One Hundred and FOURTH issue
February 18th, 2026
Acral melanoma - the ultimate stealth operator
Acral lentiginous melanoma (ALM) is a rare melanoma subtype arising on the palms, soles, and nails and, unlike cutaneous melanoma (CM), is not strongly associated with UV exposure. AM disproportionately affects patients with darker skin types and often has worse outcomes due to delayed diagnosis and limited therapeutic targets. Risk factors remain poorly defined, particularly in groups such as US veterans with unique occupational and environmental exposures. This nested case-control study used nationwide Veterans Affairs data (2000–2024) to identify demographic, environmental, and clinical risk factors for ALM compared with CM and melanoma-free controls.
What did they find?
Acral lentiginous melanoma (ALM) is a rare melanoma subtype arising on the palms, soles, and nails and, unlike cutaneous melanoma (CM), is not strongly associated with UV exposure. AM disproportionately affects patients with darker skin types and often has worse outcomes due to delayed diagnosis and limited therapeutic targets. Risk factors remain poorly defined, particularly in groups such as US veterans with unique occupational and environmental exposures. This nested case-control study used nationwide Veterans Affairs data (2000–2024) to identify demographic, environmental, and clinical risk factors for ALM compared with CM and melanoma-free controls.
What did they find?
- Agent Orange exposure was associated with higher odds of ALM compared with CM (AOR 1.31) and compared with melanoma-free controls (AOR 1.27).
- Marked disparities were observed for Black veterans (AOR 41.20 vs CM; 1.54 vs controls), Hispanic veterans (AOR 7.77 vs CM; 2.12 vs controls), and women (AOR 2.31 vs CM; 2.08 vs controls).
- Smoking was associated with lower odds of ALM compared with melanoma-free controls (AOR 0.50) and CM (AOR 0.65).
There’s more to morphea than just scleroderma!
Localized scleroderma, or morphea, is an autoimmune condition that causes hardening of the skin and sometimes deeper tissues. Morphea has been linked to a higher likelihood of other autoimmune diseases, but it is less clear which subtypes carry the highest risk and what comorbidities are most common. This study evaluated morphea subtypes and associated comorbidities in 155 patients in Southwest Finland.
What did they find?
Localized scleroderma, or morphea, is an autoimmune condition that causes hardening of the skin and sometimes deeper tissues. Morphea has been linked to a higher likelihood of other autoimmune diseases, but it is less clear which subtypes carry the highest risk and what comorbidities are most common. This study evaluated morphea subtypes and associated comorbidities in 155 patients in Southwest Finland.
What did they find?
- The most common subtype was limited plaque-type morphea (71; 45.8%), followed by generalized morphea (57; 36.8%). Concurrent systemic sclerosis was rare (3; 1.9%).
- 59 concomitant autoimmune diseases were identified in 45 patients (29.0%), most commonly autoimmune thyroid disease (23; 14.8%).
- 27 malignancies were identified in 23 of 155 patients (14.8%); the most common was breast cancer (11; 7.1%).
- Most malignancies (26 of 27) occurred in adult-onset morphea, but this difference was not statistically significant.
Upper vs lower limb ALM: different travel routes.
Acral lentiginous melanoma (ALM) is an uncommon melanoma subtype arising on the palms, soles, and nail units. While early-stage melanoma typically spreads first via lymphatics, some ALMs develop distant metastasis without nodal involvement, and predictors of the first metastatic “route” remain unclear. This retrospective cohort study analyzed 281 early-stage ALM cases with photo-confirmed anatomic location (upper vs lower limb) to compare first metastasis patterns and site-specific prognosis.
What did they find?
Main Takeaway: In early-stage ALM, anatomic site predicts the first metastatic pathway. Lower-limb, especially toenail, tumors more often progress first to lymph nodes, while upper-limb, especially fingernail, tumors more often develop early distant metastasis, supporting site-specific surveillance strategies.
Acral lentiginous melanoma (ALM) is an uncommon melanoma subtype arising on the palms, soles, and nail units. While early-stage melanoma typically spreads first via lymphatics, some ALMs develop distant metastasis without nodal involvement, and predictors of the first metastatic “route” remain unclear. This retrospective cohort study analyzed 281 early-stage ALM cases with photo-confirmed anatomic location (upper vs lower limb) to compare first metastasis patterns and site-specific prognosis.
What did they find?
- Upper-limb ALM had less first lymph node metastasis (10.8% vs 22.7%, P = 0.021) but more first distant metastasis (14.5% vs 4.5%, P = 0.004) than lower-limb ALM.
- First lung metastasis was higher in upper-limb ALM (8.4% vs 2.5%, P = 0.046).
- Overall outcomes were similar by site, but upper-limb ALM had worse systemic metastasis–free survival (P = 0.009), while lower-limb ALM had worse lymph node progression–free survival (P = 0.026).
- Upper-limb location predicted earlier systemic spread (HR 4.651, P = 0.003), as did ulceration (HR 4.904, P = 0.005) and lymphovascular invasion (HR 24.108, P < 0.001).
Main Takeaway: In early-stage ALM, anatomic site predicts the first metastatic pathway. Lower-limb, especially toenail, tumors more often progress first to lymph nodes, while upper-limb, especially fingernail, tumors more often develop early distant metastasis, supporting site-specific surveillance strategies.
Itch happens… especially in patients with moderate-to-severe AA.
Alopecia areata (AA) commonly co-exists with other immune-mediated diseases, but how AA severity relates to the risk of atopic dermatitis (AD) is less clear. Using U.S. Merative MarketScan claims data, this large real-world cohort study examined the prevalence, incidence, and relative risk of AD among more than 11,000 adolescents and adults with AA, stratified by AA severity.
What did they find?
Alopecia areata (AA) commonly co-exists with other immune-mediated diseases, but how AA severity relates to the risk of atopic dermatitis (AD) is less clear. Using U.S. Merative MarketScan claims data, this large real-world cohort study examined the prevalence, incidence, and relative risk of AD among more than 11,000 adolescents and adults with AA, stratified by AA severity.
What did they find?
- Baseline AD prevalence was 3.2% overall and increased with AA severity (4.9% in moderate to severe AA vs 2.7% in mild AA).
- 7.6% of adolescents with AA had AD at baseline, with prevalence exceeding 14% in those with moderate to severe disease.
- Moderate to severe AA was associated with a 78% higher risk of incident AD compared with mild AA (adjusted HR 1.8).
- Patients diagnosed by dermatologists had higher documented rates of comorbid AD regardless of AA severity.
- Mean time to AD diagnosis was about 2 years after AA diagnosis.
Turning shortages into solutions: Strengthening dermatology training in resource-limited regions
Skin disease affects nearly 5 billion people globally and has a disproportionate burden in low- and middle-income countries (LMICs), yet it has long been underprioritized in global health. In 2025, the World Health Assembly elevated skin disease to a global public health priority and the Lancet Commission on Skin Health was established to develop a coordinated framework and action plan. In 2024, the International League of Dermatological Societies launched the SkinObservatory study, which aims to provide the first systematic global assessment of dermatology workforce capacity and access to care across all World Health Organization member countries.
What did they find?
Main Takeaway: Global access to dermatological care is a health equity crisis driven by workforce and training program shortages, particularly in LMICs in the African and South-East regions. Ensuring equitable access to skin health requires expanding training of dermatology providers and increased investment in resource-limited communities.
Skin disease affects nearly 5 billion people globally and has a disproportionate burden in low- and middle-income countries (LMICs), yet it has long been underprioritized in global health. In 2025, the World Health Assembly elevated skin disease to a global public health priority and the Lancet Commission on Skin Health was established to develop a coordinated framework and action plan. In 2024, the International League of Dermatological Societies launched the SkinObservatory study, which aims to provide the first systematic global assessment of dermatology workforce capacity and access to care across all World Health Organization member countries.
What did they find?
- Data were collected from 158 countries, representing 96.7% of the world’s population.
- An estimated 175,633 dermatologists worldwide (95% CI 173,598–177,668).
- 62% of the dermatology workforce is female and 79% of dermatologists work in urban areas.
- Mean workforce density was 2.66 dermatologists per 100,000 people. Nine countries reported no dermatologists, while Greece had the highest density (13.96 per 100,000).
- 89% of countries require both medical school and dermatology residency to practice as a dermatologist, but only 79% have domestic dermatology training programs.
- In low- and middle-income countries, 92% of dermatologists obtain training abroad.
- 89% of low-income countries reported dermatologist shortages, compared with 57% of high-income countries.
- The authors estimate a workforce density of ≥5.6 per 100,000 is needed for adequate access. Only 14% of countries met this threshold, with none in the African or South-East regions.
Main Takeaway: Global access to dermatological care is a health equity crisis driven by workforce and training program shortages, particularly in LMICs in the African and South-East regions. Ensuring equitable access to skin health requires expanding training of dermatology providers and increased investment in resource-limited communities.
Getting to the root of these pustules!
Eosinophilic pustular folliculitis (EPF) is a rare, recurrent inflammatory skin disorder characterized by pruritic pustular lesions that can significantly affect quality of life. Early recognition is important in infants because EPF can be difficult to diagnose due to variable presentation and overlap with other pustular dermatoses. This systematic review and meta-analysis evaluated the epidemiology, clinical features, and treatment outcomes of infancy-associated EPF using observational studies, case series, and case reports.
What did they find?
Eosinophilic pustular folliculitis (EPF) is a rare, recurrent inflammatory skin disorder characterized by pruritic pustular lesions that can significantly affect quality of life. Early recognition is important in infants because EPF can be difficult to diagnose due to variable presentation and overlap with other pustular dermatoses. This systematic review and meta-analysis evaluated the epidemiology, clinical features, and treatment outcomes of infancy-associated EPF using observational studies, case series, and case reports.
What did they find?
- EPF predominantly affects male infants (male prevalence 80.58%, 95% CI 71.60–88.20), with mean onset at 11.16 months (95% CI 5.11–17.22).
- The scalp was the most common site (92.10%, 95% CI 71.25–100.00), with less frequent involvement of the limbs, trunk, and face.
- Topical corticosteroids were the most commonly used treatment, but no clearly superior therapy was identified due to limited and variable pooled response data.
- Most studies had low risk of bias (73%), though heterogeneity and reliance on small observational studies limit the strength of conclusions.
Treating scleroderma-induced microstomia with CO2 laser assisted delivery of hyaluronidase
Innovations in Dermatology
Innovations in Dermatology
Sculpting scleroderma smiles with strategic CO₂
Scleroderma-induced microstomia (SIM) is a consequence of perioral fibrosis that limits mouth opening and can cause discomfort and difficulty with eating, speaking, and oral hygiene. Standard approaches include intradermal hyaluronidase and ablative lasers. This study evaluated CO2 laser-assisted delivery of hyaluronidase (LADDH) in three systemic sclerosis patients using changes in mouth opening measurements and patient-reported outcomes (the Short Form-36 and Mouth Handicap in Systemic Sclerosis questionnaires).
What did they find?
Scleroderma-induced microstomia (SIM) is a consequence of perioral fibrosis that limits mouth opening and can cause discomfort and difficulty with eating, speaking, and oral hygiene. Standard approaches include intradermal hyaluronidase and ablative lasers. This study evaluated CO2 laser-assisted delivery of hyaluronidase (LADDH) in three systemic sclerosis patients using changes in mouth opening measurements and patient-reported outcomes (the Short Form-36 and Mouth Handicap in Systemic Sclerosis questionnaires).
What did they find?
- Topical anesthetic was applied to the upper and lower cutaneous lips, including the nasolabial folds, marionette lines, and mental crease.
- A non-overlapping CO2 laser was used to ablate the treated areas, followed by application of 150 units of hyaluronidase evenly across the ablated skin. This was repeated three times at 4–6 week intervals.
- Mouth handicap scores decreased from 26 to 18 by study end.
Physical functioning scores increased from 26.9 to 37.0, while emotional functioning changed minimally (52.9 to 53.2). - Mean interincisal, intercommissural, and intervermillion distances improved.
- Adverse events included pain and perioral erythema, with no bleeding or infection.
DERMLITE Dermoscopy QUESTION OF THE WEEK
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Copyright © 2025 - All Rights Reserved.