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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: Oct 2017. | This topic last updated: Nov 14, 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 (algorithm 1). (See "Treatment of acne vulgaris", section on 'Acne fulminans'.)

ATOPIC DERMATITIS AND OTHER DERMATITIS

Probiotics ineffective for the prevention of early childhood eczema (October 2017)

Two meta-analyses in 2012 and 2014 suggested that there was a modest protective effect of probiotics used in late pregnancy/early infancy on the development of eczema within the first two years of life, although subsequent trials did not confirm these findings. A recent randomized trial provides further evidence of the lack of effectiveness of probiotics for eczema prevention [3]. In this trial, 184 high-risk infants received either Lactobacillus rhamnosus GG plus inulin or inulin alone for the first six months of life. Eczema was diagnosed by age two in approximately 30 percent of the children in both groups. We suggest not giving probiotics during pregnancy and infancy for the prevention of eczema. (See "Prebiotics and probiotics for prevention of allergic disease", section on 'Efficacy'.)

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 [4]. 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'.)

AUTOIMMUNE AND SYSTEMIC DISEASES

Screening for thyroid disease in children with alopecia areata (September 2017)

Alopecia areata is associated with several other autoimmune diseases, and screening affected patients for thyroid disease is commonly performed. A single-center retrospective study of children with alopecia areata found the risk of thyroid abnormalities was increased among children with Down syndrome, atopy, or a family history of thyroid disease, and suggested that limiting screening to certain populations may be reasonable [5]. While this study provides a basis for additional research, we continue to screen all children with alopecia areata for thyroid disease, pending additional data to support other screening strategies. (See "Clinical manifestations and diagnosis of alopecia areata", section on 'Laboratory studies'.)

INFECTIONS AND INFESTATIONS

Syphilis incidence in the United States (October 2017)

Syphilis causes a wide range of clinical syndromes and is associated with HIV transmission. The United States Centers for Disease Control and Prevention reported an approximately 18 percent increase in the rate of primary and secondary syphilis (the most infectious stages of the disease) in 2016, with 8.7 cases per 100,000 population, the highest rate since 1993 [6]. More than 600 cases of congenital syphilis were also reported. Although syphilis rates increased among men and women, the rise was primarily attributable to men who have sex with men (MSM). These findings stress the importance of screening and treatment for sexually transmitted infection, especially in MSM and pregnant women. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients", section on 'Epidemiology'.)

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 [7]. 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) [8]. 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 [9-11]. 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 [12]. 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 [13]. 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 [14]. 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 [15]. 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 [16]. 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 [17,18]. 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 [19]. 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 [20]. 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'.)

OTHER DERMATOLOGY

Cyclosporine for Stevens-Johnson syndrome/toxic epidermal necrolysis (November 2017)

Beyond supportive care, there are no established therapies for Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), a severe and often life-threatening drug reaction. Immunosuppressive or immunomodulating therapies used in clinical practice include systemic corticosteroids, intravenous immune globulins, and cyclosporine. None has been adequately studied in randomized trials, but there is increasing evidence that cyclosporine may slow the progression of SJS/TEN. In a meta-analysis of observational studies including 134 patients with SJS/TEN treated with cyclosporine, the observed mortality rate was approximately 60 percent lower than that expected based upon the SCORTEN prognostic score at admission [21]. We suggest cyclosporine in addition to supportive care for the treatment of SJS/TEN. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae", section on 'Cyclosporine'.)

Recommendations for the management of comorbidities in patients with hidradenitis suppurativa (October 2017)

Hidradenitis suppurativa is associated with multiple comorbidities. A multispecialty working group outlined recommendations for dermatologists regarding assessment, referral, and management for comorbidities in patients with hidradenitis suppurativa [22]. We agree with the implementation of measures to support early detection and appropriate treatment of comorbidities in this population, including yearly screening for comorbidities. (See "Hidradenitis suppurativa: Treatment", section on 'Management of comorbidities'.)

Risk of Stevens-Johnson syndrome in cancer patients (September 2017)

Patients with active malignancy, and in particular those with hematologic cancers, have an increased risk of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), a severe mucocutaneous reaction most commonly triggered by medications. An analysis of data from a large cohort of over 100,000 cancer patients found that the average annual incidence rate of SJS/TEN was approximately 30 to 60 times higher than in the general population [23]. Whether the increased risk is due to the malignancy itself, the frequent immunocompromised state of cancer patients, or the increased exposure of these patients to potentially causative medications remains uncertain. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Malignancy'.)

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: 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. Cabana MD, McKean M, Caughey AB, et al. Early Probiotic Supplementation for Eczema and Asthma Prevention: A Randomized Controlled Trial. Pediatrics 2017; 140.
  4. 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.
  5. Patel D, Li P, Bauer AJ, Castelo-Soccio L. Screening Guidelines for Thyroid Function in Children With Alopecia Areata. JAMA Dermatol 2017.
  6. United States Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2016. https://www.cdc.gov/std/stats16/Syphilis.htm (Accessed on October 05, 2017).
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Osier E, Wang AS, Tollefson MM, et al. Pediatric Psoriasis Comorbidity Screening Guidelines. JAMA Dermatol 2017; 153:698.
  14. 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.
  15. www.accessdata.fda.gov/drugsatfda_docs/label/2017/125377s087lbl.pdf (Accessed on August 04, 2017).
  16. Dalvin LA, Damento GM, Yawn BP, et al. Parkinson Disease and Melanoma: Confirming and Reexamining an Association. Mayo Clin Proc 2017; 92:1070.
  17. 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.
  18. 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.
  19. Faries MB, Thompson JF, Cochran AJ, et al. Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma. N Engl J Med 2017; 376:2211.
  20. 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.
  21. González-Herrada C, Rodríguez-Martín S, Cachafeiro L, et al. Cyclosporine Use in Epidermal Necrolysis Is Associated with an Important Mortality Reduction: Evidence from Three Different Approaches. J Invest Dermatol 2017; 137:2092.
  22. Dauden E, Lazaro P, Aguilar MD, et al. Recommendations for the management of comorbidity in hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2017.
  23. Gillis NK, Hicks JK, Bell GC, et al. Incidence and Triggers of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in a Large Cancer Patient Cohort. J Invest Dermatol 2017; 137:2021.
  24. Albers LN, Arbiser JL, Feldman RJ. Treatment of Hailey-Hailey Disease With Low-Dose Naltrexone. JAMA Dermatol 2017; 153:1018.
  25. Ibrahim O, Hogan SR, Vij A, Fernandez AP. Low-Dose Naltrexone Treatment of Familial Benign Pemphigus (Hailey-Hailey Disease). JAMA Dermatol 2017; 153:1015.
  26. Houriet C, Seyed Jafari SM, Thomi R, et al. Canakinumab for Severe Hidradenitis Suppurativa: Preliminary Experience in 2 Cases. JAMA Dermatol 2017; 153:1195.
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