SECOND ISSUE
January 26, 2022
Assessing the Potential for Patient-led Surveillance After Treatment of Localized Melanoma (MEL-SELF)
JAMA Dermatology
Ever wondered if patients actually do their own skin self-examinations once you ask them to? And are they even effective enough for us to be asking patients to do them? Well here’s your chance to find out. After treatment of a localized melanoma, patients are encouraged to follow-up via clinician-led surveillance. Studies have shown that this varies from provider to provider and has some associated detrimental effects, such as patient anxiety and poor resource utilization. Patient-led surveillance is an alternative, but its efficacy has not yet been studied. With increasing amounts of telehealth after the COVID-19 pandemic, determining the efficacy of patient-led versus clinician-led examinations could alter the visit type needed. In this pilot study of a randomized clinical trial (RCT) of patients previously treated for melanoma, nine physicians from 2 melanoma specialty clinics and 1 primary care skin cancer clinic recruited participants. 100 patients were randomized to either patient-led or clinician-led surveillance for 6 months. The patient-led surveillance included education on performing a skin exam, reminders, a mobile dermatoscope attached to their smartphone, and a smartphone application for tracking. After 6 months, the intervention group had higher levels of confidence and knowledge of skin self-examination (SSE), more positive attitudes and beliefs toward SSE, and were more likely to engage in SSE compared with the control group. Patients in the intervention group were more likely to perform SSE at least every 2 months (odds ratio [OR], 3.5; 95% CI, 0.9-14.0) and examine all body areas (OR, 2.2; 95% CI, 0.8-5.7). They were also more likely to use a mirror to check difficult-to-see areas, such as the back (OR, 2.6; 95% CI, 0.8-7.8) and to do SSE with their skin-check partner (OR, 2.4; 95% CI, 0.4-14.3). There was no evidence of a difference in psychological outcomes between the randomized groups. Participants in the intervention group attended more clinic visits compared with those in the control group (risk ratio [RR], 1.5; 95% CI, 1.1-2.1). Overall, the patient-led surveillance demonstrated an increase in understanding of the examination, quality of the examination, and continuity of care without any adverse psychological effects. The study is limited by small size, but suggests that a larger trial would create more robust results. Based on the results, it seems safe to say that dermatologists should keep encouraging patient-led surveillance after a diagnosis of melanoma.
What should dermatologists know about adverse pregnancy and maternal outcomes in women with hidradenitis suppurativa?
Journal of American Academy of Dermatology
When you think OBGYN is behind you, but then you realize…it’s not! Hidradenitis supurativa (HS), which presents with recurrent boils most commonly in the intertriginous regions, disproportionately affects women of childbearing age. HS is also typically associated with multiple comorbidities that may impact pregnancy outcomes, including diabetes, obesity, thyroid disease and polycystic ovary syndrome. While dermatologists commonly treat this challenging disease, little is known about the implications of HS on pregnancy-related and maternal outcomes. In this retrospective cohort study using a multihealth system data and analytics research program, 1,862 pregnancies among 1,600 women with HS were compared to 64,218 pregnancies among 53,278 women without HS in order to evaluate the influence of comorbidities in HS that may affect pregnancy-related outcomes. The analysis took place between January 1, 2011 to September 30, 2015. Pregnant women with HS were found to have increased risk of spontaneous abortion (15.5% v 11.3%; 37% increase), preterm birth (9.1% v 6.7%; 25% increase), gestational diabetes (11.6% v 8.4%; 59% increase), gestational hypertension (6.1% v 4.4%; 38% increase), preeclampsia (6.6% v 3.8%; 57% increase), and ceaseran section (34.2% v 27.1%; 19% increase) compared to women without HS. In the fully adjusted model, women with HS had a higher likelihood of having a spontaneous abortion (odds ratio, 1.20; 95% CI, 1.04-1.38), gestational diabetes mellitus (odds ratio, 1.26; 95% CI, 1.07-1.48), and cesarean section (odds ratio, 1.09; 95% CI, 1.004-1.17). Based on this study, HS is associated with adverse pregnancy and maternal outcomes, although certain adverse outcomes may be mitigated by early intervention and reduction of comorbidities. As dermatologists are intimately involved in the care of HS patients, understanding the impact of HS on pregnancy related outcomes should help with counseling and may help reduce the adverse events for these patients. Limitations include the inability to evaluate disease severity, duration and treatment status on outcomes.
Investigating the rare, but serious, metastatic SCCs
American Journal of Dermatopathology
Diagnosis: not melanoma. Not so bad, right? Not so fast. Squamous cell carcinoma (SCC) is the second most common skin cancer in the United States. While only 2-5% metastasize, those that do are concerning. Knowledge of the genes involved in SCC metastasis are crucial in understanding tumor growth. LRP1B is a low-density lipoprotein receptor believed to function as a tumor-suppressor. In other cancers, LRP1B expression has aided in identifying immunotherapy response. The University of Nebraska’s Department of Pathology identified 14 cases of SCC with matched lymph node metastasis and studied sample expression of LRP1B. Results showed a positive correlation between patient age and abundance of LRP1B in a given sample (R2=0.44, p=0.01). H-scores quantifying LRP1B expression were significantly higher in samples that included perineural invasion (without PNI=102, with PNI=161; p=0.03). This study is limited in its small sample size; future studies are necessary to further understand the consequences of LRP1B mutations. This study identifies LRP1B mutations in metastatic SCC and has the potential to predict future immunotherapy response.
JAMA Dermatology
Ever wondered if patients actually do their own skin self-examinations once you ask them to? And are they even effective enough for us to be asking patients to do them? Well here’s your chance to find out. After treatment of a localized melanoma, patients are encouraged to follow-up via clinician-led surveillance. Studies have shown that this varies from provider to provider and has some associated detrimental effects, such as patient anxiety and poor resource utilization. Patient-led surveillance is an alternative, but its efficacy has not yet been studied. With increasing amounts of telehealth after the COVID-19 pandemic, determining the efficacy of patient-led versus clinician-led examinations could alter the visit type needed. In this pilot study of a randomized clinical trial (RCT) of patients previously treated for melanoma, nine physicians from 2 melanoma specialty clinics and 1 primary care skin cancer clinic recruited participants. 100 patients were randomized to either patient-led or clinician-led surveillance for 6 months. The patient-led surveillance included education on performing a skin exam, reminders, a mobile dermatoscope attached to their smartphone, and a smartphone application for tracking. After 6 months, the intervention group had higher levels of confidence and knowledge of skin self-examination (SSE), more positive attitudes and beliefs toward SSE, and were more likely to engage in SSE compared with the control group. Patients in the intervention group were more likely to perform SSE at least every 2 months (odds ratio [OR], 3.5; 95% CI, 0.9-14.0) and examine all body areas (OR, 2.2; 95% CI, 0.8-5.7). They were also more likely to use a mirror to check difficult-to-see areas, such as the back (OR, 2.6; 95% CI, 0.8-7.8) and to do SSE with their skin-check partner (OR, 2.4; 95% CI, 0.4-14.3). There was no evidence of a difference in psychological outcomes between the randomized groups. Participants in the intervention group attended more clinic visits compared with those in the control group (risk ratio [RR], 1.5; 95% CI, 1.1-2.1). Overall, the patient-led surveillance demonstrated an increase in understanding of the examination, quality of the examination, and continuity of care without any adverse psychological effects. The study is limited by small size, but suggests that a larger trial would create more robust results. Based on the results, it seems safe to say that dermatologists should keep encouraging patient-led surveillance after a diagnosis of melanoma.
What should dermatologists know about adverse pregnancy and maternal outcomes in women with hidradenitis suppurativa?
Journal of American Academy of Dermatology
When you think OBGYN is behind you, but then you realize…it’s not! Hidradenitis supurativa (HS), which presents with recurrent boils most commonly in the intertriginous regions, disproportionately affects women of childbearing age. HS is also typically associated with multiple comorbidities that may impact pregnancy outcomes, including diabetes, obesity, thyroid disease and polycystic ovary syndrome. While dermatologists commonly treat this challenging disease, little is known about the implications of HS on pregnancy-related and maternal outcomes. In this retrospective cohort study using a multihealth system data and analytics research program, 1,862 pregnancies among 1,600 women with HS were compared to 64,218 pregnancies among 53,278 women without HS in order to evaluate the influence of comorbidities in HS that may affect pregnancy-related outcomes. The analysis took place between January 1, 2011 to September 30, 2015. Pregnant women with HS were found to have increased risk of spontaneous abortion (15.5% v 11.3%; 37% increase), preterm birth (9.1% v 6.7%; 25% increase), gestational diabetes (11.6% v 8.4%; 59% increase), gestational hypertension (6.1% v 4.4%; 38% increase), preeclampsia (6.6% v 3.8%; 57% increase), and ceaseran section (34.2% v 27.1%; 19% increase) compared to women without HS. In the fully adjusted model, women with HS had a higher likelihood of having a spontaneous abortion (odds ratio, 1.20; 95% CI, 1.04-1.38), gestational diabetes mellitus (odds ratio, 1.26; 95% CI, 1.07-1.48), and cesarean section (odds ratio, 1.09; 95% CI, 1.004-1.17). Based on this study, HS is associated with adverse pregnancy and maternal outcomes, although certain adverse outcomes may be mitigated by early intervention and reduction of comorbidities. As dermatologists are intimately involved in the care of HS patients, understanding the impact of HS on pregnancy related outcomes should help with counseling and may help reduce the adverse events for these patients. Limitations include the inability to evaluate disease severity, duration and treatment status on outcomes.
Investigating the rare, but serious, metastatic SCCs
American Journal of Dermatopathology
Diagnosis: not melanoma. Not so bad, right? Not so fast. Squamous cell carcinoma (SCC) is the second most common skin cancer in the United States. While only 2-5% metastasize, those that do are concerning. Knowledge of the genes involved in SCC metastasis are crucial in understanding tumor growth. LRP1B is a low-density lipoprotein receptor believed to function as a tumor-suppressor. In other cancers, LRP1B expression has aided in identifying immunotherapy response. The University of Nebraska’s Department of Pathology identified 14 cases of SCC with matched lymph node metastasis and studied sample expression of LRP1B. Results showed a positive correlation between patient age and abundance of LRP1B in a given sample (R2=0.44, p=0.01). H-scores quantifying LRP1B expression were significantly higher in samples that included perineural invasion (without PNI=102, with PNI=161; p=0.03). This study is limited in its small sample size; future studies are necessary to further understand the consequences of LRP1B mutations. This study identifies LRP1B mutations in metastatic SCC and has the potential to predict future immunotherapy response.
question of the week
NEJM challenge question: Blueberry Muffin" rash in infant
A female infant delivered at term had a “blueberry muffin” rash at birth. Laboratory tests and imaging studies were normal. Skin biopsy showed a dense infiltrate of cells with kidney-shaped nuclei and positive S100+ and CD1a+ on immunohistochemistry. What is the most likely diagnosis?
A. Congenital cytomegalovirus infection
B. Congenital rubella syndrome
C. Langerhans-cell histiocytosis
D. Leukemia cutis
E. Transient myeloproliferative disorder of Down syndrome
A. Congenital cytomegalovirus infection
B. Congenital rubella syndrome
C. Langerhans-cell histiocytosis
D. Leukemia cutis
E. Transient myeloproliferative disorder of Down syndrome
Answer:
The patient was diagnosed with congenital Langerhans-cell histiocytosis, which is a rare condition that is almost always evident at birth. Most typical lesions are crusted papules, pustules and papulovesicles, but nodules may be present. Because of the lack of extracutaneous involvement, the lesions were expected to resolve without treatment. At follow-up 6 weeks later, the skin lesions had resolved. The infant continues to be followed for signs of recurrence.
Congenital cytomegalovirus infection: the most common congenital infection and one of the “TORCH” infections. Approximately 5-10% of infected neonates have symptoms at birth, including jaundice, hepatosplenomegaly, chorioretinitis and/or intracranial calcifications. Cutaneous manifestations include purpuric papules and nodules of dermal hematopoiesis (“blueberry muffin” lesions) as well as petechiae, purpura and vesicles. Congenital CMV is the most common cause of congenital deafness and mental retardation.
Congenital rubella syndrome: a TORCH infection which presents with soft spongy 2-20 mm erythematous to violaceous papules (“blueberry muffin”) which is secondary to intradermal extramedullary hematopoiesis. Hemorrhage and petechiae may also be present. Other features include deafness, cataracts, congenital heart disease and patent ductus arteriosus.
Leukemia cutis: While congenital leukemia cutis can present with a rash that appears consistent with a “blueberry muffin rash” (extramedullary hematopoiesis), there is an atypical infiltrate of immature leukocytes in leukemia cutis.
Transient myeloproliferative disorder of Down syndrome: approximately 10% of neonates with Down Syndrome present with a vesiculopustular eruption which is associated with transient myeloproliferative disorder, a congenital leukemoid reaction. The infiltrating cells include immature myeloid cells, which are usually present in the peripheral blood. Although the skin lesions resolve, affected patients are at increased risk for development of acute megakaryocytic leukemia during the first few years of life.
The patient was diagnosed with congenital Langerhans-cell histiocytosis, which is a rare condition that is almost always evident at birth. Most typical lesions are crusted papules, pustules and papulovesicles, but nodules may be present. Because of the lack of extracutaneous involvement, the lesions were expected to resolve without treatment. At follow-up 6 weeks later, the skin lesions had resolved. The infant continues to be followed for signs of recurrence.
Congenital cytomegalovirus infection: the most common congenital infection and one of the “TORCH” infections. Approximately 5-10% of infected neonates have symptoms at birth, including jaundice, hepatosplenomegaly, chorioretinitis and/or intracranial calcifications. Cutaneous manifestations include purpuric papules and nodules of dermal hematopoiesis (“blueberry muffin” lesions) as well as petechiae, purpura and vesicles. Congenital CMV is the most common cause of congenital deafness and mental retardation.
Congenital rubella syndrome: a TORCH infection which presents with soft spongy 2-20 mm erythematous to violaceous papules (“blueberry muffin”) which is secondary to intradermal extramedullary hematopoiesis. Hemorrhage and petechiae may also be present. Other features include deafness, cataracts, congenital heart disease and patent ductus arteriosus.
Leukemia cutis: While congenital leukemia cutis can present with a rash that appears consistent with a “blueberry muffin rash” (extramedullary hematopoiesis), there is an atypical infiltrate of immature leukocytes in leukemia cutis.
Transient myeloproliferative disorder of Down syndrome: approximately 10% of neonates with Down Syndrome present with a vesiculopustular eruption which is associated with transient myeloproliferative disorder, a congenital leukemoid reaction. The infiltrating cells include immature myeloid cells, which are usually present in the peripheral blood. Although the skin lesions resolve, affected patients are at increased risk for development of acute megakaryocytic leukemia during the first few years of life.