eightY-Fourth issue
April 30, 2025
Acne relapse and isotretinoin retrial in patients with acne
JAMA Dermatology
JAMA Dermatology
When it’s not about how much you take each day – but how long you stay in the game.
Acne is a chronic and often relapsing inflammatory condition, and isotretinoin is the only medical therapy proven to induce long-term remission. However, recurrence and the need for retrial is common. Understanding whether total cumulative dosage or daily dose is more predictive of relapse is essential for optimizing treatment plans while minimizing adverse effects. This retrospective cohort study of nearly 20,000 patients used claims data to assess the rates of acne relapse and isotretinoin retrial, identifying patient and treatment factors associated with these outcomes.
What did they find?
Main Takeaway: Higher cumulative dosage of isotretinoin protects against relapse and retrial, while daily dose plays a lesser role. Acne relapse remains common, particularly among female patients, underscoring the need for personalized treatment planning. Daily dosing can likely be tailored to patient preferences as long as total cumulative dosage is sufficient.
Acne is a chronic and often relapsing inflammatory condition, and isotretinoin is the only medical therapy proven to induce long-term remission. However, recurrence and the need for retrial is common. Understanding whether total cumulative dosage or daily dose is more predictive of relapse is essential for optimizing treatment plans while minimizing adverse effects. This retrospective cohort study of nearly 20,000 patients used claims data to assess the rates of acne relapse and isotretinoin retrial, identifying patient and treatment factors associated with these outcomes.
What did they find?
- 22.5% of patients relapsed after completing a ≥4-month isotretinoin course and 8.2% required a retrial of isotretinoin.
- Higher cumulative dosage (mg/kg) was associated with decreased rates of both relapse and retrial.
- Daily dose was not associated with reduced risk of relapse or retrial in patients receiving conventional or high cumulative dosages.
- Female sex was associated with increased risk of relapse (HR, 1.43) but decreased likelihood of retrial (HR, 0.68).
- Second isotretinoin courses tended to be shorter and lower-dose than first courses.
Main Takeaway: Higher cumulative dosage of isotretinoin protects against relapse and retrial, while daily dose plays a lesser role. Acne relapse remains common, particularly among female patients, underscoring the need for personalized treatment planning. Daily dosing can likely be tailored to patient preferences as long as total cumulative dosage is sufficient.
Long-term evolution of prepubertal-onset anogenital lichen sclerosus: A 35-year retrospective, cross-sectional, single-center study
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
It isn’t just a phase – ALS, we’re looking at you.
Lichen sclerosus (LS) is a chronic inflammatory dermatosis that primarily affects the anogenital region, most commonly in postmenopausal women; however, approximately 15% of cases occur before puberty. Although LS was previously considered self-limiting after puberty, emerging evidence suggests that prepubertal-onset anogenital LS (ALS) may persist into adulthood. Potential long-term sequelae include persistent disease activity, anatomical changes, sexual dysfunction, reduced quality of life (QOL), and an increased risk of vulvar squamous cell carcinoma. This 35-year, single-center cross-sectional study aimed to assess postpubertal outcomes in individuals diagnosed with prepubertal ALS, with a particular focus on disease persistence and QOL impact, through retrospective chart review and follow-up via telephone questionnaire and in-person evaluation.
What did they find?
Main Takeaway: Prepubertal ALS often persists after puberty, with the majority of patients showing clinical signs of disease despite a lack of symptoms and minimal impact on quality of life.
Lichen sclerosus (LS) is a chronic inflammatory dermatosis that primarily affects the anogenital region, most commonly in postmenopausal women; however, approximately 15% of cases occur before puberty. Although LS was previously considered self-limiting after puberty, emerging evidence suggests that prepubertal-onset anogenital LS (ALS) may persist into adulthood. Potential long-term sequelae include persistent disease activity, anatomical changes, sexual dysfunction, reduced quality of life (QOL), and an increased risk of vulvar squamous cell carcinoma. This 35-year, single-center cross-sectional study aimed to assess postpubertal outcomes in individuals diagnosed with prepubertal ALS, with a particular focus on disease persistence and QOL impact, through retrospective chart review and follow-up via telephone questionnaire and in-person evaluation.
What did they find?
- Of the 65 patients originally diagnosed with prepubertal ALS, 18% had a concurrent autoimmune disease and 29% had a family history of autoimmunity; vitiligo was present in 4% of cases at other anatomic locations.
- At follow-up, 47% of patients were asymptomatic post-menarche, though pruritus (37%) and dyspareunia (40% of sexually active patients) were reported and 56% of patients were still using treatment, most commonly clobetasol propionate.
- On examination, 92% of those examined still showed clinical signs of disease, most commonly atrophy and hypopigmentation.
- No cases of vulvar cancer were reported, and four patients had successful pregnancies, though one experienced ALS deterioration during pregnancy.
- Quality of life was not impacted by 73% of respondents, with a mean DLQI score of 1.73 (indicating no effect on quality of life).
Main Takeaway: Prepubertal ALS often persists after puberty, with the majority of patients showing clinical signs of disease despite a lack of symptoms and minimal impact on quality of life.
Evaluation of benzene presence and formation in benzoyl peroxide drug products
Journal of Investigative Dermatology
Journal of Investigative Dermatology
Say no to benzene in BPO!
Benzoyl peroxide (BPO) is an active ingredient used in a variety of over the counter and prescription topical drugs for acne and rosacea. Benzene, a known carcinogen, is a degradation product of BPO. This study evaluated the levels of benzene in BPO products at various temperatures, and upon exposure to ultraviolet (UV) light.
What did they find?
Main Takeaway: Benzoyl peroxide products may contain or form unsafe amounts of benzene when exposed to high temperatures or UV light during use and transportation.
Benzoyl peroxide (BPO) is an active ingredient used in a variety of over the counter and prescription topical drugs for acne and rosacea. Benzene, a known carcinogen, is a degradation product of BPO. This study evaluated the levels of benzene in BPO products at various temperatures, and upon exposure to ultraviolet (UV) light.
What did they find?
- Of the 111 BPO products tested, 34% surpassed the FDA’s allowable limit of benzene levels at room temperature.
- Storing Epsolay, a prescription BPO product, at cold temperatures decreased benzene formation, while storage at higher temperatures (50 °C) produced 9 parts per million of benzene per day.
- Exposure of BPO to UVA/B light produced 4.36 parts per billion of benzene per hour.
Main Takeaway: Benzoyl peroxide products may contain or form unsafe amounts of benzene when exposed to high temperatures or UV light during use and transportation.
Clinicopathologic features of PRAME-Positive common melanocytic nevi: A case-control study
Journal of Dermatopathology
Journal of Dermatopathology
Blame it on PRAME
Preferentially Expressed Antigen in Melanoma (PRAME) is a relatively sensitive and specific immunohistochemical marker for melanoma; however, its expression in certain melanocytic nevi limits its diagnostic specificity. In this retrospective study, researchers compared the histologic features of PRAME-positive nevi (PPN, n=41) and PRAME-negative nevi (PNN, n=43). Three dermatopathologists, blinded to PRAME status, independently reviewed all samples, and their assessments were compared to the original pathology diagnoses.
What did they find?
Main Takeaway: Melanocytic nevi demonstrating severe solar elastosis and a lentiginous growth pattern are more likely to show PRAME positivity. Awareness of PRAME status may bias pathologists toward classifying nevi with minimal or mild atypia as severely atypical.
Preferentially Expressed Antigen in Melanoma (PRAME) is a relatively sensitive and specific immunohistochemical marker for melanoma; however, its expression in certain melanocytic nevi limits its diagnostic specificity. In this retrospective study, researchers compared the histologic features of PRAME-positive nevi (PPN, n=41) and PRAME-negative nevi (PNN, n=43). Three dermatopathologists, blinded to PRAME status, independently reviewed all samples, and their assessments were compared to the original pathology diagnoses.
What did they find?
- Solar elastosis was present in 32 of 41 PPN cases (including 13 severe cases), with greater severity significantly associated with PRAME positivity (P=0.02).
- A lentiginous epidermal growth pattern was significantly associated with PPN (P=0.01), while a pure nested growth pattern was more common in PNN.
- PRAME positivity was significantly associated with an original diagnosis of severe atypia (P<0.001); however, this association was not observed when reviewed by PRAME-masked dermatopathologists.
- 54% of PPN were diagnosed with severe atypia on original review, compared to only 7% when reviewed without knowledge of PRAME status, suggesting potential diagnostic bias.
Main Takeaway: Melanocytic nevi demonstrating severe solar elastosis and a lentiginous growth pattern are more likely to show PRAME positivity. Awareness of PRAME status may bias pathologists toward classifying nevi with minimal or mild atypia as severely atypical.
Atypical fibroxanthoma and pleomorphic dermal sarcoma: A retrospective review and survival analysis
Journal of Dermatologic Surgery
Journal of Dermatologic Surgery
Not all skin bumps are created equal
Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are rare, aggressive skin tumors with variable prognoses. This retrospective study analyzed 44 patients (34 AFX, 10 PDS) over a ten-year period at a single institution to identify factors associated with survival and recurrence.
What did they find?
Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are rare, aggressive skin tumors with variable prognoses. This retrospective study analyzed 44 patients (34 AFX, 10 PDS) over a ten-year period at a single institution to identify factors associated with survival and recurrence.
What did they find?
- PDS was associated with significantly worse outcomes, with an overall mortality rate of 60% compared to 26.5% for AFX (P=0.0031).
- PDS lesions were larger at presentation (mean 8.9 cm² vs. 2.4 cm², P<0.0001).
- Recurrence rates were significantly higher for PDS (50%) than for AFX (5.9%, P=0.0039).
- Female gender (HR=22.18), immunosuppression (HR=5.02), and perineural invasion (HR=78.46) were significant predictors of recurrence or death.
Cryolipolysis for reducing local adipose tissue in the abdominal area: evaluating the efficacy and safety in a randomized pilot study
Journal of Cutaneous Dermatology
Journal of Cutaneous Dermatology
Freeze Fat, Not Confidence: Targeted Results with Cryolipolysis
Cryolipolysis is a non-invasive fat reduction technique that exploits the cold sensitivity of adipocytes to selectively reduce excess fat. This study evaluated the efficacy of the Cryo Angel 360 Small device in reducing abdominal fat in women. Fifteen participants were assigned to either a study group (n=9) or control group (n=6). The study group underwent three cryolipolysis sessions at −8°C for 45 minutes, spaced six weeks apart. Body composition was assessed via bioelectrical impedance analysis (BIA), along with measurements of waist, abdominal, and hip circumference, percent body fat, and total body mass, collected before treatment initiation and one month after the final session.
What did they find?
Cryolipolysis is a non-invasive fat reduction technique that exploits the cold sensitivity of adipocytes to selectively reduce excess fat. This study evaluated the efficacy of the Cryo Angel 360 Small device in reducing abdominal fat in women. Fifteen participants were assigned to either a study group (n=9) or control group (n=6). The study group underwent three cryolipolysis sessions at −8°C for 45 minutes, spaced six weeks apart. Body composition was assessed via bioelectrical impedance analysis (BIA), along with measurements of waist, abdominal, and hip circumference, percent body fat, and total body mass, collected before treatment initiation and one month after the final session.
What did they find?
- After three months, body fat reduction in the study group approached statistical significance compared to the control group (P=0.05).
- BMI significantly decreased in the study group (27.69 ± 3.32 to 27.08 ± 2.58) and increased in the control group (25.27 ± 2.45 to 25.98 ± 2.60) (P<0.001).
- Abdominal circumference decreased in the study group and increased in the control group, though the difference was not statistically significant.
- The study group demonstrated a 0.98% reduction in mean body fat and a 1.06 cm decrease in abdominal circumference after treatment.
Digital photography guide for dermatologists with special considerations for diverse populations
JAMA Dermatology (Skin of Color)
JAMA Dermatology (Skin of Color)
Clinical photography struggles... until you level up
High-quality photography is important for diagnosing, monitoring, and teaching about dermatologic conditions. This article reviewed best practices for photographing skin of color, highlighting both technical and humanistic approaches to improve image quality and patient experience.
What did they find?
High-quality photography is important for diagnosing, monitoring, and teaching about dermatologic conditions. This article reviewed best practices for photographing skin of color, highlighting both technical and humanistic approaches to improve image quality and patient experience.
What did they find?
- Historically, photography technologies were calibrated to lighter skin, leading to challenges capturing skin of color accurately.
- Royal blue, white, and gray backgrounds enhance contrast for darker skin tones, while soft, diffuse lighting minimize glare and distortion.
- Cross-polarized light improved the visualization of erythema and pigmentary changes in skin color but could obscure lesion texture.
- Patient consent, cultural sensitivity, and clear communication were emphasized as critical parts of ethical dermatologic photography.
Podcasts are a growing, accessible source of information on skin diseases for patients and healthcare providers. Dermatologists familiar with them can better guide patients to reliable content. This study analyzed the content and objectives of popular eczema and acne podcasts. In September 2023, the first three episodes of 25 English-language podcasts, identified from the top 50 search results for "acne" and "eczema" on major platforms, were reviewed for accuracy based on American Academy of Dermatology guidelines.
What did they find?
Main Takeaway: This study highlights the prevalence of misinformation about acne and eczema on popular podcasts, which may shape patient beliefs and treatment choices before clinical encounters. As a result, clinicians may need to spend more time addressing misconceptions and guiding patients toward evidence-based care and educational resources.
What did they find?
- All (100%) of the evaluated podcasts were intended to provide educational content to listeners.
- Most acne and eczema podcasts (84%) featured personal anecdotes, with many hosted by non-medical professionals such as patients, "health coaches," or organizations, while only a minority featured dermatologists.
- Misinformation was present in 56% of the podcasts, and 32% promoted advice contrary to dermatologic standards.
- Content in only 7 out of 25 total podcasts, all featuring dermatologists, aligned with AAD treatment guidelines.
Main Takeaway: This study highlights the prevalence of misinformation about acne and eczema on popular podcasts, which may shape patient beliefs and treatment choices before clinical encounters. As a result, clinicians may need to spend more time addressing misconceptions and guiding patients toward evidence-based care and educational resources.
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