sure how much more provocative you can get in terms of data,” added Dr. Silverberg, director of clinical research and contact dermatitis at George Washington University, Washington. “It’s really eye-opening. I think many clinicians may feel like they’re doing a perfect job in managing this disease. These data suggest that at least at the national level that may not be the case.”

Mr. Cheng reported having no financial disclosures. Dr. Silverberg reported that he is a consultant to and/or an advisory board member for several pharmaceutical companies. He is also a speaker for Regeneron and Sanofi and has received a grant from Galderma.

dbrunk@mdedge.com

Abrocitinib, an investigational drug proven to be a safe and effective treatment for moderate to severe atopic dermatitis (AD) in adults 18 years and older, is also safe and effective in patients aged 12-17 years, according to a randomized trial of the oral, once-daily Janus kinase (JAK) 1 selective inhibitor, used in combination with medicated topical therapy.

The results, from the phase 3 JADE TEEN study, were presented during an oral abstract session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“We’re very excited about the introduction of oral JAKs into our armamentarium for atopic dermatitis,” lead author Lawrence Eichenfield, MD, professor of dermatology and pediatrics, University of California, San Diego, and chief of pediatric and adolescent dermatology, Rady Children’s Hospital, also in San Diego, said in an interview.

AD ranges in severity, and there is a great deal of moderate to severe AD that has a tremendous negative impact on the individual, Dr. Eichenfield said. “Traditionally we have treated it with intermittent topical corticosteroids, but this has left a significant percentage of patients without long-term disease control.”

JAK inhibitors are effective mediators of the inflammation response that occurs in moderate to severe AD. They inhibit the stimulation of the JAK pathway and allow anti-inflammatory effects and therefore have potential, especially in more severe disease, Dr. Eichenfield said.

In the current study, which is a spin-off of the original study that looked at abrocitinib in adults, he and his team randomly assigned 285 teens (mean age, 14.9 years; 50.9% male; 56.1% White) with moderate to severe AD to receive one of the following treatments for 12 weeks: abrocitinib 200 mg plus topical therapy (95); abrocitinib 100 mg plus topical therapy (95); or placebo, which consisted of topical therapy alone (95).

The primary endpoints were an Investigator’s Global Assessment response of clear or almost clear (scores of 0 and 1, respectively), with an improvement of at least 2 points, and an improvement in Eczema Area and Severity Index score of at least 75% at week 12.

Secondary endpoints included an improvement in Peak Pruritus Numerical Rating Scale (PP-NRS) response of at least 4 points at week 12.

The teens who received abrocitinib along with medicated topical therapy showed significant improvement in the severity of their AD at the end of the 12-week period, compared with those in the placebo group.

“The percentage of patients achieving essentially no itch, as captured in the fact that more than half of those on the higher dose of abrocitinib made it to no itch, is a new data point and is important to note,” Dr. Eichenfield said. “A lot of the other medicines don’t really get a significant percentage of the population to an itch score of 0 to 1. This drug brought about a rapid and profound itch relief.”

He added: “The results from JADE TEEN extend the drug’s utility in this younger population and show that abrocitinib performs the same with regard to efficacy and safety in the teenagers. Having atopic dermatitis that does not respond to treatment is especially hard for adolescents, but now we know that abrocitinib will be safe and effective and so we now have something to offer these kids.”

“Abrocitinib achieved a good response in this study that was statistically significant, compared to standard treatment,” Jonathan A. Bernstein, MD, professor of medicine at the University of Cincinnati, commented in an interview.

“JAK inhibitors are very promising, and this study adds to that promise. They play an important role in atopic dermatitis, so obviously, teenagers with AD represent an important population,” said Dr. Bernstein, who was not part of the study. “These results are very encouraging, and I think that we will probably see some of these JAK inhibitors approved by the FDA, if not this year, probably next.”

The study was sponsored by Pfizer. Dr. Eichenfield serves as an investigator, speaker, and consultant for Pfizer; and as an investigator, speaker, consultant, and/or is on a data safety monitoring board for AbbVie, Almirall, Amgen, Arcutis, Asana, Dermavant, Dermira, Forte, Galderma, Ichnos/Glenmark, Incyte, LEO, Lilly, L’Oreal, Novartis, Regeneron, Sanofi-Genzyme, and Verrica. Dr. Bernstein disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Abrocitinib, an investigational drug proven to be a safe and effective treatment for moderate to severe atopic dermatitis (AD) in adults 18 years and older, is also safe and effective in patients aged 12-17 years, according to a randomized trial of the oral, once-daily Janus kinase (JAK) 1 selective inhibitor, used in combination with medicated topical therapy.

The results, from the phase 3 JADE TEEN study, were presented during an oral abstract session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“We’re very excited about the introduction of oral JAKs into our armamentarium for atopic dermatitis,” lead author Lawrence Eichenfield, MD, professor of dermatology and pediatrics, University of California, San Diego, and chief of pediatric and adolescent dermatology, Rady Children’s Hospital, also in San Diego, said in an interview.

AD ranges in severity, and there is a great deal of moderate to severe AD that has a tremendous negative impact on the individual, Dr. Eichenfield said. “Traditionally we have treated it with intermittent topical corticosteroids, but this has left a significant percentage of patients without long-term disease control.”

JAK inhibitors are effective mediators of the inflammation response that occurs in moderate to severe AD. They inhibit the stimulation of the JAK pathway and allow anti-inflammatory effects and therefore have potential, especially in more severe disease, Dr. Eichenfield said.

In the current study, which is a spin-off of the original study that looked at abrocitinib in adults, he and his team randomly assigned 285 teens (mean age, 14.9 years; 50.9% male; 56.1% White) with moderate to severe AD to receive one of the following treatments for 12 weeks: abrocitinib 200 mg plus topical therapy (95); abrocitinib 100 mg plus topical therapy (95); or placebo, which consisted of topical therapy alone (95).

The primary endpoints were an Investigator’s Global Assessment response of clear or almost clear (scores of 0 and 1, respectively), with an improvement of at least 2 points, and an improvement in Eczema Area and Severity Index score of at least 75% at week 12.

Secondary endpoints included an improvement in Peak Pruritus Numerical Rating Scale (PP-NRS) response of at least 4 points at week 12.

The teens who received abrocitinib along with medicated topical therapy showed significant improvement in the severity of their AD at the end of the 12-week period, compared with those in the placebo group.

“The percentage of patients achieving essentially no itch, as captured in the fact that more than half of those on the higher dose of abrocitinib made it to no itch, is a new data point and is important to note,” Dr. Eichenfield said. “A lot of the other medicines don’t really get a significant percentage of the population to an itch score of 0 to 1. This drug brought about a rapid and profound itch relief.”

He added: “The results from JADE TEEN extend the drug’s utility in this younger population and show that abrocitinib performs the same with regard to efficacy and safety in the teenagers. Having atopic dermatitis that does not respond to treatment is especially hard for adolescents, but now we know that abrocitinib will be safe and effective and so we now have something to offer these kids.”

“Abrocitinib achieved a good response in this study that was statistically significant, compared to standard treatment,” Jonathan A. Bernstein, MD, professor of medicine at the University of Cincinnati, commented in an interview.

“JAK inhibitors are very promising, and this study adds to that promise. They play an important role in atopic dermatitis, so obviously, teenagers with AD represent an important population,” said Dr. Bernstein, who was not part of the study. “These results are very encouraging, and I think that we will probably see some of these JAK inhibitors approved by the FDA, if not this year, probably next.”

The study was sponsored by Pfizer. Dr. Eichenfield serves as an investigator, speaker, and consultant for Pfizer; and as an investigator, speaker, consultant, and/or is on a data safety monitoring board for AbbVie, Almirall, Amgen, Arcutis, Asana, Dermavant, Dermira, Forte, Galderma, Ichnos/Glenmark, Incyte, LEO, Lilly, L’Oreal, Novartis, Regeneron, Sanofi-Genzyme, and Verrica. Dr. Bernstein disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Abrocitinib, an investigational drug proven to be a safe and effective treatment for moderate to severe atopic dermatitis (AD) in adults 18 years and older, is also safe and effective in patients aged 12-17 years, according to a randomized trial of the oral, once-daily Janus kinase (JAK) 1 selective inhibitor, used in combination with medicated topical therapy.

The results, from the phase 3 JADE TEEN study, were presented during an oral abstract session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“We’re very excited about the introduction of oral JAKs into our armamentarium for atopic dermatitis,” lead author Lawrence Eichenfield, MD, professor of dermatology and pediatrics, University of California, San Diego, and chief of pediatric and adolescent dermatology, Rady Children’s Hospital, also in San Diego, said in an interview.

AD ranges in severity, and there is a great deal of moderate to severe AD that has a tremendous negative impact on the individual, Dr. Eichenfield said. “Traditionally we have treated it with intermittent topical corticosteroids, but this has left a significant percentage of patients without long-term disease control.”

JAK inhibitors are effective mediators of the inflammation response that occurs in moderate to severe AD. They inhibit the stimulation of the JAK pathway and allow anti-inflammatory effects and therefore have potential, especially in more severe disease, Dr. Eichenfield said.

In the current study, which is a spin-off of the original study that looked at abrocitinib in adults, he and his team randomly assigned 285 teens (mean age, 14.9 years; 50.9% male; 56.1% White) with moderate to severe AD to receive one of the following treatments for 12 weeks: abrocitinib 200 mg plus topical therapy (95); abrocitinib 100 mg plus topical therapy (95); or placebo, which consisted of topical therapy alone (95).

The primary endpoints were an Investigator’s Global Assessment response of clear or almost clear (scores of 0 and 1, respectively), with an improvement of at least 2 points, and an improvement in Eczema Area and Severity Index score of at least 75% at week 12.

Secondary endpoints included an improvement in Peak Pruritus Numerical Rating Scale (PP-NRS) response of at least 4 points at week 12.

The teens who received abrocitinib along with medicated topical therapy showed significant improvement in the severity of their AD at the end of the 12-week period, compared with those in the placebo group.

“The percentage of patients achieving essentially no itch, as captured in the fact that more than half of those on the higher dose of abrocitinib made it to no itch, is a new data point and is important to note,” Dr. Eichenfield said. “A lot of the other medicines don’t really get a significant percentage of the population to an itch score of 0 to 1. This drug brought about a rapid and profound itch relief.”

He added: “The results from JADE TEEN extend the drug’s utility in this younger population and show that abrocitinib performs the same with regard to efficacy and safety in the teenagers. Having atopic dermatitis that does not respond to treatment is especially hard for adolescents, but now we know that abrocitinib will be safe and effective and so we now have something to offer these kids.”

“Abrocitinib achieved a good response in this study that was statistically significant, compared to standard treatment,” Jonathan A. Bernstein, MD, professor of medicine at the University of Cincinnati, commented in an interview.

“JAK inhibitors are very promising, and this study adds to that promise. They play an important role in atopic dermatitis, so obviously, teenagers with AD represent an important population,” said Dr. Bernstein, who was not part of the study. “These results are very encouraging, and I think that we will probably see some of these JAK inhibitors approved by the FDA, if not this year, probably next.”

The study was sponsored by Pfizer. Dr. Eichenfield serves as an investigator, speaker, and consultant for Pfizer; and as an investigator, speaker, consultant, and/or is on a data safety monitoring board for AbbVie, Almirall, Amgen, Arcutis, Asana, Dermavant, Dermira, Forte, Galderma, Ichnos/Glenmark, Incyte, LEO, Lilly, L’Oreal, Novartis, Regeneron, Sanofi-Genzyme, and Verrica. Dr. Bernstein disclosed no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.

The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.

Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with an overlying telangiectasia (FIGURE 1A and 1B). Although the lesion appeared benign, the treatment team and the patient agreed to pursue a consultation. The dermoscopy images were sent to a dermatologist to help identify the lesion.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Sebaceous carcinoma

A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.

Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.¹ They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.¹ Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.¹ Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.

A lesson in considering the full differential

While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:

Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.² The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.²

Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.² The lesions are usually asymptomatic, small, and slow growing.²

Continue to: Basal and squamous cell carcinomas

Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.³ Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.⁴

Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.⁵ These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.⁵

Dermoscopy can (and did) help with the Dx

Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.⁶ Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.⁶ Carcinomas can manifest in an undifferentiated way early in their course.

Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.^7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.⁹

Patients benefit from Mohs surgery

Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.¹⁰

Continue to: Our patient

Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.

The dermatologist recommended yearly skin examination for 5 years for the patient.

A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.

The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.

Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with an overlying telangiectasia (FIGURE 1A and 1B). Although the lesion appeared benign, the treatment team and the patient agreed to pursue a consultation. The dermoscopy images were sent to a dermatologist to help identify the lesion.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Sebaceous carcinoma

A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.

Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.¹ They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.¹ Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.¹ Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.

A lesson in considering the full differential

While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:

Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.² The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.²

Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.² The lesions are usually asymptomatic, small, and slow growing.²

Continue to: Basal and squamous cell carcinomas

Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.³ Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.⁴

Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.⁵ These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.⁵

Dermoscopy can (and did) help with the Dx

Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.⁶ Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.⁶ Carcinomas can manifest in an undifferentiated way early in their course.

Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.^7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.⁹

Patients benefit from Mohs surgery

Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.¹⁰

Continue to: Our patient

Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.

The dermatologist recommended yearly skin examination for 5 years for the patient.

A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.

The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.

Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with an overlying telangiectasia (FIGURE 1A and 1B). Although the lesion appeared benign, the treatment team and the patient agreed to pursue a consultation. The dermoscopy images were sent to a dermatologist to help identify the lesion.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Sebaceous carcinoma

A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.

Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.¹ They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.¹ Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.¹ Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.

A lesson in considering the full differential

While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:

Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.² The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.²

Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.² The lesions are usually asymptomatic, small, and slow growing.²

Continue to: Basal and squamous cell carcinomas

Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.³ Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.⁴

Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.⁵ These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.⁵

Dermoscopy can (and did) help with the Dx

Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.⁶ Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.⁶ Carcinomas can manifest in an undifferentiated way early in their course.

Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.^7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.⁹

Patients benefit from Mohs surgery

Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.¹⁰

Continue to: Our patient

Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.

The dermatologist recommended yearly skin examination for 5 years for the patient.

A 49-year-old woman with a history of end-stage renal disease, uncontrolled type 2 diabetes, and congestive heart failure visited the hospital for an acute heart failure exacerbation secondary to missed dialysis appointments. On admission, her provider noted that she had tender, pruritic lesions on the extensor surface of her arms. She said they had appeared 2 to 3 months after she started dialysis. She had attempted to control the pain and pruritus with over-the-counter topical hydrocortisone and oral diphenhydramine but nothing provided relief. She was recommended for follow-up at the hospital for further examination and biopsy of one of her lesions.

At this follow-up visit, the patient noted that the lesions had spread to her left knee. Multiple firm discrete papules and nodules, with central hyperkeratotic plugs, were noted along the extensor surfaces of her forearms, left extensor knee, and around her ankles (FIGURES 1A and 1B). Some of the lesions were tender. Examination of the rest of her skin was normal. A punch biopsy was obtained.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Kyrle disease

The patient’s end-stage renal disease and type 2 diabetes—along with findings from the physical examination—led us to suspect Kyrle disease. The punch biopsy, as well as the characteristic keratotic plugs (FIGURE 2) within epidermal invagination that was bordered by hyperkeratotic epidermis, confirmed the diagnosis.

The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.

Kyrle disease (also known as hyperkeratosis follicularis et follicularis in cutem penetrans) is a rare skin condition. It is 1 of 4 skin conditions that are classified as perforating skin disorders; the other 3 are elastosis perforans serpiginosa, reactive perforating collagenosis, and perforating folliculitis (TABLE^1,2).³ Perforating skin disorders share the common characteristic of transepidermal elimination of material from the upper dermis.⁴ These disorders are typically classified based on the nature of the eliminated material and the type of epidermal disruption.⁵

There are 2 forms of Kyrle disease: an inherited form often seen in childhood that is not associated with systemic disease and an acquired form that occurs in adulthood, most commonly among women ages 35 to 70 years who have systemic disease.^3,4,6 The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.^7,8

Characteristic findings include discrete pruritic, dry papules and nodules with central keratotic plugs that are occasionally tender. These can manifest over the extensor surface of the extremities, trunk, face, and scalp.^4,7,9 Lesions most commonly manifest on the extensor surfaces of the lower extremities.

Other conditions that feature pruritic lesions

In addition to the other perforating skin disorders described in the TABLE,^1,2 the differential for Kyrle disease includes the following:

Prurigo nodularis (PN) is a skin disorder in which the manifestation of extremely pruritic nodules leads to vigorous scratching and secondary infections. These lesions typically have a grouped and symmetrically distributed appearance. They often appear on extensor surfaces of upper and lower extremities.¹⁰ PN has no known etiology, but like Kyrle disease, is associated with renal failure. Biopsy can help to distinguish PN from Kyrle disease.

Continue to: Hypertrophic lichen planus

Hypertrophic lichen planus is a pruritic skin disorder characterized by the “6 Ps”: planar, purple, polygonal, pruritic, papules, and plaques. These lesions can mimic the early stages of Kyrle disease.¹¹ However, in the later stages of Kyrle disease, discrete papules with hyperkeratotic plugs develop, whereas large plaques will be seen with lichen planus.

Keratosis pilaris (KP) is an extremely common, yet benign, disorder in which hair follicles become keratinized.¹² KP can feature rough papules that are often described as “goosebumps” or having a sandpaper–like appearance. These papules often affect the upper arms. KP usually manifests in adolescents or young adults and tends to improve with age.¹² The lesions are typically smaller than those seen in Kyrle disease and are asymptomatic. In addition, KP is not associated with systemic disease.

Target symptoms and any underlying conditions

In patients who have an acquired form of the disease, symptoms may improve by treating the underlying condition. For instance, better control of type 2 diabetes may improve symptoms. In patients with end-stage renal disease, a renal transplant can bring complete resolution.¹³

For patients whose Kyrle disease is inherited or whose underlying condition is not easily treated, there are a number of treatment options to consider. First-line treatment includes topical keratolytics (salicylic acid and urea), topical retinoids, and ultraviolet light therapy.^5,7 Systemic retinoids, topical steroids, cryotherapy, electrosurgery, CO₂ laser surgery, and surgical excision have also been used with some success.^7,14 Oral histamines and emollients also may help to relieve the pruritus. Lesions often recur upon discontinuation of therapy.

Our patient was referred to Dermatology for ultraviolet light therapy. She was also treated with topical 12% ammonium lactate twice daily. Within a few months, she reported improvement of her symptoms.

A 49-year-old woman with a history of end-stage renal disease, uncontrolled type 2 diabetes, and congestive heart failure visited the hospital for an acute heart failure exacerbation secondary to missed dialysis appointments. On admission, her provider noted that she had tender, pruritic lesions on the extensor surface of her arms. She said they had appeared 2 to 3 months after she started dialysis. She had attempted to control the pain and pruritus with over-the-counter topical hydrocortisone and oral diphenhydramine but nothing provided relief. She was recommended for follow-up at the hospital for further examination and biopsy of one of her lesions.

At this follow-up visit, the patient noted that the lesions had spread to her left knee. Multiple firm discrete papules and nodules, with central hyperkeratotic plugs, were noted along the extensor surfaces of her forearms, left extensor knee, and around her ankles (FIGURES 1A and 1B). Some of the lesions were tender. Examination of the rest of her skin was normal. A punch biopsy was obtained.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Kyrle disease

The patient’s end-stage renal disease and type 2 diabetes—along with findings from the physical examination—led us to suspect Kyrle disease. The punch biopsy, as well as the characteristic keratotic plugs (FIGURE 2) within epidermal invagination that was bordered by hyperkeratotic epidermis, confirmed the diagnosis.

The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.

Kyrle disease (also known as hyperkeratosis follicularis et follicularis in cutem penetrans) is a rare skin condition. It is 1 of 4 skin conditions that are classified as perforating skin disorders; the other 3 are elastosis perforans serpiginosa, reactive perforating collagenosis, and perforating folliculitis (TABLE^1,2).³ Perforating skin disorders share the common characteristic of transepidermal elimination of material from the upper dermis.⁴ These disorders are typically classified based on the nature of the eliminated material and the type of epidermal disruption.⁵

There are 2 forms of Kyrle disease: an inherited form often seen in childhood that is not associated with systemic disease and an acquired form that occurs in adulthood, most commonly among women ages 35 to 70 years who have systemic disease.^3,4,6 The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.^7,8

Characteristic findings include discrete pruritic, dry papules and nodules with central keratotic plugs that are occasionally tender. These can manifest over the extensor surface of the extremities, trunk, face, and scalp.^4,7,9 Lesions most commonly manifest on the extensor surfaces of the lower extremities.

Other conditions that feature pruritic lesions

In addition to the other perforating skin disorders described in the TABLE,^1,2 the differential for Kyrle disease includes the following:

Prurigo nodularis (PN) is a skin disorder in which the manifestation of extremely pruritic nodules leads to vigorous scratching and secondary infections. These lesions typically have a grouped and symmetrically distributed appearance. They often appear on extensor surfaces of upper and lower extremities.¹⁰ PN has no known etiology, but like Kyrle disease, is associated with renal failure. Biopsy can help to distinguish PN from Kyrle disease.

Continue to: Hypertrophic lichen planus

Hypertrophic lichen planus is a pruritic skin disorder characterized by the “6 Ps”: planar, purple, polygonal, pruritic, papules, and plaques. These lesions can mimic the early stages of Kyrle disease.¹¹ However, in the later stages of Kyrle disease, discrete papules with hyperkeratotic plugs develop, whereas large plaques will be seen with lichen planus.

Keratosis pilaris (KP) is an extremely common, yet benign, disorder in which hair follicles become keratinized.¹² KP can feature rough papules that are often described as “goosebumps” or having a sandpaper–like appearance. These papules often affect the upper arms. KP usually manifests in adolescents or young adults and tends to improve with age.¹² The lesions are typically smaller than those seen in Kyrle disease and are asymptomatic. In addition, KP is not associated with systemic disease.

Target symptoms and any underlying conditions

In patients who have an acquired form of the disease, symptoms may improve by treating the underlying condition. For instance, better control of type 2 diabetes may improve symptoms. In patients with end-stage renal disease, a renal transplant can bring complete resolution.¹³

For patients whose Kyrle disease is inherited or whose underlying condition is not easily treated, there are a number of treatment options to consider. First-line treatment includes topical keratolytics (salicylic acid and urea), topical retinoids, and ultraviolet light therapy.^5,7 Systemic retinoids, topical steroids, cryotherapy, electrosurgery, CO₂ laser surgery, and surgical excision have also been used with some success.^7,14 Oral histamines and emollients also may help to relieve the pruritus. Lesions often recur upon discontinuation of therapy.

Our patient was referred to Dermatology for ultraviolet light therapy. She was also treated with topical 12% ammonium lactate twice daily. Within a few months, she reported improvement of her symptoms.

A 49-year-old woman with a history of end-stage renal disease, uncontrolled type 2 diabetes, and congestive heart failure visited the hospital for an acute heart failure exacerbation secondary to missed dialysis appointments. On admission, her provider noted that she had tender, pruritic lesions on the extensor surface of her arms. She said they had appeared 2 to 3 months after she started dialysis. She had attempted to control the pain and pruritus with over-the-counter topical hydrocortisone and oral diphenhydramine but nothing provided relief. She was recommended for follow-up at the hospital for further examination and biopsy of one of her lesions.

At this follow-up visit, the patient noted that the lesions had spread to her left knee. Multiple firm discrete papules and nodules, with central hyperkeratotic plugs, were noted along the extensor surfaces of her forearms, left extensor knee, and around her ankles (FIGURES 1A and 1B). Some of the lesions were tender. Examination of the rest of her skin was normal. A punch biopsy was obtained.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Diagnosis: Kyrle disease

The patient’s end-stage renal disease and type 2 diabetes—along with findings from the physical examination—led us to suspect Kyrle disease. The punch biopsy, as well as the characteristic keratotic plugs (FIGURE 2) within epidermal invagination that was bordered by hyperkeratotic epidermis, confirmed the diagnosis.

The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.

Kyrle disease (also known as hyperkeratosis follicularis et follicularis in cutem penetrans) is a rare skin condition. It is 1 of 4 skin conditions that are classified as perforating skin disorders; the other 3 are elastosis perforans serpiginosa, reactive perforating collagenosis, and perforating folliculitis (TABLE^1,2).³ Perforating skin disorders share the common characteristic of transepidermal elimination of material from the upper dermis.⁴ These disorders are typically classified based on the nature of the eliminated material and the type of epidermal disruption.⁵

There are 2 forms of Kyrle disease: an inherited form often seen in childhood that is not associated with systemic disease and an acquired form that occurs in adulthood, most commonly among women ages 35 to 70 years who have systemic disease.^3,4,6 The acquired form of Kyrle disease is associated with diabetes and renal failure, but there is a lack of data on its pathogenesis.^7,8

Characteristic findings include discrete pruritic, dry papules and nodules with central keratotic plugs that are occasionally tender. These can manifest over the extensor surface of the extremities, trunk, face, and scalp.^4,7,9 Lesions most commonly manifest on the extensor surfaces of the lower extremities.

Other conditions that feature pruritic lesions

In addition to the other perforating skin disorders described in the TABLE,^1,2 the differential for Kyrle disease includes the following:

Prurigo nodularis (PN) is a skin disorder in which the manifestation of extremely pruritic nodules leads to vigorous scratching and secondary infections. These lesions typically have a grouped and symmetrically distributed appearance. They often appear on extensor surfaces of upper and lower extremities.¹⁰ PN has no known etiology, but like Kyrle disease, is associated with renal failure. Biopsy can help to distinguish PN from Kyrle disease.

Continue to: Hypertrophic lichen planus

Hypertrophic lichen planus is a pruritic skin disorder characterized by the “6 Ps”: planar, purple, polygonal, pruritic, papules, and plaques. These lesions can mimic the early stages of Kyrle disease.¹¹ However, in the later stages of Kyrle disease, discrete papules with hyperkeratotic plugs develop, whereas large plaques will be seen with lichen planus.

Keratosis pilaris (KP) is an extremely common, yet benign, disorder in which hair follicles become keratinized.¹² KP can feature rough papules that are often described as “goosebumps” or having a sandpaper–like appearance. These papules often affect the upper arms. KP usually manifests in adolescents or young adults and tends to improve with age.¹² The lesions are typically smaller than those seen in Kyrle disease and are asymptomatic. In addition, KP is not associated with systemic disease.

Target symptoms and any underlying conditions

In patients who have an acquired form of the disease, symptoms may improve by treating the underlying condition. For instance, better control of type 2 diabetes may improve symptoms. In patients with end-stage renal disease, a renal transplant can bring complete resolution.¹³

For patients whose Kyrle disease is inherited or whose underlying condition is not easily treated, there are a number of treatment options to consider. First-line treatment includes topical keratolytics (salicylic acid and urea), topical retinoids, and ultraviolet light therapy.^5,7 Systemic retinoids, topical steroids, cryotherapy, electrosurgery, CO₂ laser surgery, and surgical excision have also been used with some success.^7,14 Oral histamines and emollients also may help to relieve the pruritus. Lesions often recur upon discontinuation of therapy.

Our patient was referred to Dermatology for ultraviolet light therapy. She was also treated with topical 12% ammonium lactate twice daily. Within a few months, she reported improvement of her symptoms.

A shave biopsy was performed and revealed a well-differentiated, invasive squamous cell carcinoma (SCC). Complete excision was performed with a 4-mm margin.

In the United States, SCC is the most common skin cancer in Black patients, as well as the second most common skin cancer overall. A history of UV exposure from the sun or artificial tanning beds is the most significant risk factor.¹ Radiation, carcinogenic chemical exposure, longstanding inflammation caused by burns, and immunosuppression are also risk factors for SCC.

When caring for a patient with SCC, the best initial work-up is a biopsy. A punch, shave, or excisional biopsy may all be appropriate if the dermis is adequately sampled. However, with a shave or shallow punch biopsy, thick keratin debris can unintentionally lead to a superficial sampling.

Cutaneous SCC should be treated by excision with 4- to 6-mm margins or Mohs microsurgery. Tumors that are smaller than 2 cm, lack aggressive histologic features, and are located in low-risk areas (eg, trunk or extremities) may be treated with standard excision. Larger tumors, recurrent tumors, higher risk histologic subtypes, and tumors on the head, neck, genitals, hands, or feet are candidates for Mohs surgery.

This patient was counseled to practice sun protection and to schedule regular follow-up visits every 6 months for the next 2 years.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

A shave biopsy was performed and revealed a well-differentiated, invasive squamous cell carcinoma (SCC). Complete excision was performed with a 4-mm margin.

In the United States, SCC is the most common skin cancer in Black patients, as well as the second most common skin cancer overall. A history of UV exposure from the sun or artificial tanning beds is the most significant risk factor.¹ Radiation, carcinogenic chemical exposure, longstanding inflammation caused by burns, and immunosuppression are also risk factors for SCC.

When caring for a patient with SCC, the best initial work-up is a biopsy. A punch, shave, or excisional biopsy may all be appropriate if the dermis is adequately sampled. However, with a shave or shallow punch biopsy, thick keratin debris can unintentionally lead to a superficial sampling.

Cutaneous SCC should be treated by excision with 4- to 6-mm margins or Mohs microsurgery. Tumors that are smaller than 2 cm, lack aggressive histologic features, and are located in low-risk areas (eg, trunk or extremities) may be treated with standard excision. Larger tumors, recurrent tumors, higher risk histologic subtypes, and tumors on the head, neck, genitals, hands, or feet are candidates for Mohs surgery.

This patient was counseled to practice sun protection and to schedule regular follow-up visits every 6 months for the next 2 years.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

A shave biopsy was performed and revealed a well-differentiated, invasive squamous cell carcinoma (SCC). Complete excision was performed with a 4-mm margin.

In the United States, SCC is the most common skin cancer in Black patients, as well as the second most common skin cancer overall. A history of UV exposure from the sun or artificial tanning beds is the most significant risk factor.¹ Radiation, carcinogenic chemical exposure, longstanding inflammation caused by burns, and immunosuppression are also risk factors for SCC.

When caring for a patient with SCC, the best initial work-up is a biopsy. A punch, shave, or excisional biopsy may all be appropriate if the dermis is adequately sampled. However, with a shave or shallow punch biopsy, thick keratin debris can unintentionally lead to a superficial sampling.

Cutaneous SCC should be treated by excision with 4- to 6-mm margins or Mohs microsurgery. Tumors that are smaller than 2 cm, lack aggressive histologic features, and are located in low-risk areas (eg, trunk or extremities) may be treated with standard excision. Larger tumors, recurrent tumors, higher risk histologic subtypes, and tumors on the head, neck, genitals, hands, or feet are candidates for Mohs surgery.

This patient was counseled to practice sun protection and to schedule regular follow-up visits every 6 months for the next 2 years.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).