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What's new in dermatology
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What's new in dermatology
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: Sep 15, 2017.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ACNE AND ROSACEA

Timing of cutaneous procedures in patients treated with oral isotretinoin (August 2017)

Delaying cutaneous procedures for at least 6 to 12 months after the completion of oral isotretinoin therapy is commonly practiced, given concerns for delayed wound healing and scarring; however, evidence to support this action are limited. Based upon a systematic review of the literature, a multi-specialty panel of experts found insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures [1]. The panel recommended avoidance of mechanical dermabrasion and fully ablative laser procedures in the setting of recent isotretinoin therapy. Although prospective, controlled trials are necessary to fully elucidate the risk for adverse procedural outcomes in this population, this information is helpful for counseling patients who may benefit from earlier performance of procedures. (See "Oral isotretinoin therapy for acne vulgaris", section on 'Cutaneous procedures'.)

Expert panel recommendations for the management of acne fulminans (July 2017)

There is a paucity of high-quality data on the management of acne fulminans, a rare, severe form of acne vulgaris. New recommendations from clinicians with expertise in severe acne vulgaris support prompt initiation of an oral glucocorticoid followed by the delayed addition of oral isotretinoin as the preferred first-line therapy [2]. We agree with the recommendations, which also discuss a new classification system for acne fulminans, prevention, and an algorithmic approach to treatment. (See "Treatment of acne vulgaris", section on 'Acne fulminans'.)

ATOPIC DERMATITIS AND OTHER DERMATITIS

Dupilumab for moderate to severe atopic dermatitis (June 2017)

Dupilumab is an interleukin (IL)-4 receptor alpha antagonist approved by the US Food and Drug Administration (FDA) for adults with moderate to severe atopic dermatitis not adequately controlled with topical therapies. In a phase III trial of over 700 patients with moderate to severe atopic dermatitis and inadequate response to topical corticosteroids, one year of treatment with dupilumab improved symptoms relative to placebo [3]. All patients received topical corticosteroids or topical calcineurin inhibitors. These results support the use of dupilumab for the long-term treatment of moderate to severe atopic dermatitis when topical therapies alone are insufficient and other systemic treatments are contraindicated. (See "Treatment of atopic dermatitis (eczema)", section on 'Dupilumab'.)

Dupilumab for moderate to severe atopic dermatitis (April 2017)

Dupilumab is an interleukin-4 receptor alpha antagonist being evaluated in atopic dermatitis. In two 16-week clinical trials (SOLO1 and SOLO2), dupilumab was more effective than placebo in improving the signs and symptoms of atopic dermatitis [4]. Based on these results, the US Food and Drug Administration has approved dupilumab for the treatment of adult patients with moderate to severe atopic dermatitis not adequately controlled with topical prescription therapies [5]. While the role for dupilumab is still evolving, it appears to be a reasonable option for adult patients with severe disease who have failed other systemic therapies. (See "Treatment of atopic dermatitis (eczema)", section on 'Dupilumab'.)

Nemolizumab for atopic dermatitis (March 2017)

Some patients with atopic dermatitis do not experience disease control with topical treatments. In a phase 2 trial, 264 patients with moderate to severe atopic dermatitis not controlled by topical corticosteroids or topical calcineurin inhibitors were randomly assigned to monthly subcutaneous nemolizumab, an investigational humanized monoclonal antibody against interleukin-31, at three different doses or to placebo [6]. At 12 weeks, pruritus was reduced by 44, 60, and 63 percent, in the low, medium, and high dose groups, respectively, versus 21 percent in the placebo group. However, nemolizumab did not reduce the body surface area affected by atopic dermatitis. Adverse effects occurred in approximately 70 percent of patients in all study groups and were generally mild, with the most frequent being exacerbation of atopic dermatitis and respiratory tract infections. Although nemolizumab appears to be a promising treatment for pruritus associated with atopic dermatitis, larger studies of longer durations are needed to confirm its efficacy and safety. (See "Treatment of atopic dermatitis (eczema)", section on 'Nemolizumab'.)

AUTOIMMUNE AND SYSTEMIC DISEASES

Rituximab plus prednisone for initial treatment of pemphigus (May 2017)

Although rituximab primarily has been used for the treatment of refractory pemphigus, data from an open-label randomized trial support the efficacy of rituximab, combined with prednisone, as a first-line treatment [7]. The trial compared rituximab plus a reduced-dose, short-term regimen of prednisone versus a higher-dose, long-term regimen of prednisone alone as initial therapy in 90 patients with newly diagnosed pemphigus vulgaris or pemphigus foliaceus. The rituximab group had increased rates of complete remission off therapy after 24 months (89 versus 34 percent) and lower rates of severe adverse effects. This trial supports the use of rituximab plus prednisone as an alternative to prednisone monotherapy for the initial treatment for pemphigus, particularly for patients with moderate to severe disease or who are less favorable candidates for high-dose, long-term prednisone therapy. Further study is necessary to clarify optimal doses and best practices for the use of rituximab in the initial treatment of pemphigus. The high cost of rituximab is a limiting factor for use in some settings. (See "Initial management of pemphigus vulgaris and pemphigus foliaceus", section on 'Efficacy'.)

Doxycycline versus prednisolone for the initial treatment of bullous pemphigoid (March 2017)

Tetracyclines have a long history of use for the management of bullous pemphigoid; however, high-quality data on the efficacy of tetracyclines are limited. In a multicenter randomized trial including approximately 250 patients receiving initial treatment for bullous pemphigoid, doxycycline was noninferior to oral prednisolone, with fewer associated severe, life-threatening, or fatal events [8]. Although topical and systemic corticosteroids remain our standard first-line treatments for bullous pemphigoid, these results support doxycycline as an alternative treatment. Doxycycline may be particularly useful when topical corticosteroid therapy is impractical and systemic corticosteroid therapy is likely to be poorly tolerated. (See "Management and prognosis of bullous pemphigoid", section on 'Antibiotics and nicotinamide'.)

INFECTIONS AND INFESTATIONS

Antibiotic therapy for skin abscess (July 2017)

Management of skin abscess consists of incision and drainage; the role of antibiotic therapy depends on individual clinical circumstances, including abscess size. In a randomized trial including more than 780 patients with skin abscess ≤5 cm (most were larger than 2 cm) who underwent incision and drainage, higher cure rates were observed among those who received antibiotic therapy with methicillin-resistant Staphylococcus aureus (MRSA) coverage (trimethoprim-sulfamethoxazole or clindamycin) than those who received placebo (82 or 83 percent versus 69 percent); MRSA was isolated in 49 percent of cases [9]. These findings support our approach to management of patients with skin abscess, in which we suggest antibiotic therapy in addition to incision and drainage for patients with skin abscess ≥2 cm. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Role of antibiotic therapy'.)

Treatment of nonpurulent cellulitis (June 2017)

Empiric antibiotic therapy for nonpurulent cellulitis (ie, with no purulent drainage and no associated abscess) should be active against beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) but not necessarily methicillin-resistant S. aureus (MRSA). This approach is supported by a randomized trial of nearly 500 patients with nonpurulent cellulitis, in which cephalexin plus placebo (active against beta-hemolytic streptococci and MSSA) and cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX, which adds activity against MRSA) resulted in statistically similar clinical cure rates (69 versus 76 percent) [10]. Although there was a trend toward higher cure rates with the addition of TMP-SMX, the results were likely skewed by a relatively large number of patients who did not complete the full course of therapy. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Cellulitis'.)

PSORIASIS AND OTHER PAPULOSQUAMOUS DISORDERS

Guselkumab and tildrakizumab for moderate to severe plaque psoriasis (July 2017)

New therapies targeting interleukin (IL)-23 are emerging for the treatment of moderate to severe plaque psoriasis and may be more effective than older biologic therapies, such as adalimumab and etanercept. Data from randomized trials support the superiority of IL-23 monoclonal antibodies guselkumab and tildrakizumab over adalimumab and etanercept, respectively [11-13]. The adverse effects were comparable. Based upon these data, the US Food and Drug Administration (FDA) approved guselkumab for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Tildrakizumab is not yet commercially available. Both represent additional highly effective treatments for moderate to severe plaque psoriasis. (See "Treatment of psoriasis in adults", section on 'Guselkumab' and "Treatment of psoriasis in adults", section on 'Future therapies'.)

Adalimumab for chronic plaque psoriasis in children (July 2017)

Although adalimumab is a common treatment for moderate to severe psoriasis in adults, there were previously no prospective randomized trials to guide its use in children. In a phase 3 trial of 114 children (ages 4 to 17 years) with severe chronic plaque psoriasis, adalimumab improved psoriasis more frequently than methotrexate, with a similar safety profile [14]. Infections were the most common side effect in both groups. This trial supports adalimumab as one of several systemic treatment options for severe pediatric chronic plaque psoriasis. However, additional study is necessary to clarify the drug's long-term efficacy and safety in this population, and methotrexate and etanercept remain our preferred first-line systemic treatments for most children with chronic plaque psoriasis. (See "Psoriasis in children: Management of chronic plaque psoriasis", section on 'Biologic agents'.)

Guidelines for comorbidity screening in children with psoriasis (May 2017)

The best approach for screening children with psoriasis for comorbidities has been unclear. An expert consensus document by members of the Pediatric Dermatology Research Alliance and National Psoriasis Foundation provides the first set of guidelines, including recommendations for assessment for overweight or obese status, diabetes, hyperlipidemia, hypertension, nonalcoholic fatty liver disease, psoriatic arthritis, depression, anxiety, and substance abuse [15]. Our approach to screening children with psoriasis is consistent with these guidelines. (See "Psoriasis in children: Epidemiology, clinical manifestations, and diagnosis", section on 'Additional evaluation'.)

SKIN CANCER

Ipilimumab in advanced pediatric melanoma (August 2017)

There are limited data on the optimal treatment of metastatic melanoma in children. In a combined analysis of two early-phase pediatric trials of ipilimumab, an anticytotoxic T-lymphocyte-associated protein 4 (CTLA-4) antibody, 2 of 17 melanoma patients ≥12 years of age experienced objective responses [16]. Immune-related adverse events included pancreatitis, pneumonitis, endocrinopathies, colitis, and transaminitis. Based upon these results and studies in adult patients with advanced melanoma, the US Food and Drug Administration approved ipilimumab for the treatment of unresectable or metastatic melanoma in children aged 12 years or older [17]. However, we await more data and longer follow-up prior to routine use of immune checkpoint inhibitors in the management of metastatic melanoma in children. (See "Melanoma in children", section on 'Pediatric clinical trials'.)

Association between Parkinson disease and melanoma (August 2017)

Several studies have suggested an association between Parkinson disease (PD) and melanoma. A retrospective study using medical records from 1976 to 2013 found that, compared with controls, PD patients had nearly a four-fold increased likelihood of having a history of melanoma; likewise, patients with melanoma had approximately a four-fold risk of developing PD after the diagnosis of melanoma [18]. Although the underlying cause of this reciprocal association remains unclear, these findings suggest that PD and melanoma may share genetic risk factors. (See "Etiology and pathogenesis of Parkinson disease", section on 'Risk factors' and "Risk factors for the development of melanoma", section on 'Other proposed risk factors'.)

Systemic therapy for melanoma brain metastases (June 2017)

Patients with central nervous system involvement from melanoma historically have had a very poor prognosis. Preliminary reports from two phase II studies suggest that the combination of nivolumab plus ipilimumab has important clinical activity against intracranial metastases [19,20]. Antitumor activity has also been observed with targeted therapy for patients whose melanoma has a BRAF V600 mutation. A multidisciplinary approach that considers all available treatment modalities is essential for the proper treatment of the patient with melanoma brain metastases. (See "Management of brain metastases in melanoma", section on 'Nivolumab plus ipilimumab'.)

Management of a positive sentinel lymph node biopsy in patients with cutaneous melanoma (June 2017)

Historically, completion dissection of all involved nodal basins was considered the standard treatment approach for patients with cutaneous melanoma and a positive sentinel lymph node biopsy (SLNB). In the phase III Multicenter Selective Lymphadenectomy Trial II (MSLT II), patients with a positive SLNB were randomly assigned to either completion lymph node dissection or observation that included ultrasound evaluation of the appropriate lymph node basins at each follow-up visit [21]. Melanoma-specific survival at three years was the same for both groups, although the incidence of recurrence in regional lymph nodes was higher in patients managed with observation and ultrasound surveillance. The incidence of lymphedema was higher in patients who underwent immediate lymph node dissection. For patients with a positive SLNB, we suggest clinical observation coupled with ultrasound surveillance of the positive nodal basin. Completion lymph node dissection is indicated if, in the absence of distant metastases, there is evidence of regional lymph node recurrence. (See "Evaluation and treatment of regional lymph nodes in melanoma", section on 'Multicenter Selective Lymphadenectomy Trial II'.)

SURGICAL AND COSMETIC DERMATOLOGY

Timing of cutaneous procedures in patients treated with oral isotretinoin (August 2017)

Delaying cutaneous procedures for at least 6 to 12 months after the completion of oral isotretinoin therapy is commonly practiced, given concerns for delayed wound healing and scarring; however, evidence to support this action are limited. Based upon a systematic review of the literature, a multi-specialty panel of experts found insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures [1]. The panel recommended avoidance of mechanical dermabrasion and fully ablative laser procedures in the setting of recent isotretinoin therapy. Although prospective, controlled trials are necessary to fully elucidate the risk for adverse procedural outcomes in this population, this information is helpful for counseling patients who may benefit from earlier performance of procedures. (See "Oral isotretinoin therapy for acne vulgaris", section on 'Cutaneous procedures'.)

URTICARIA AND ANGIOEDEMA

Systemic symptoms in patients with chronic idiopathic urticaria (June 2017)

Patients with chronic idiopathic urticaria (CIU) sometimes report accompanying systemic symptoms, although the prevalence of such symptoms has not been specifically examined. In a study of 155 CIU patients presenting to a referral allergy clinic, 66 percent reported systemic symptoms, including headache, fatigue, joint pain or swelling, wheezing, flushing, gastrointestinal symptoms, and palpitations [22]. Patients with systemic symptoms had a greater disease burden compared with those without symptoms. Although this study population was probably skewed towards more severe disease, it is helpful to recognize that systemic symptoms are not uncommon in CIU. (See "Chronic urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history", section on 'Systemic symptoms'.)

Glucocorticoids not necessary for simple acute urticaria (May 2017)

Although patients with urticaria and symptoms involving other organ systems are treated with epinephrine given the likelihood of anaphylaxis, H1 antihistamines are the initial treatment for those with isolated urticaria. For such patients, the additive benefit of glucocorticoids is not well defined. In a randomized trial of 100 adults presenting to the emergency department with isolated urticaria (without angioedema, anaphylaxis, or fever) of ≤24 hours duration, patients received the H1 antihistamine levocetirizine plus either prednisone or placebo for four days [23]. There was no significant difference in the rate of symptom resolution, and most patients were symptom-free within two days. This study supports our suggestion to reserve glucocorticoids for those patients with new urticaria who have prominent angioedema or whose symptoms persist despite antihistamines. (See "New-onset urticaria", section on 'Glucocorticoids'.)

OTHER DERMATOLOGY

Naltrexone for Hailey-Hailey disease (September 2017)

Hailey-Hailey disease (HHD), or "benign familial pemphigus," is a rare, autosomal-dominant bullous disorder characterized by blistering, erosions, and maceration in the flexural areas. The therapeutic options for HHD are limited and usually directed at controlling infection and inflammation. However, in two reports, low-dose treatment with the opioid antagonist naltrexone led to complete resolution of intertriginous lesions over three to four months in six patients with recalcitrant HHD [24,25]. Treatment was well tolerated. Although promising, these findings need to be confirmed in additional studies before low-dose naltrexone can be recommended for the treatment of severe recalcitrant HHD. (See "Hailey-Hailey disease (benign familial pemphigus)", section on 'Emerging medical therapies'.)

Canakinumab for severe hidradenitis suppurativa (September 2017)

Severe hidradenitis suppurativa is a disabling condition that is challenging to treat. In a case report, two patients treated with canakinumab (a human IgG kappa monoclonal antibody targeting the proinflammatory cytokine IL-1 beta) for severe hidradenitis suppurativa had improvement in disease severity scores and pain [26]. No adverse effects occurred. Additional study is necessary to confirm efficacy and safety of this treatment. (See "Hidradenitis suppurativa (acne inversa): Treatment", section on 'Emerging therapies'.)

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REFERENCES

  1. Spring LK, Krakowski AC, Alam M, et al. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations. JAMA Dermatol 2017; 153:802.
  2. Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol 2017; 77:109.
  3. Blauvelt A, de Bruin-Weller M, Gooderham M, et al. Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a 1-year, randomised, double-blinded, placebo-controlled, phase 3 trial. Lancet 2017; 389:2287.
  4. Simpson EL, Bieber T, Guttman-Yassky E, et al. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. N Engl J Med 2016; 375:2335.
  5. www.accessdata.fda.gov/drugsatfda_docs/label/2017/761055lbl.pdf (Accessed on April 04, 2017).
  6. Ruzicka T, Hanifin JM, Furue M, et al. Anti-Interleukin-31 Receptor A Antibody for Atopic Dermatitis. N Engl J Med 2017; 376:826.
  7. Joly P, Maho-Vaillant M, Prost-Squarcioni C, et al. First-line rituximab combined with short-term prednisone versus prednisone alone for the treatment of pemphigus (Ritux 3): a prospective, multicentre, parallel-group, open-label randomised trial. Lancet 2017; 389:2031.
  8. Williams HC, Wojnarowska F, Kirtschig G, et al. Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial. Lancet 2017; 389:1630.
  9. Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med 2017; 376:2545.
  10. Moran GJ, Krishnadasan A, Mower WR, et al. Effect of Cephalexin Plus Trimethoprim-Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A Randomized Clinical Trial. JAMA 2017; 317:2088.
  11. Blauvelt A, Papp KA, Griffiths CE, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase III, double-blinded, placebo- and active comparator-controlled VOYAGE 1 trial. J Am Acad Dermatol 2017; 76:405.
  12. Reich K, Armstrong AW, Foley P, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase III, double-blind, placebo- and active comparator-controlled VOYAGE 2 trial. J Am Acad Dermatol 2017; 76:418.
  13. Reich K, Papp KA, Blauvelt A, et al. Tildrakizumab versus placebo or etanercept for chronic plaque psoriasis (reSURFACE 1 and reSURFACE 2): results from two randomised controlled, phase 3 trials. Lancet 2017; 390:276.
  14. Papp K, Thaçi D, Marcoux D, et al. Efficacy and safety of adalimumab every other week versus methotrexate once weekly in children and adolescents with severe chronic plaque psoriasis: a randomised, double-blind, phase 3 trial. Lancet 2017; 390:40.
  15. Osier E, Wang AS, Tollefson MM, et al. Pediatric Psoriasis Comorbidity Screening Guidelines. JAMA Dermatol 2017; 153:698.
  16. Merchant MS, Wright M, Baird K, et al. Phase I Clinical Trial of Ipilimumab in Pediatric Patients with Advanced Solid Tumors. Clin Cancer Res 2016; 22:1364.
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  18. Dalvin LA, Damento GM, Yawn BP, et al. Parkinson Disease and Melanoma: Confirming and Reexamining an Association. Mayo Clin Proc 2017; 92:1070.
  19. Long GV, Atkinson V, Menzies AM, et al. A randomized phase II study of nivolumab or nivolumab combined with ipilimumab in patients with melanoma brain metastases: the Anti-PD1 Collaboration (ABC) (abstract 9508). 2017 American Society of Clinical Oncology annual meeting.
  20. Tawbi HA, Forsyth PA, Algazi AP, et al. Efficacy and safety of nivolumab plus ipilimumab in patients with melanoma metastatic to the brain: results of the phase II study Checkmate 204 (abstract 9507). 2017 American Society of Clinical Oncology annual meeting.
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  22. Doong JC, Chichester K, Oliver ET, et al. Chronic Idiopathic Urticaria: Systemic Complaints and Their Relationship with Disease and Immune Measures. J Allergy Clin Immunol Pract 2017; 5:1314.
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