eightY-NINTH issue
JULY 9, 2025
A tale of trading one itch for another...
Patients with atopic dermatitis (AD) are often treated with dupilumab, a biologic that targets Th2-mediated inflammation. However, recent evidence suggests that dupilumab may increase the risk of new-onset psoriasis (PSO) or exacerbate pre-existing PSO. This study examined whether dupilumab use in AD patients is associated with a higher incidence of PSO.
What did they find?
Main Takeaway: Dupilumab may increase the risk of psoriasis, possibly due to a shift in immune dominance from Th2 to Th1/Th17 pathways. Clinicians should be aware of this potential paradoxical reaction when managing patients on dupilumab.
Patients with atopic dermatitis (AD) are often treated with dupilumab, a biologic that targets Th2-mediated inflammation. However, recent evidence suggests that dupilumab may increase the risk of new-onset psoriasis (PSO) or exacerbate pre-existing PSO. This study examined whether dupilumab use in AD patients is associated with a higher incidence of PSO.
What did they find?
- PSO developed in 193 patients (2.0%) in the dupilumab cohort compared to 113 patients (1.1%) in the control cohort (P < 0.001).
- The 3-year cumulative incidence of PSO was significantly higher in the dupilumab group than in controls (2.86% vs. 1.79%; P < 0.001).
- There was no significant difference in the 3-year cumulative incidence of psoriatic arthritis (PsA) between the two groups (0.20% vs. 0.13%; P = 0.53).
- Among asthma patients without AD, dupilumab was also associated with a higher risk of PSO compared to conventional therapies (HR 2.13; 95% CI, 1.38–3.31).
Main Takeaway: Dupilumab may increase the risk of psoriasis, possibly due to a shift in immune dominance from Th2 to Th1/Th17 pathways. Clinicians should be aware of this potential paradoxical reaction when managing patients on dupilumab.
Improved survival for patients with advanced Merkel cell carcinoma following availability of immunotherapy
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
Modern medicine has brought us a Merkel Miracle!
Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine skin cancer with historically poor outcomes. Prior to 2017, chemotherapy was the mainstay for advanced MCC, but offered only short-lived tumor responses. Immune checkpoint inhibitors (ICIs) were approved for MCC in 2017, yet their real-world survival impact remains uncertain. In this population-based cohort study, researchers analyzed data from 4,786 MCC patients in the SEER database (2010–2021) to assess changes in 2-year relative and overall survival before and after ICI approval.
What did they find?
Limitations: SEER lacks individual treatment data, so survival improvements cannot be definitively linked to ICI use. However, the timing and magnitude of benefit strongly suggest ICIs as the driving factor.
Main Takeaway: Population-wide data demonstrates significant survival improvements for advanced MCC in the post-immunotherapy era, supporting ICIs as a potential practice-changing intervention with real-world impact for patients with MCC.
Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine skin cancer with historically poor outcomes. Prior to 2017, chemotherapy was the mainstay for advanced MCC, but offered only short-lived tumor responses. Immune checkpoint inhibitors (ICIs) were approved for MCC in 2017, yet their real-world survival impact remains uncertain. In this population-based cohort study, researchers analyzed data from 4,786 MCC patients in the SEER database (2010–2021) to assess changes in 2-year relative and overall survival before and after ICI approval.
What did they find?
- Among 453 patients with metastatic MCC, 2-year relative survival more than doubled, from 23% (2010–2012) to 54% (2019–2021) (P < 0.001); median overall survival also rose from 8.8 to 15.9 months.
- Overall MCC survival improved: 2-year relative survival rose from 73% to 81% (P = 0.004), and overall survival from 66% to 72% (P = 0.012).
- Patients with regional disease saw 2-year survival increase from 65.1% to 77.1% (P = 0.015).
- No significant survival change was observed for localized MCC, suggesting that the benefits of immunotherapy are limited to more advanced disease.
- These gains equate to an estimated 220 fewer MCC-related deaths annually, based on 2021 U.S. incidence.
Limitations: SEER lacks individual treatment data, so survival improvements cannot be definitively linked to ICI use. However, the timing and magnitude of benefit strongly suggest ICIs as the driving factor.
Main Takeaway: Population-wide data demonstrates significant survival improvements for advanced MCC in the post-immunotherapy era, supporting ICIs as a potential practice-changing intervention with real-world impact for patients with MCC.
Ustekinumab and guselkumab are associated with lower risk of herpes zoster and postherpetic neuralgia in patients with psoriasis
British Journal of Dermatology
British Journal of Dermatology
Defending the dermis and dodging disease: Biologics do double duty
Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus and can lead to postherpetic neuralgia (PHN), a painful and sometimes debilitating complication. Patients with psoriasis often require systemic immunomodulatory treatments, including both traditional systemic immunosuppressants (TSIs) and newer biologic therapies. To evaluate how different psoriasis treatments affect HZ and PHN risk, researchers analyzed data from Taiwan’s National Health Insurance Research Database (2011–2021), comparing biologic agents with TSIs in patients with moderate-to-severe psoriasis.
What did they find?
Main takeaway: Ustekinumab and guselkumab may offer protective benefits against herpes zoster and postherpetic neuralgia in patients with moderate-to-severe psoriasis, compared to traditional systemic treatments.
Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus and can lead to postherpetic neuralgia (PHN), a painful and sometimes debilitating complication. Patients with psoriasis often require systemic immunomodulatory treatments, including both traditional systemic immunosuppressants (TSIs) and newer biologic therapies. To evaluate how different psoriasis treatments affect HZ and PHN risk, researchers analyzed data from Taiwan’s National Health Insurance Research Database (2011–2021), comparing biologic agents with TSIs in patients with moderate-to-severe psoriasis.
What did they find?
- The study included 6,769 patients with psoriasis treated with etanercept (n = 815), adalimumab (n = 1,870), ustekinumab (n = 1,095), secukinumab (n = 2,327), ixekizumab (n = 261), brodalumab (n = 303), and guselkumab (n = 98).
- Ustekinumab was associated with a lower risk of both HZ (HR 0.82; 95% CI 0.61–1.11) and PHN (HR 0.22; 95% CI 0.08–0.64) compared to TSIs.
- Guselkumab was associated with a lower HZ risk compared to TSIs (HR 0.48; 95% CI 0.22–1.02).
- Adalimumab was associated with a significantly higher risk of HZ than TSIs (HR 1.63; 95% CI 1.22–2.18).
Main takeaway: Ustekinumab and guselkumab may offer protective benefits against herpes zoster and postherpetic neuralgia in patients with moderate-to-severe psoriasis, compared to traditional systemic treatments.
An AI imaging model for the skin tumor burden assessment of mycosis fungoides
Journal of Investigative Dermatology
Journal of Investigative Dermatology
Out with the old and in with the new: mSWAT-Net is coming to our rescue!
Mycosis fungoides (MF), the most common cutaneous T-cell lymphoma, requires precise and time-intensive tumor burden assessments to guide treatment and monitor progression. The modified Severity Weighted Assessment Tool (mSWAT) is the current standard, but is time-consuming, subjective, and prone to errors like double-counting lesions across photo angles. This study introduces mSWAT-Net, an AI model trained on over 2,400 standardized images to automate mSWAT scoring using multi-angle photographs and 3D-informed overlap correction.
What did they find?
Main Takeaway: mSWAT-Net is the first AI model capable of reliably quantifying skin tumor burden in MF using clinical photographs. By segmenting lesions by body region and type and correcting for image overlap, it offers a fast, objective, and reproducible alternative to manual mSWAT scoring, with promising applications in clinical monitoring and teledermatology.
Mycosis fungoides (MF), the most common cutaneous T-cell lymphoma, requires precise and time-intensive tumor burden assessments to guide treatment and monitor progression. The modified Severity Weighted Assessment Tool (mSWAT) is the current standard, but is time-consuming, subjective, and prone to errors like double-counting lesions across photo angles. This study introduces mSWAT-Net, an AI model trained on over 2,400 standardized images to automate mSWAT scoring using multi-angle photographs and 3D-informed overlap correction.
What did they find?
- mSWAT-Net demonstrated expert-level accuracy, with intraclass correlation coefficients (ICCs) of 0.917 (internal validation) and 0.846 (temporal validation) compared to bedside mSWAT scores.
- It outperformed three junior dermatologists in image-based scoring (mean absolute error: 8.45 vs. 14.02).
- When benchmarked against 3D imaging ground truth, it achieved an ICC of 0.812.
- The model reliably tracked treatment response in longitudinal images of MF patients receiving brentuximab.
Main Takeaway: mSWAT-Net is the first AI model capable of reliably quantifying skin tumor burden in MF using clinical photographs. By segmenting lesions by body region and type and correcting for image overlap, it offers a fast, objective, and reproducible alternative to manual mSWAT scoring, with promising applications in clinical monitoring and teledermatology.
Utilizing the ultraviolet capabilities of a dermatoscope to distinguish malignant and benign acral lesions
Journal of the American Academy of Dermatology
Journal of the American Academy of Dermatology
Ultraviolet dermoscopy is so GROOVY
In acral dermoscopy, distinguishing between benign and malignant melanocytic lesions often hinges on whether pigmentation lies along the ridges (more concerning for melanoma) or the grooves (more typical of benign lesions). When this ridge-groove pattern is difficult to discern, the Ink Test is commonly used to enhance contrast, applying ink to the skin, allowing it to settle in the grooves, and wiping it away. However, the method is time-consuming, involves multiple steps, and can be uncomfortable for patients.
This study examined whether newly available UV (Wood’s lamp) modes integrated into dermatoscopes could assist in distinguishing acral ridges and grooves more easily and accurately, offering a potential alternative to the Ink Test.
What did they find?
Main Takeaway: UV-mode dermatoscopes reveal a “highway view” that enhances visualization of acral skin markings, enabling clearer distinction between grooves and ridges. This technique provides a simpler, faster, and more patient-friendly alternative to the Ink Test and may improve diagnostic accuracy in acral melanocytic lesions.
In acral dermoscopy, distinguishing between benign and malignant melanocytic lesions often hinges on whether pigmentation lies along the ridges (more concerning for melanoma) or the grooves (more typical of benign lesions). When this ridge-groove pattern is difficult to discern, the Ink Test is commonly used to enhance contrast, applying ink to the skin, allowing it to settle in the grooves, and wiping it away. However, the method is time-consuming, involves multiple steps, and can be uncomfortable for patients.
This study examined whether newly available UV (Wood’s lamp) modes integrated into dermatoscopes could assist in distinguishing acral ridges and grooves more easily and accurately, offering a potential alternative to the Ink Test.
What did they find?
- When using a dermatoscope in UV mode, light refracts off the acral skin surface in a way that clearly delineates ridges and grooves.
- This creates a distinctive pattern of parallel lines, resembling a "highway view," that highlights the topography of acral skin.
- Even inexperienced observers were better able to identify ridge and groove structures using this technique.
Main Takeaway: UV-mode dermatoscopes reveal a “highway view” that enhances visualization of acral skin markings, enabling clearer distinction between grooves and ridges. This technique provides a simpler, faster, and more patient-friendly alternative to the Ink Test and may improve diagnostic accuracy in acral melanocytic lesions.
Figure 1: A: UV mode with Highway view where white lines running parallel are ridges and highway lines are the grooves B: Polarized view with unclear Highway view
Assessing ChatGPT-4o and ChatGLM-4 in answering pediatric atopic dermatitis queries
Pediatric Dermatology
Pediatric Dermatology
AI Replies for Kids’ Skin Cries
Atopic dermatitis (AD) is a common, chronic, and relapsing skin disorder affecting children worldwide. Despite its high prevalence, parents often struggle to find accessible and reliable management advice. Recently, large language models (LLMs) like ChatGPT and ChatGLM have emerged as promising tools for delivering medical information through conversational AI. This cross-sectional comparative analysis evaluated how effectively ChatGPT-4 omni (ChatGPT-4o) and ChatGLM-4 respond to common parent-posed questions about pediatric AD.
What did they find?
Main Takeaway: Both ChatGPT-4o and ChatGLM-4 provided responses with reliability and clinical applicability. These findings highlight the potential of LLMs as accessible, supplementary tools for guiding parents in managing pediatric atopic dermatitis. However, dermatologists remain the experts, and their involvement is essential for nuanced judgment, accurate interpretation, and personalized care beyond the scope of AI tools.
Atopic dermatitis (AD) is a common, chronic, and relapsing skin disorder affecting children worldwide. Despite its high prevalence, parents often struggle to find accessible and reliable management advice. Recently, large language models (LLMs) like ChatGPT and ChatGLM have emerged as promising tools for delivering medical information through conversational AI. This cross-sectional comparative analysis evaluated how effectively ChatGPT-4 omni (ChatGPT-4o) and ChatGLM-4 respond to common parent-posed questions about pediatric AD.
What did they find?
- ChatGPT-4o and ChatGLM-4 demonstrated comparable performance, with ChatGPT-4o scoring slightly higher for reliability and clinical applicability (92.98%–95.97% of the maximum) compared to ChatGLM-4 (82.59%–96.83%).
- No statistically significant difference was found between the two models (P > 0.05).
- Dermatologists’ ratings showed moderate consistency across both models (Kendall’s coefficient > 0.40), particularly in topics like skincare, treatment, and special manifestations.
Main Takeaway: Both ChatGPT-4o and ChatGLM-4 provided responses with reliability and clinical applicability. These findings highlight the potential of LLMs as accessible, supplementary tools for guiding parents in managing pediatric atopic dermatitis. However, dermatologists remain the experts, and their involvement is essential for nuanced judgment, accurate interpretation, and personalized care beyond the scope of AI tools.
Are current training materials for skin-related neglected tropical diseases meeting the needs of frontline healthcare workers in endemic regions?
Clinical and Experimental Dermatology
Clinical and Experimental Dermatology
From neglected to respected: Enhancing training for skin-related NTDs
Neglected tropical diseases (NTDs) affect over a billion people worldwide, disproportionately burdening impoverished communities in tropical and subtropical regions. Many NTDs present with skin findings and are referred to as "skin-related NTDs," such as leprosy, cutaneous leishmaniasis, and scabies. Although initiatives such as OpenWHO and InfoNTD provide training materials for healthcare workers, the availability and quality of these resources have not been comprehensively assessed. This scoping review assessed 114 existing skin-related NTD training materials to identify content gaps and inform future resource development.
What did they find?
Main Takeaway: This review identified significant gaps in content coverage, interactivity, and accessibility in current skin-related NTD training materials. More comprehensive, visually rich, and multilingual resources are needed to better support frontline healthcare workers in diagnosing, treating, and managing complications of these diseases.
Neglected tropical diseases (NTDs) affect over a billion people worldwide, disproportionately burdening impoverished communities in tropical and subtropical regions. Many NTDs present with skin findings and are referred to as "skin-related NTDs," such as leprosy, cutaneous leishmaniasis, and scabies. Although initiatives such as OpenWHO and InfoNTD provide training materials for healthcare workers, the availability and quality of these resources have not been comprehensively assessed. This scoping review assessed 114 existing skin-related NTD training materials to identify content gaps and inform future resource development.
What did they find?
- Half of the 114 resources were developed between 2022 and 2024, likely in response to the WHO’s 2021–2030 NTD roadmap.
- Most materials (81.6%) focused on a single skin-related NTD, with leprosy (35.1%), lymphatic filariasis (21.9%), and cutaneous leishmaniasis (18.4%) most frequently covered.
- While treatment (90.4%) and diagnosis (78.1%) were commonly covered, fewer resources addressed complications (57.0%) or follow-up care (29.8%).
- The majority were in English (71.1%), with limited translations into French, Spanish, and Arabic.
- While the majority of materials were current (93.1%) and readable (94.7%), nearly one-third (31.6%) lacked images, which are useful for providers in low-resource settings who may benefit from visual learning.
Main Takeaway: This review identified significant gaps in content coverage, interactivity, and accessibility in current skin-related NTD training materials. More comprehensive, visually rich, and multilingual resources are needed to better support frontline healthcare workers in diagnosing, treating, and managing complications of these diseases.
The importance of early detection of cutaneous leiomyosarcoma in the context of trauma
Cutaneous leiomyosarcoma (cLMS) is a rare malignant tumor of smooth muscle origin, most commonly seen in Caucasian men aged 50 to 70. Its low incidence and often benign appearance make it prone to misdiagnosis, particularly when it arises in the setting of trauma. Early recognition is critical due to its potential for local recurrence and metastasis. This case report describes the clinical, histopathologic, and immunohistochemical findings in a patient who underwent a deep tangential shave biopsy to confirm the diagnosis.
What did they find?
Main Takeaway: This case highlights the importance of maintaining a broad differential diagnosis for persistent nodules, even those with a trauma history. It underscores the value of biopsy and immunohistochemistry in diagnosing rare cutaneous malignancies like cLMS.
What did they find?
- The patient presented with a painful pretibial nodule that developed six months after blunt trauma to the right leg and was initially presumed benign.
- Differential diagnoses based on appearance and trauma history included pyogenic granuloma, squamous cell carcinoma, dermatofibroma, and epidermal inclusion cyst.
- Histologic analysis showed interlacing bundles of spindle-shaped cells positive for desmin and smooth muscle actin, confirming cLMS. Ki-67 staining was also positive, indicating active tumor proliferation.
Main Takeaway: This case highlights the importance of maintaining a broad differential diagnosis for persistent nodules, even those with a trauma history. It underscores the value of biopsy and immunohistochemistry in diagnosing rare cutaneous malignancies like cLMS.
DERMLITE Dermoscopy QUESTION OF THE WEEK
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