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Regular skin exams reduced advanced KCs in posttransplant patients
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
ORLANDO – Annual skin exams reduced the rate of advanced keratinocyte carcinoma (KC) after solid organ transplant by 34%, according to a review of 10,198 transplant patients in Ontario, Canada.
Transplant patients have a far higher risk of KC than the general public because of immunosuppression: A quarter of patients are affected within 5 years. Transplant guidelines have recommended annual skin exams.
Other studies have reported adherence rates of up to 50%, but the numbers were based largely on patient self-report. Instead, the Ontario study used billing codes and other administrative data to get an idea of how many patients actually followed through.
“I would be surprised if other jurisdictions have significantly better rates of adherence,” said lead investigator An-Wen Chan, MD, of the division of dermatology at the University of Toronto and director of a transplant dermatology clinic at the University Health Network.
Part of the problem is that there’s just not a lot of evidence that annual screenings improve KC outcomes, he noted.
To help plug that evidence gap, Dr. Chan and his team reviewed transplant cases in Ontario going back to the mid-1990s; 62% of the patients had kidney transplants, 24% had liver transplants, and the rest had heart or lung transplants. The patients were all aged over 18 years; 60% were white, 15% Asian, 4% black, and the rest unknown. About two-thirds were men.
Adherence to annual dermatology checkups at least 75% of the time was associated with a marked reduction in the development of advanced KC, defined as lesions greater than 2 cm and requiring reconstruction and lymphadenectomy (adjusted hazard ratio, 0.66; 95% CI, 0.48-0.92).
Increasing age at transplant, white race, male sex, and past history of skin cancer were among the factors that were associated with increased risk. There was a trend toward increased risk with liver, lung, and heart transplants, as opposed to kidney transplants. Results were adjusted for demographic, transplant, and other variables.
In short, “adherence to annual dermatology assessments ... reduced KC-related morbidity and death. The highest risk patients were not necessarily the ones that saw their dermatologist annually,” Dr. Chan said.
Rates of adherence varied across transplant sites. It’s probably less of a problem at the University of Toronto, where Dr. Chan is embedded with the transplant team and where he can educate patients and providers on the importance of annual screening and help ensure that it’s done.
“We have a rigorous skin referral policy in place and really target transplant patients to be seen within a year. Having a dermatologist dedicated to transplant dermatology really helps,” he said. The next step is to define the optimal frequency of posttransplant skin cancer screening and to address barriers to screening.
There was no industry funding for the work, and Dr. Chan had no relevant disclosures.
SOURCE: Chan A et al. IID 2018, Abstract 522.
REPORTING FROM IID 2018
Key clinical point: Transplant patients need help to ensure they get annual dermatology checkups.
Major finding: Just 2.1% of the patients in the review had annual exams, and less than half saw a dermatologist even once during an average of 5-years follow-up.
Study details: A review of 10,198 solid organ transplant cases.
Disclosures: There was no industry funding, and the lead investigator had no disclosures.
Source: Chan A et al. IID 2018, Abstract 522
Effects of psoriatic arthritis not just physical
conducted by the Harris Poll on behalf of Pfizer.
Over 90% of respondents said that their psoriatic arthritis had negatively impacted their emotional and mental well-being and 75% reported negative effects on their relationships with friends and family, Pfizer reported. Among the 301 adults aged 18 years and older who responded to the survey, 58% had stopped participating in sports or recreational activities and 51% had stopped participating in social activities.
The effects on patients’ professional lives also were considerable: Almost 74% said that it had a negative effect on their career path, 41% had experienced decreased productivity, and 13% had quit or been let go from a job, Pfizer said.
Some of the survey results suggested a disconnect between patients and their physicians. Of the 89% of patients who were very or somewhat satisfied with their prescription medication, 90% said that they would like to make changes to their treatment regimen and 89% described their illness as moderate to severe, Pfizer reported.
The survey was conducted online from Nov. 2 to Dec. 1, 2017.
conducted by the Harris Poll on behalf of Pfizer.
Over 90% of respondents said that their psoriatic arthritis had negatively impacted their emotional and mental well-being and 75% reported negative effects on their relationships with friends and family, Pfizer reported. Among the 301 adults aged 18 years and older who responded to the survey, 58% had stopped participating in sports or recreational activities and 51% had stopped participating in social activities.
The effects on patients’ professional lives also were considerable: Almost 74% said that it had a negative effect on their career path, 41% had experienced decreased productivity, and 13% had quit or been let go from a job, Pfizer said.
Some of the survey results suggested a disconnect between patients and their physicians. Of the 89% of patients who were very or somewhat satisfied with their prescription medication, 90% said that they would like to make changes to their treatment regimen and 89% described their illness as moderate to severe, Pfizer reported.
The survey was conducted online from Nov. 2 to Dec. 1, 2017.
conducted by the Harris Poll on behalf of Pfizer.
Over 90% of respondents said that their psoriatic arthritis had negatively impacted their emotional and mental well-being and 75% reported negative effects on their relationships with friends and family, Pfizer reported. Among the 301 adults aged 18 years and older who responded to the survey, 58% had stopped participating in sports or recreational activities and 51% had stopped participating in social activities.
The effects on patients’ professional lives also were considerable: Almost 74% said that it had a negative effect on their career path, 41% had experienced decreased productivity, and 13% had quit or been let go from a job, Pfizer said.
Some of the survey results suggested a disconnect between patients and their physicians. Of the 89% of patients who were very or somewhat satisfied with their prescription medication, 90% said that they would like to make changes to their treatment regimen and 89% described their illness as moderate to severe, Pfizer reported.
The survey was conducted online from Nov. 2 to Dec. 1, 2017.
MDedge Daily News: Keeping patients summer safe
Memorial Day is the traditional kickoff to summer, so patients will need information on some important topics. To that end, the Food and Drug Administration reminds that there is no such thing as a supplement that prevents sun damage. The CDC warns that nasty things happen when people (kids) drink the pool water. And the federal government advises on what should be included in an approved insect repellent.
Listen to the MDedge Daily News podcast for all the details.
Memorial Day is the traditional kickoff to summer, so patients will need information on some important topics. To that end, the Food and Drug Administration reminds that there is no such thing as a supplement that prevents sun damage. The CDC warns that nasty things happen when people (kids) drink the pool water. And the federal government advises on what should be included in an approved insect repellent.
Listen to the MDedge Daily News podcast for all the details.
Memorial Day is the traditional kickoff to summer, so patients will need information on some important topics. To that end, the Food and Drug Administration reminds that there is no such thing as a supplement that prevents sun damage. The CDC warns that nasty things happen when people (kids) drink the pool water. And the federal government advises on what should be included in an approved insect repellent.
Listen to the MDedge Daily News podcast for all the details.
Time Won't Heal This Wound
An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.
An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”
The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.
EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.
What is the diagnosis?
DISCUSSION
The pathology report showed evidence of a basosquamous cell carcinoma.
This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.
The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.
The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.
The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.
TAKE-HOME LEARNING POINTS
- Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
- Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
- Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
- Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.
An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.
An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”
The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.
EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.
What is the diagnosis?
DISCUSSION
The pathology report showed evidence of a basosquamous cell carcinoma.
This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.
The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.
The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.
The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.
TAKE-HOME LEARNING POINTS
- Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
- Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
- Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
- Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.
An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.
An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”
The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.
EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.
What is the diagnosis?
DISCUSSION
The pathology report showed evidence of a basosquamous cell carcinoma.
This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.
The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.
The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.
The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.
TAKE-HOME LEARNING POINTS
- Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
- Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
- Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
- Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.
Spotlight on nonmelanoma skin cancer’s true burden
CHICAGO – The true extent of the burden imposed by nonmelanoma skin cancer remains widely underappreciated by health policy makers, the public, employers, and nondermatologist physicians, Marta J. Van Beek, MD, asserted at the annual meeting of the American College of Mohs Surgery.
It’s very much in the interest of Mohs surgeons, as the experts in cutaneous malignancies, to get the accurate message out, she added.
Abundant evidence indicates there is an ongoing epidemic of nonmelanoma skin cancer (NMSC) in the United States – and it is associated with a surprising amount of morbidity and mortality, the dermatologic surgeon observed.
For example, while the American Academy of Dermatology’s 93-page Burden of Skin Disease report identified melanoma as the No. 1 cause of mortality because of skin disease – no surprise there – what may come as news to many is that NMSC was No. 2, accounting for 4,376 deaths in 2013, or 19% of the total. That’s more deaths than occurred because of wounds and burns.
And while the number of cases of NMSC is going up year after year as the population ages, it’s also the case that patients with complex NMSC are developing it at a younger and younger age. As documented in the AAD’s DataDerm registry encompassing more than 6 million patients seen by dermatologists during 2015-2017, well over 20,000 patients who underwent Mohs micrographic surgery for NMSC were aged 45-55 years, and another 60,000 were aged 55-65 years. That being said, Mohs surgery was used to treat 477,365 NMSCs in 318,933 patients included in DataDerm during 2015-2017, and in that population, basal cell carcinomas outnumbered squamous cell carcinomas 2:1.
An interesting aspect of the burden imparted by NMSC is that patients with NMSC have a higher risk of other types of cancer, and when they develop those other primary cancers they tend to do more poorly than cancer patients without a history of NMSC, Dr. Van Beek continued.
She cited a comprehensive study by investigators at the Medical University of South Carolina, Charleston, who concluded that the odds of developing a noncutaneous second primary malignancy were 27% greater in individuals with a history of NMSC than in those without such a history. The increased risk was statistically significant for 26 types of noncutaneous cancer, consistent in both men and women, and the younger a patient’s age at onset of NMSC, the stronger the association with noncutaneous cancers (Adv Cancer Res. 2016;130:257-91).
In a separate systematic review by some of the same investigators, patients with a history of squamous cell carcinoma were at a 30% increased risk of all-cause mortality and 117% greater cancer-specific mortality than those without a history of the disease. The associations were less potent for basal cell carcinoma (Arch Dermatol Res. 2017 May;309[4]:243-51).
“You are more likely to die of your nonskin cancer if you’ve ever had a skin cancer, regardless of what that other cancer is. This may mean that once you have a skin cancer, maybe that proves you have poor protoplasm that makes you more prone to other cancers, but even if that’s the case I think it demonstrates that nonmelanoma skin cancer has a substantial contribution to morbidity and mortality outside of what we normally think about,” Dr. Van Beek said.
Another underappreciated aspect of the burden of NMSC is what economists call lost opportunity cost. This isn’t the direct medical cost, but work time missed because of disease. In 2013, according to the AAD Burden of Skin Disease report, melanoma was responsible for $88 million worth of lost productivity, while for NMSC, the figure was $376 million.
“When you’re talking about the burden of disease, it’s important to actually talk to employers about how important it is to pay for the treatment of skin cancer because that keeps people at work and productive,” the dermatologist said.
Investigators for the World Health Organization’s Global Burden of Disease project estimate that the total years lost to disability for patients with NMSC are comparable with the figures for patients with thyroid, esophageal, or ovarian cancer, Dr. Van Beek noted.
Payers and health policy makers are unnerved by the growing utilization of Mohs surgery, she warned.
“This is really important: If you want to substantiate our utilization, you have to make policy makers understand that we are doing this because more people have skin cancer,” she emphasized.
Dr. Van Beek reported no financial conflicts regarding her presentation.
CHICAGO – The true extent of the burden imposed by nonmelanoma skin cancer remains widely underappreciated by health policy makers, the public, employers, and nondermatologist physicians, Marta J. Van Beek, MD, asserted at the annual meeting of the American College of Mohs Surgery.
It’s very much in the interest of Mohs surgeons, as the experts in cutaneous malignancies, to get the accurate message out, she added.
Abundant evidence indicates there is an ongoing epidemic of nonmelanoma skin cancer (NMSC) in the United States – and it is associated with a surprising amount of morbidity and mortality, the dermatologic surgeon observed.
For example, while the American Academy of Dermatology’s 93-page Burden of Skin Disease report identified melanoma as the No. 1 cause of mortality because of skin disease – no surprise there – what may come as news to many is that NMSC was No. 2, accounting for 4,376 deaths in 2013, or 19% of the total. That’s more deaths than occurred because of wounds and burns.
And while the number of cases of NMSC is going up year after year as the population ages, it’s also the case that patients with complex NMSC are developing it at a younger and younger age. As documented in the AAD’s DataDerm registry encompassing more than 6 million patients seen by dermatologists during 2015-2017, well over 20,000 patients who underwent Mohs micrographic surgery for NMSC were aged 45-55 years, and another 60,000 were aged 55-65 years. That being said, Mohs surgery was used to treat 477,365 NMSCs in 318,933 patients included in DataDerm during 2015-2017, and in that population, basal cell carcinomas outnumbered squamous cell carcinomas 2:1.
An interesting aspect of the burden imparted by NMSC is that patients with NMSC have a higher risk of other types of cancer, and when they develop those other primary cancers they tend to do more poorly than cancer patients without a history of NMSC, Dr. Van Beek continued.
She cited a comprehensive study by investigators at the Medical University of South Carolina, Charleston, who concluded that the odds of developing a noncutaneous second primary malignancy were 27% greater in individuals with a history of NMSC than in those without such a history. The increased risk was statistically significant for 26 types of noncutaneous cancer, consistent in both men and women, and the younger a patient’s age at onset of NMSC, the stronger the association with noncutaneous cancers (Adv Cancer Res. 2016;130:257-91).
In a separate systematic review by some of the same investigators, patients with a history of squamous cell carcinoma were at a 30% increased risk of all-cause mortality and 117% greater cancer-specific mortality than those without a history of the disease. The associations were less potent for basal cell carcinoma (Arch Dermatol Res. 2017 May;309[4]:243-51).
“You are more likely to die of your nonskin cancer if you’ve ever had a skin cancer, regardless of what that other cancer is. This may mean that once you have a skin cancer, maybe that proves you have poor protoplasm that makes you more prone to other cancers, but even if that’s the case I think it demonstrates that nonmelanoma skin cancer has a substantial contribution to morbidity and mortality outside of what we normally think about,” Dr. Van Beek said.
Another underappreciated aspect of the burden of NMSC is what economists call lost opportunity cost. This isn’t the direct medical cost, but work time missed because of disease. In 2013, according to the AAD Burden of Skin Disease report, melanoma was responsible for $88 million worth of lost productivity, while for NMSC, the figure was $376 million.
“When you’re talking about the burden of disease, it’s important to actually talk to employers about how important it is to pay for the treatment of skin cancer because that keeps people at work and productive,” the dermatologist said.
Investigators for the World Health Organization’s Global Burden of Disease project estimate that the total years lost to disability for patients with NMSC are comparable with the figures for patients with thyroid, esophageal, or ovarian cancer, Dr. Van Beek noted.
Payers and health policy makers are unnerved by the growing utilization of Mohs surgery, she warned.
“This is really important: If you want to substantiate our utilization, you have to make policy makers understand that we are doing this because more people have skin cancer,” she emphasized.
Dr. Van Beek reported no financial conflicts regarding her presentation.
CHICAGO – The true extent of the burden imposed by nonmelanoma skin cancer remains widely underappreciated by health policy makers, the public, employers, and nondermatologist physicians, Marta J. Van Beek, MD, asserted at the annual meeting of the American College of Mohs Surgery.
It’s very much in the interest of Mohs surgeons, as the experts in cutaneous malignancies, to get the accurate message out, she added.
Abundant evidence indicates there is an ongoing epidemic of nonmelanoma skin cancer (NMSC) in the United States – and it is associated with a surprising amount of morbidity and mortality, the dermatologic surgeon observed.
For example, while the American Academy of Dermatology’s 93-page Burden of Skin Disease report identified melanoma as the No. 1 cause of mortality because of skin disease – no surprise there – what may come as news to many is that NMSC was No. 2, accounting for 4,376 deaths in 2013, or 19% of the total. That’s more deaths than occurred because of wounds and burns.
And while the number of cases of NMSC is going up year after year as the population ages, it’s also the case that patients with complex NMSC are developing it at a younger and younger age. As documented in the AAD’s DataDerm registry encompassing more than 6 million patients seen by dermatologists during 2015-2017, well over 20,000 patients who underwent Mohs micrographic surgery for NMSC were aged 45-55 years, and another 60,000 were aged 55-65 years. That being said, Mohs surgery was used to treat 477,365 NMSCs in 318,933 patients included in DataDerm during 2015-2017, and in that population, basal cell carcinomas outnumbered squamous cell carcinomas 2:1.
An interesting aspect of the burden imparted by NMSC is that patients with NMSC have a higher risk of other types of cancer, and when they develop those other primary cancers they tend to do more poorly than cancer patients without a history of NMSC, Dr. Van Beek continued.
She cited a comprehensive study by investigators at the Medical University of South Carolina, Charleston, who concluded that the odds of developing a noncutaneous second primary malignancy were 27% greater in individuals with a history of NMSC than in those without such a history. The increased risk was statistically significant for 26 types of noncutaneous cancer, consistent in both men and women, and the younger a patient’s age at onset of NMSC, the stronger the association with noncutaneous cancers (Adv Cancer Res. 2016;130:257-91).
In a separate systematic review by some of the same investigators, patients with a history of squamous cell carcinoma were at a 30% increased risk of all-cause mortality and 117% greater cancer-specific mortality than those without a history of the disease. The associations were less potent for basal cell carcinoma (Arch Dermatol Res. 2017 May;309[4]:243-51).
“You are more likely to die of your nonskin cancer if you’ve ever had a skin cancer, regardless of what that other cancer is. This may mean that once you have a skin cancer, maybe that proves you have poor protoplasm that makes you more prone to other cancers, but even if that’s the case I think it demonstrates that nonmelanoma skin cancer has a substantial contribution to morbidity and mortality outside of what we normally think about,” Dr. Van Beek said.
Another underappreciated aspect of the burden of NMSC is what economists call lost opportunity cost. This isn’t the direct medical cost, but work time missed because of disease. In 2013, according to the AAD Burden of Skin Disease report, melanoma was responsible for $88 million worth of lost productivity, while for NMSC, the figure was $376 million.
“When you’re talking about the burden of disease, it’s important to actually talk to employers about how important it is to pay for the treatment of skin cancer because that keeps people at work and productive,” the dermatologist said.
Investigators for the World Health Organization’s Global Burden of Disease project estimate that the total years lost to disability for patients with NMSC are comparable with the figures for patients with thyroid, esophageal, or ovarian cancer, Dr. Van Beek noted.
Payers and health policy makers are unnerved by the growing utilization of Mohs surgery, she warned.
“This is really important: If you want to substantiate our utilization, you have to make policy makers understand that we are doing this because more people have skin cancer,” she emphasized.
Dr. Van Beek reported no financial conflicts regarding her presentation.
EXPERT ANALYSIS FROM THE ACMS ANNUAL MEETING
Large dark discoloration on the back
The FP recognized that this child had a large bathing trunk nevus with multiple small melanocytic satellite lesions on her arms.
He explained to the worried parents that their daughter had a bathing trunk nevus and that a local expert was needed. The FP consulted a local dermatologist, who subsequently explained to the parents that there was a significant risk of cutaneous melanoma if nothing was done about this large congenital nevus. The dermatologist indicated that while removal could decrease that risk, the process would require multiple large surgeries by a plastic surgeon. She also explained that a magnetic resonance imaging scan of the brain would be needed at about 6 months to look for neurocutaneous melanosis, which can cause seizures, hydrocephalus, and a central nervous system melanoma.
The parents were conflicted about whether to put their child through a series of massive surgeries or to accept the higher risk of melanoma and proceed with careful monitoring by the dermatologist. (No additional details on how this case resolved are available—Editor.)
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP recognized that this child had a large bathing trunk nevus with multiple small melanocytic satellite lesions on her arms.
He explained to the worried parents that their daughter had a bathing trunk nevus and that a local expert was needed. The FP consulted a local dermatologist, who subsequently explained to the parents that there was a significant risk of cutaneous melanoma if nothing was done about this large congenital nevus. The dermatologist indicated that while removal could decrease that risk, the process would require multiple large surgeries by a plastic surgeon. She also explained that a magnetic resonance imaging scan of the brain would be needed at about 6 months to look for neurocutaneous melanosis, which can cause seizures, hydrocephalus, and a central nervous system melanoma.
The parents were conflicted about whether to put their child through a series of massive surgeries or to accept the higher risk of melanoma and proceed with careful monitoring by the dermatologist. (No additional details on how this case resolved are available—Editor.)
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
The FP recognized that this child had a large bathing trunk nevus with multiple small melanocytic satellite lesions on her arms.
He explained to the worried parents that their daughter had a bathing trunk nevus and that a local expert was needed. The FP consulted a local dermatologist, who subsequently explained to the parents that there was a significant risk of cutaneous melanoma if nothing was done about this large congenital nevus. The dermatologist indicated that while removal could decrease that risk, the process would require multiple large surgeries by a plastic surgeon. She also explained that a magnetic resonance imaging scan of the brain would be needed at about 6 months to look for neurocutaneous melanosis, which can cause seizures, hydrocephalus, and a central nervous system melanoma.
The parents were conflicted about whether to put their child through a series of massive surgeries or to accept the higher risk of melanoma and proceed with careful monitoring by the dermatologist. (No additional details on how this case resolved are available—Editor.)
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
Atopic eczema linked to cardiovascular disease risk
according to a case-control study published online May 23 in BMJ.
In a population-based cohort study, researchers compared the electronic health records of 387,439 adults with eczema and 1,528,477 patients without eczema in the United Kingddom, matched according to age, sex, general practice, and calendar time, during 1998-2015. Patients were followed up for a median of 5.1 years
With the exception of cardiovascular death, atopic eczema was associated with all cardiovascular outcomes (MI, unstable angina, heart failure, atrial fibrillation, and stroke). The associations were stronger for severe atopic eczema, with significantly higher risks of MI, unstable angina, atrial fibrillation, stroke, cardiovascular death, and coronary revascularization among individuals with severe atopic eczema, compared with controls.
After adjustment for potential mediators such as body mass index, smoking, hyperlipidemia, diabetes, and severe alcohol use, individuals with severe eczema had a significant 37% increased risk of MI, 67% greater risk of heart failure, 35% greater risk of atrial fibrillation, 30% greater risk of cardiovascular death, and 36% greater risk of coronary revascularization, compared with controls with no eczema.
Increased cardiovascular risks also were seen in individuals whose atopic eczema was active more than half the time at follow-up. This group had a 37% greater risk of heart failure, 36% greater risk of unstable angina, and 19% greater risk of stroke, as well as significantly elevated risks of MI, atrial fibrillation, cardiovascular death, and coronary revascularization, compared with those without eczema.
Overall, atopic eczema contributed around 2.4% of the population-attributable risk for unstable angina, and 1.9% for heart failure (the highest population attributable risks). Ethnicity or high-dose corticosteroid use did not significantly impact outcomes.
Richard J. Silverwood, PhD, from the London School of Hygiene and Tropical Medicine, and his coauthors wrote that previous work examining the relationship between atopic eczema and cardiovascular disease had shown inconsistent outcomes, with some studies even pointing to a possible protective effect of mild atopic eczema.
“Mechanistic work suggests that atopic eczema may be associated with increased platelet activation and decreased fibrinolysis, which may increase the risk of clotting, though a recent study found no association with metabolite levels,” the authors wrote.
They noted that the strengths of their study were that it was largest to examine the association between atopic eczema and cardiovascular risk, and that they had access to data on body mass index, smoking, and severe alcohol use for most of the study population, which enabled them to adjust for these potential mediators.
“Consideration should be given to developing prevention strategies to reduce the risk of cardiovascular disease among patients with severe or predominantly active atopic eczema, including awareness of and screening for conventional cardiovascular risk factors by those providing clinical care,” they wrote.
The study was supported by the Wellcome Trust, and no relevant conflicts of interest were declared.
SOURCE: Silverwood R et al. BMJ 2018 May 23;361:k1786. doi: 10.1136/bmj.k1786.
The evidence in favor of a link between chronic inflammatory conditions, such as rheumatoid arthritis, and cardiovascular disease is growing. However, there are conflicting data and some of the uncertainty may be a result of a dose-response effect, where the increased cardiovascular risk is seen only in people with more severe disease.
This study and its finding of increased cardiovascular risk in patients with severe or more active eczema supports the case for targeted screening of this group for standard cardiovascular disease risk factors. It also could prompt incorporation of severe eczema as an independent cardiovascular disease risk factor in calculation of thresholds for primary prevention interventions.
The findings also may have implications for health care resources allocated to treatment of eczema, as prevention of cardiovascular disease could contribute to the argument in favor of the more expensive next-generation biologic treatments for eczema that are becoming available.
John R. Ingram, MD, is senior lecturer and consultant dermatologist, dermatology and academic wound healing in the division of infection and immunity at Cardiff (U.K.) University. These comments are taken from an accompanying editorial No conflicts of interest were declared. (BMJ. 2018 May 23. doi: 10.1136/bmj.k2064).
The evidence in favor of a link between chronic inflammatory conditions, such as rheumatoid arthritis, and cardiovascular disease is growing. However, there are conflicting data and some of the uncertainty may be a result of a dose-response effect, where the increased cardiovascular risk is seen only in people with more severe disease.
This study and its finding of increased cardiovascular risk in patients with severe or more active eczema supports the case for targeted screening of this group for standard cardiovascular disease risk factors. It also could prompt incorporation of severe eczema as an independent cardiovascular disease risk factor in calculation of thresholds for primary prevention interventions.
The findings also may have implications for health care resources allocated to treatment of eczema, as prevention of cardiovascular disease could contribute to the argument in favor of the more expensive next-generation biologic treatments for eczema that are becoming available.
John R. Ingram, MD, is senior lecturer and consultant dermatologist, dermatology and academic wound healing in the division of infection and immunity at Cardiff (U.K.) University. These comments are taken from an accompanying editorial No conflicts of interest were declared. (BMJ. 2018 May 23. doi: 10.1136/bmj.k2064).
The evidence in favor of a link between chronic inflammatory conditions, such as rheumatoid arthritis, and cardiovascular disease is growing. However, there are conflicting data and some of the uncertainty may be a result of a dose-response effect, where the increased cardiovascular risk is seen only in people with more severe disease.
This study and its finding of increased cardiovascular risk in patients with severe or more active eczema supports the case for targeted screening of this group for standard cardiovascular disease risk factors. It also could prompt incorporation of severe eczema as an independent cardiovascular disease risk factor in calculation of thresholds for primary prevention interventions.
The findings also may have implications for health care resources allocated to treatment of eczema, as prevention of cardiovascular disease could contribute to the argument in favor of the more expensive next-generation biologic treatments for eczema that are becoming available.
John R. Ingram, MD, is senior lecturer and consultant dermatologist, dermatology and academic wound healing in the division of infection and immunity at Cardiff (U.K.) University. These comments are taken from an accompanying editorial No conflicts of interest were declared. (BMJ. 2018 May 23. doi: 10.1136/bmj.k2064).
according to a case-control study published online May 23 in BMJ.
In a population-based cohort study, researchers compared the electronic health records of 387,439 adults with eczema and 1,528,477 patients without eczema in the United Kingddom, matched according to age, sex, general practice, and calendar time, during 1998-2015. Patients were followed up for a median of 5.1 years
With the exception of cardiovascular death, atopic eczema was associated with all cardiovascular outcomes (MI, unstable angina, heart failure, atrial fibrillation, and stroke). The associations were stronger for severe atopic eczema, with significantly higher risks of MI, unstable angina, atrial fibrillation, stroke, cardiovascular death, and coronary revascularization among individuals with severe atopic eczema, compared with controls.
After adjustment for potential mediators such as body mass index, smoking, hyperlipidemia, diabetes, and severe alcohol use, individuals with severe eczema had a significant 37% increased risk of MI, 67% greater risk of heart failure, 35% greater risk of atrial fibrillation, 30% greater risk of cardiovascular death, and 36% greater risk of coronary revascularization, compared with controls with no eczema.
Increased cardiovascular risks also were seen in individuals whose atopic eczema was active more than half the time at follow-up. This group had a 37% greater risk of heart failure, 36% greater risk of unstable angina, and 19% greater risk of stroke, as well as significantly elevated risks of MI, atrial fibrillation, cardiovascular death, and coronary revascularization, compared with those without eczema.
Overall, atopic eczema contributed around 2.4% of the population-attributable risk for unstable angina, and 1.9% for heart failure (the highest population attributable risks). Ethnicity or high-dose corticosteroid use did not significantly impact outcomes.
Richard J. Silverwood, PhD, from the London School of Hygiene and Tropical Medicine, and his coauthors wrote that previous work examining the relationship between atopic eczema and cardiovascular disease had shown inconsistent outcomes, with some studies even pointing to a possible protective effect of mild atopic eczema.
“Mechanistic work suggests that atopic eczema may be associated with increased platelet activation and decreased fibrinolysis, which may increase the risk of clotting, though a recent study found no association with metabolite levels,” the authors wrote.
They noted that the strengths of their study were that it was largest to examine the association between atopic eczema and cardiovascular risk, and that they had access to data on body mass index, smoking, and severe alcohol use for most of the study population, which enabled them to adjust for these potential mediators.
“Consideration should be given to developing prevention strategies to reduce the risk of cardiovascular disease among patients with severe or predominantly active atopic eczema, including awareness of and screening for conventional cardiovascular risk factors by those providing clinical care,” they wrote.
The study was supported by the Wellcome Trust, and no relevant conflicts of interest were declared.
SOURCE: Silverwood R et al. BMJ 2018 May 23;361:k1786. doi: 10.1136/bmj.k1786.
according to a case-control study published online May 23 in BMJ.
In a population-based cohort study, researchers compared the electronic health records of 387,439 adults with eczema and 1,528,477 patients without eczema in the United Kingddom, matched according to age, sex, general practice, and calendar time, during 1998-2015. Patients were followed up for a median of 5.1 years
With the exception of cardiovascular death, atopic eczema was associated with all cardiovascular outcomes (MI, unstable angina, heart failure, atrial fibrillation, and stroke). The associations were stronger for severe atopic eczema, with significantly higher risks of MI, unstable angina, atrial fibrillation, stroke, cardiovascular death, and coronary revascularization among individuals with severe atopic eczema, compared with controls.
After adjustment for potential mediators such as body mass index, smoking, hyperlipidemia, diabetes, and severe alcohol use, individuals with severe eczema had a significant 37% increased risk of MI, 67% greater risk of heart failure, 35% greater risk of atrial fibrillation, 30% greater risk of cardiovascular death, and 36% greater risk of coronary revascularization, compared with controls with no eczema.
Increased cardiovascular risks also were seen in individuals whose atopic eczema was active more than half the time at follow-up. This group had a 37% greater risk of heart failure, 36% greater risk of unstable angina, and 19% greater risk of stroke, as well as significantly elevated risks of MI, atrial fibrillation, cardiovascular death, and coronary revascularization, compared with those without eczema.
Overall, atopic eczema contributed around 2.4% of the population-attributable risk for unstable angina, and 1.9% for heart failure (the highest population attributable risks). Ethnicity or high-dose corticosteroid use did not significantly impact outcomes.
Richard J. Silverwood, PhD, from the London School of Hygiene and Tropical Medicine, and his coauthors wrote that previous work examining the relationship between atopic eczema and cardiovascular disease had shown inconsistent outcomes, with some studies even pointing to a possible protective effect of mild atopic eczema.
“Mechanistic work suggests that atopic eczema may be associated with increased platelet activation and decreased fibrinolysis, which may increase the risk of clotting, though a recent study found no association with metabolite levels,” the authors wrote.
They noted that the strengths of their study were that it was largest to examine the association between atopic eczema and cardiovascular risk, and that they had access to data on body mass index, smoking, and severe alcohol use for most of the study population, which enabled them to adjust for these potential mediators.
“Consideration should be given to developing prevention strategies to reduce the risk of cardiovascular disease among patients with severe or predominantly active atopic eczema, including awareness of and screening for conventional cardiovascular risk factors by those providing clinical care,” they wrote.
The study was supported by the Wellcome Trust, and no relevant conflicts of interest were declared.
SOURCE: Silverwood R et al. BMJ 2018 May 23;361:k1786. doi: 10.1136/bmj.k1786.
FROM THE BMJ
Key clinical point: Severe atopic eczema may be associated with a significantly increased risk of cardiovascular disease.
Major finding: Individuals with severe atopic eczema were at increased for cardiovascular disease, including a 67% greater risk of heart failure.
Study details: A population-based case-control cohort study in 387,439 patients with atopic eczema, compared with more than 1 million controls.
Disclosures: The study was supported by the Wellcome Trust, and no relevant conflicts of interest were declared.
Source: Silverwood R et al. BMJ. 2018 May 23;361:k1786.
CBC values linked to CVD risk in psoriasis
ORLANDO – conducted by researchers at Case Western Reserve University, Cleveland.*
It’s generally accepted that psoriasis increases the risk of cardiovascular disease (CVD), but it’s not clear who’s most at risk. “We really wanted to find something that is cheap and easy to risk stratify these patients” said lead investigator Rosalynn Conic, MD, of Case Western’s department of dermatology.
What they found was “very impressive, for sure,” Dr. Conic said at the International Investigative Dermatology meeting.
The incidence of MI was highest among the 1,920 patients (5%) with elevated RDW and MPV (odds ratio, 3.4; 95% confidence interval, 2.7-4.2; P less than .001), followed by the 7,060 (18%) patients with high RDW and normal MPV (OR, 2.4; 95% CI, 2.1-2.8; P less than .001), as compared with normal/low MPV and RDW patients.
Elevated RDW or elevated RDW plus MPV increased the odds of atrial fibrillation, coronary artery disease, heart failure, and peripheral vascular disease anywhere from 2 to 8.3 times (P less than .001). Among psoriatic arthritis patients, elevated RDW almost doubled the risk of MI (OR, 1.8; P less than .001). Results were adjusted for age, gender, and hypertension.
In a subanalysis of treatment effects, 4 of 23 psoriasis patients at Case Western had elevated RDWs at baseline. Values normalized in the three patients who achieved a 75% reduction in the Psoriasis Area and Severity Index score after about a year of systemic treatment.
“We aim to validate [the study results] with a Veterans Administration data set,” Dr. Conic said. If it pans out, “one use would be to send [patients with elevated values] to a cardiologist earlier” so other CVD risk factors can be monitored and treated. The findings also add to the case for good control, she noted.
Systemic inflammation is the common denominator between the blood value elevations and CVD. The same inflammatory cytokines that cause skin problems in psoriasis also stimulate bone marrow to release immature red blood cells, which are larger than mature cells, leading to an increased RDW. Similarly, elevated MPV indicates a higher number of larger, younger platelets in the blood.
“It’s probably something along those lines, but I think we need to go back to basic science and really figure it out,” Dr. Conic said.
Patients were 18-65 years old. The study excluded patients with diabetes, Crohn’s disease, RA, and generalized atherosclerosis.
The National Institutes of Health funded the work. Dr. Conic reported no relevant financial disclosures.
*This article was updated on May 30, 2018.
SOURCE: Conic R et al. IID 2018, Abstract 550.
ORLANDO – conducted by researchers at Case Western Reserve University, Cleveland.*
It’s generally accepted that psoriasis increases the risk of cardiovascular disease (CVD), but it’s not clear who’s most at risk. “We really wanted to find something that is cheap and easy to risk stratify these patients” said lead investigator Rosalynn Conic, MD, of Case Western’s department of dermatology.
What they found was “very impressive, for sure,” Dr. Conic said at the International Investigative Dermatology meeting.
The incidence of MI was highest among the 1,920 patients (5%) with elevated RDW and MPV (odds ratio, 3.4; 95% confidence interval, 2.7-4.2; P less than .001), followed by the 7,060 (18%) patients with high RDW and normal MPV (OR, 2.4; 95% CI, 2.1-2.8; P less than .001), as compared with normal/low MPV and RDW patients.
Elevated RDW or elevated RDW plus MPV increased the odds of atrial fibrillation, coronary artery disease, heart failure, and peripheral vascular disease anywhere from 2 to 8.3 times (P less than .001). Among psoriatic arthritis patients, elevated RDW almost doubled the risk of MI (OR, 1.8; P less than .001). Results were adjusted for age, gender, and hypertension.
In a subanalysis of treatment effects, 4 of 23 psoriasis patients at Case Western had elevated RDWs at baseline. Values normalized in the three patients who achieved a 75% reduction in the Psoriasis Area and Severity Index score after about a year of systemic treatment.
“We aim to validate [the study results] with a Veterans Administration data set,” Dr. Conic said. If it pans out, “one use would be to send [patients with elevated values] to a cardiologist earlier” so other CVD risk factors can be monitored and treated. The findings also add to the case for good control, she noted.
Systemic inflammation is the common denominator between the blood value elevations and CVD. The same inflammatory cytokines that cause skin problems in psoriasis also stimulate bone marrow to release immature red blood cells, which are larger than mature cells, leading to an increased RDW. Similarly, elevated MPV indicates a higher number of larger, younger platelets in the blood.
“It’s probably something along those lines, but I think we need to go back to basic science and really figure it out,” Dr. Conic said.
Patients were 18-65 years old. The study excluded patients with diabetes, Crohn’s disease, RA, and generalized atherosclerosis.
The National Institutes of Health funded the work. Dr. Conic reported no relevant financial disclosures.
*This article was updated on May 30, 2018.
SOURCE: Conic R et al. IID 2018, Abstract 550.
ORLANDO – conducted by researchers at Case Western Reserve University, Cleveland.*
It’s generally accepted that psoriasis increases the risk of cardiovascular disease (CVD), but it’s not clear who’s most at risk. “We really wanted to find something that is cheap and easy to risk stratify these patients” said lead investigator Rosalynn Conic, MD, of Case Western’s department of dermatology.
What they found was “very impressive, for sure,” Dr. Conic said at the International Investigative Dermatology meeting.
The incidence of MI was highest among the 1,920 patients (5%) with elevated RDW and MPV (odds ratio, 3.4; 95% confidence interval, 2.7-4.2; P less than .001), followed by the 7,060 (18%) patients with high RDW and normal MPV (OR, 2.4; 95% CI, 2.1-2.8; P less than .001), as compared with normal/low MPV and RDW patients.
Elevated RDW or elevated RDW plus MPV increased the odds of atrial fibrillation, coronary artery disease, heart failure, and peripheral vascular disease anywhere from 2 to 8.3 times (P less than .001). Among psoriatic arthritis patients, elevated RDW almost doubled the risk of MI (OR, 1.8; P less than .001). Results were adjusted for age, gender, and hypertension.
In a subanalysis of treatment effects, 4 of 23 psoriasis patients at Case Western had elevated RDWs at baseline. Values normalized in the three patients who achieved a 75% reduction in the Psoriasis Area and Severity Index score after about a year of systemic treatment.
“We aim to validate [the study results] with a Veterans Administration data set,” Dr. Conic said. If it pans out, “one use would be to send [patients with elevated values] to a cardiologist earlier” so other CVD risk factors can be monitored and treated. The findings also add to the case for good control, she noted.
Systemic inflammation is the common denominator between the blood value elevations and CVD. The same inflammatory cytokines that cause skin problems in psoriasis also stimulate bone marrow to release immature red blood cells, which are larger than mature cells, leading to an increased RDW. Similarly, elevated MPV indicates a higher number of larger, younger platelets in the blood.
“It’s probably something along those lines, but I think we need to go back to basic science and really figure it out,” Dr. Conic said.
Patients were 18-65 years old. The study excluded patients with diabetes, Crohn’s disease, RA, and generalized atherosclerosis.
The National Institutes of Health funded the work. Dr. Conic reported no relevant financial disclosures.
*This article was updated on May 30, 2018.
SOURCE: Conic R et al. IID 2018, Abstract 550.
REPORTING FROM IID 2018
Key clinical point: Elevated red blood cell distribution width and mean platelet volume might identify psoriasis patients at risk for cardiovascular disease.
Major finding: The incidence of MI was highest among the 1,920 patients with elevated red cell distribution width and mean platelet volume (odds ratio, 3.4; 95% confidence interval, 2.7-4.2; P less than .001).
Study details: A database review of 39,510 patients with psoriasis.
Disclosures: The National Institutes of Health funded the work. The lead investigator had no disclosures to report.
Source: Conic R et al. IID 2018, Abstract 550.
Atopic dermatitis severity reduced by topical microbiome treatment
The Beginning Assessment of Cutaneous Treatment Efficacy of Roseomonas in Atopic Dermatitis trial; BACTERiAD I/II study, an open-label phase I/II trial, first looked at the therapeutic use of R. mucosa in 10 adults aged 18 years or older. Three sucrose mixtures with increasing doses of live R. mucosa bacteria were topically applied to two body areas – the antecubital fossae and a body surface of their choice – twice per week for 2 weeks per dose. At 6 weeks, the patients stopped using the mixtures and followed a 4-week washout phase.
Treatment was found to reduce mean antecubital SCORAD (SCORing Atopic Dermatitis) scores by 59.8%. Reduction in pruritus was even more pronounced, with a mean decrease of 78.5%. Treating the hands did not improve disease severity, even in patients whose symptoms improved in other body areas. One explanation may be the increased exposure of the hands to topical antimicrobials and environmental exposures, the researchers noted.
With the success in the adult cohort, the researchers enrolled five children aged 7-17 years in the study. These patients were treated twice weekly for 16 weeks. The pediatric patients experienced a mean decrease of 70.3% in their SCORAD scores. The mean decrease in pruritis was 78.8%.
All adults who responded continued to report improved symptoms after the washout period. The pediatric patients are now being evaluated in a washout period.
Four patients did not respond; three of them had a family history of AD persisting into adulthood. “The association between these complex medical histories and the lack of clinical response suggests that differences in heritable host and/or microbial factors may impact treatment responses,” wrote Ian A. Myles, MD, and his colleagues.
“Overall, our findings suggest the safety of topical R. mucosa therapy and justify continuation of our ongoing trial to assess safety and activity in a pediatric cohort of patients with AD. These studies will additionally assess changes in host serum markers, skin metabolomics, and the skin microbiota by culture and genomic methods.”
The researchers noted that expanding to the pediatric population will deepen understanding of topical microbiome transplantation and lay the foundation for placebo-controlled trials to assess efficacy.
This work was supported by the Intramural Research Program of the National Institutes of Allergy and Infectious Diseases and the National Institutes of Health. The researchers had no disclosures.
SOURCE: Myles IA et al. JCI Insight. 2018 May 3. doi: 10.1172/jci.insight.120608.
The Beginning Assessment of Cutaneous Treatment Efficacy of Roseomonas in Atopic Dermatitis trial; BACTERiAD I/II study, an open-label phase I/II trial, first looked at the therapeutic use of R. mucosa in 10 adults aged 18 years or older. Three sucrose mixtures with increasing doses of live R. mucosa bacteria were topically applied to two body areas – the antecubital fossae and a body surface of their choice – twice per week for 2 weeks per dose. At 6 weeks, the patients stopped using the mixtures and followed a 4-week washout phase.
Treatment was found to reduce mean antecubital SCORAD (SCORing Atopic Dermatitis) scores by 59.8%. Reduction in pruritus was even more pronounced, with a mean decrease of 78.5%. Treating the hands did not improve disease severity, even in patients whose symptoms improved in other body areas. One explanation may be the increased exposure of the hands to topical antimicrobials and environmental exposures, the researchers noted.
With the success in the adult cohort, the researchers enrolled five children aged 7-17 years in the study. These patients were treated twice weekly for 16 weeks. The pediatric patients experienced a mean decrease of 70.3% in their SCORAD scores. The mean decrease in pruritis was 78.8%.
All adults who responded continued to report improved symptoms after the washout period. The pediatric patients are now being evaluated in a washout period.
Four patients did not respond; three of them had a family history of AD persisting into adulthood. “The association between these complex medical histories and the lack of clinical response suggests that differences in heritable host and/or microbial factors may impact treatment responses,” wrote Ian A. Myles, MD, and his colleagues.
“Overall, our findings suggest the safety of topical R. mucosa therapy and justify continuation of our ongoing trial to assess safety and activity in a pediatric cohort of patients with AD. These studies will additionally assess changes in host serum markers, skin metabolomics, and the skin microbiota by culture and genomic methods.”
The researchers noted that expanding to the pediatric population will deepen understanding of topical microbiome transplantation and lay the foundation for placebo-controlled trials to assess efficacy.
This work was supported by the Intramural Research Program of the National Institutes of Allergy and Infectious Diseases and the National Institutes of Health. The researchers had no disclosures.
SOURCE: Myles IA et al. JCI Insight. 2018 May 3. doi: 10.1172/jci.insight.120608.
The Beginning Assessment of Cutaneous Treatment Efficacy of Roseomonas in Atopic Dermatitis trial; BACTERiAD I/II study, an open-label phase I/II trial, first looked at the therapeutic use of R. mucosa in 10 adults aged 18 years or older. Three sucrose mixtures with increasing doses of live R. mucosa bacteria were topically applied to two body areas – the antecubital fossae and a body surface of their choice – twice per week for 2 weeks per dose. At 6 weeks, the patients stopped using the mixtures and followed a 4-week washout phase.
Treatment was found to reduce mean antecubital SCORAD (SCORing Atopic Dermatitis) scores by 59.8%. Reduction in pruritus was even more pronounced, with a mean decrease of 78.5%. Treating the hands did not improve disease severity, even in patients whose symptoms improved in other body areas. One explanation may be the increased exposure of the hands to topical antimicrobials and environmental exposures, the researchers noted.
With the success in the adult cohort, the researchers enrolled five children aged 7-17 years in the study. These patients were treated twice weekly for 16 weeks. The pediatric patients experienced a mean decrease of 70.3% in their SCORAD scores. The mean decrease in pruritis was 78.8%.
All adults who responded continued to report improved symptoms after the washout period. The pediatric patients are now being evaluated in a washout period.
Four patients did not respond; three of them had a family history of AD persisting into adulthood. “The association between these complex medical histories and the lack of clinical response suggests that differences in heritable host and/or microbial factors may impact treatment responses,” wrote Ian A. Myles, MD, and his colleagues.
“Overall, our findings suggest the safety of topical R. mucosa therapy and justify continuation of our ongoing trial to assess safety and activity in a pediatric cohort of patients with AD. These studies will additionally assess changes in host serum markers, skin metabolomics, and the skin microbiota by culture and genomic methods.”
The researchers noted that expanding to the pediatric population will deepen understanding of topical microbiome transplantation and lay the foundation for placebo-controlled trials to assess efficacy.
This work was supported by the Intramural Research Program of the National Institutes of Allergy and Infectious Diseases and the National Institutes of Health. The researchers had no disclosures.
SOURCE: Myles IA et al. JCI Insight. 2018 May 3. doi: 10.1172/jci.insight.120608.
FROM JCI INSIGHT
Key clinical point: Roseomonas mucosa reduces disease severity.
Major finding: There were reductions in SCORAD scores of 78.5% and 70.3% in the adult and pediatric cohorts, respectively.
Study details: Case study of 10 adult and 5 pediatric patients with atopic dermatitis.
Disclosures: No relevant financial disclosures were reported.
Source: Myles IA et al. JCI Insight. 2018 May 3. doi: 10.1172/jci.insight.120608.
VIDEO: Characteristic flora define intestinal microbiome in scleroderma
SANDESTIN, FLA. – Scleroderma patients appear to have a characteristic microbiome composition, which is consistent in samples taken around the world.
These patients showed decreased populations of beneficial commensal flora and increased populations of proinflammatory species, Elizabeth Volkmann, MD, said at the annual Congress of Clinical Rheumatology.
Furthermore, specific species seem to correlate with specific gastrointestinal symptoms, said Dr. Volkmann of the University of California, Los Angeles. “Features also unexpectedly overlap with the consortium typical for Crohn’s disease, a disease with both inflammatory and fibrosing phenotype,” she said.
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Her recent exploration of this topic included 17 patients with scleroderma and GI symptoms and 17 matched healthy controls (BMJ Open Gastro. 2017;3:e000134). Everyone underwent a bowel prep and colonoscopy, during which cecum and sigmoid mucosal lavage samples were obtained. Those samples underwent RNA sequencing.
In addition to quantifying the species present, Dr. Volkmann sought to associate populations with symptoms. The primary assessment tool was the GIT 2.0, which measures distention/bloating; diarrhea; fecal soilage; constipation; emotional well-being; and social functioning.
Similar to the findings in inflammatory disease states, scleroderma patients had decreased levels of commensal Clostridia, a class of Firmicutes that is established in early infancy and very important in the maintenance of gut homeostasis. They also showed a decreased proportion of Faecalibacterium, a genus with anti-inflammatory activity; this finding has been observed in patients with Crohn’s disease.
Patients also showed relative increases in pathobionts. These are potentially pathological organisms that, under normal circumstances, live symbiotically. Janet Chow, PhD, who coined the term in a 2011 paper, said these species are typically proinflammatory (Curr Opin Immunol. 2011 Aug; 23[4]:473-80).
“Organisms proposed as pathobionts are associated with chronic inflammatory conditions – unlike opportunistic pathogens, which often cause acute infections and are typically acquired from the environment or other parts of the body. In addition, pathobionts are innocuous to the host under normal conditions,” wrote Dr. Chow of the California Institute of Technology, Pasadena.
In Dr. Volkmann’s study, Bifidobacterium and Lactobacillus, which are usually reduced in proinflammatory disorders, were relatively abundant in patients, compared with controls.
She noted specific associations with both symptoms. Parabacteroides and Enterobacteriaceae were associated with increased constipation. Prevotella was associated with increased diarrhea and increased distention/bloating.
Her results are consistent with a Swedish study (Arthritis Res Ther. 2016 Nov 1;18[1]:278) and three Italian studies conducted in Rome, Milan, and Piacenza.
“It’s fascinating that we seem to be identifying a consistent microbiome profile for scleroderma patients,” Dr. Volkmann said.
Dr. Volkmann had no relevant financial disclosures.
SANDESTIN, FLA. – Scleroderma patients appear to have a characteristic microbiome composition, which is consistent in samples taken around the world.
These patients showed decreased populations of beneficial commensal flora and increased populations of proinflammatory species, Elizabeth Volkmann, MD, said at the annual Congress of Clinical Rheumatology.
Furthermore, specific species seem to correlate with specific gastrointestinal symptoms, said Dr. Volkmann of the University of California, Los Angeles. “Features also unexpectedly overlap with the consortium typical for Crohn’s disease, a disease with both inflammatory and fibrosing phenotype,” she said.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Her recent exploration of this topic included 17 patients with scleroderma and GI symptoms and 17 matched healthy controls (BMJ Open Gastro. 2017;3:e000134). Everyone underwent a bowel prep and colonoscopy, during which cecum and sigmoid mucosal lavage samples were obtained. Those samples underwent RNA sequencing.
In addition to quantifying the species present, Dr. Volkmann sought to associate populations with symptoms. The primary assessment tool was the GIT 2.0, which measures distention/bloating; diarrhea; fecal soilage; constipation; emotional well-being; and social functioning.
Similar to the findings in inflammatory disease states, scleroderma patients had decreased levels of commensal Clostridia, a class of Firmicutes that is established in early infancy and very important in the maintenance of gut homeostasis. They also showed a decreased proportion of Faecalibacterium, a genus with anti-inflammatory activity; this finding has been observed in patients with Crohn’s disease.
Patients also showed relative increases in pathobionts. These are potentially pathological organisms that, under normal circumstances, live symbiotically. Janet Chow, PhD, who coined the term in a 2011 paper, said these species are typically proinflammatory (Curr Opin Immunol. 2011 Aug; 23[4]:473-80).
“Organisms proposed as pathobionts are associated with chronic inflammatory conditions – unlike opportunistic pathogens, which often cause acute infections and are typically acquired from the environment or other parts of the body. In addition, pathobionts are innocuous to the host under normal conditions,” wrote Dr. Chow of the California Institute of Technology, Pasadena.
In Dr. Volkmann’s study, Bifidobacterium and Lactobacillus, which are usually reduced in proinflammatory disorders, were relatively abundant in patients, compared with controls.
She noted specific associations with both symptoms. Parabacteroides and Enterobacteriaceae were associated with increased constipation. Prevotella was associated with increased diarrhea and increased distention/bloating.
Her results are consistent with a Swedish study (Arthritis Res Ther. 2016 Nov 1;18[1]:278) and three Italian studies conducted in Rome, Milan, and Piacenza.
“It’s fascinating that we seem to be identifying a consistent microbiome profile for scleroderma patients,” Dr. Volkmann said.
Dr. Volkmann had no relevant financial disclosures.
SANDESTIN, FLA. – Scleroderma patients appear to have a characteristic microbiome composition, which is consistent in samples taken around the world.
These patients showed decreased populations of beneficial commensal flora and increased populations of proinflammatory species, Elizabeth Volkmann, MD, said at the annual Congress of Clinical Rheumatology.
Furthermore, specific species seem to correlate with specific gastrointestinal symptoms, said Dr. Volkmann of the University of California, Los Angeles. “Features also unexpectedly overlap with the consortium typical for Crohn’s disease, a disease with both inflammatory and fibrosing phenotype,” she said.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Her recent exploration of this topic included 17 patients with scleroderma and GI symptoms and 17 matched healthy controls (BMJ Open Gastro. 2017;3:e000134). Everyone underwent a bowel prep and colonoscopy, during which cecum and sigmoid mucosal lavage samples were obtained. Those samples underwent RNA sequencing.
In addition to quantifying the species present, Dr. Volkmann sought to associate populations with symptoms. The primary assessment tool was the GIT 2.0, which measures distention/bloating; diarrhea; fecal soilage; constipation; emotional well-being; and social functioning.
Similar to the findings in inflammatory disease states, scleroderma patients had decreased levels of commensal Clostridia, a class of Firmicutes that is established in early infancy and very important in the maintenance of gut homeostasis. They also showed a decreased proportion of Faecalibacterium, a genus with anti-inflammatory activity; this finding has been observed in patients with Crohn’s disease.
Patients also showed relative increases in pathobionts. These are potentially pathological organisms that, under normal circumstances, live symbiotically. Janet Chow, PhD, who coined the term in a 2011 paper, said these species are typically proinflammatory (Curr Opin Immunol. 2011 Aug; 23[4]:473-80).
“Organisms proposed as pathobionts are associated with chronic inflammatory conditions – unlike opportunistic pathogens, which often cause acute infections and are typically acquired from the environment or other parts of the body. In addition, pathobionts are innocuous to the host under normal conditions,” wrote Dr. Chow of the California Institute of Technology, Pasadena.
In Dr. Volkmann’s study, Bifidobacterium and Lactobacillus, which are usually reduced in proinflammatory disorders, were relatively abundant in patients, compared with controls.
She noted specific associations with both symptoms. Parabacteroides and Enterobacteriaceae were associated with increased constipation. Prevotella was associated with increased diarrhea and increased distention/bloating.
Her results are consistent with a Swedish study (Arthritis Res Ther. 2016 Nov 1;18[1]:278) and three Italian studies conducted in Rome, Milan, and Piacenza.
“It’s fascinating that we seem to be identifying a consistent microbiome profile for scleroderma patients,” Dr. Volkmann said.
Dr. Volkmann had no relevant financial disclosures.
REPORTING FROM CCR 18