PracticeUpdate Dermatology Best of 2018

EXPERT OPINION 20

Dr. Dirk Elston and the Best of JAAD By Dirk Elston MD, FAAD

Dr. Elston is Clinical Professor of Dermatology at the Robert Wood Johnson School of Medicine of Rutgers University, Clinical Professor of Medicine (Dermatology) at the New York College of Osteopathic Medicine, Clinical Professor of Medicine (Dermatology) at the Touro College of Osteopathic Medicine in Brooklyn, New York. Dr. Elston, Editor of the Journal of the American Academy of Dermatology , summarizes his favorite clinically relevant articles published by JAAD over the past year.

Cost-effective medicine Following in the tradition of the Choosing Wisely campaign, the authors of a paper entitled, “5 Laboratory Tests to Reconsider,” suggest several studies that the prudent, cost-conscious physician may choose to forgo. 1 Potassium testing in young healthy women on acne doses of spironolactone (typically 50 mg/day) • In my practice, I do not routinely check potassium levels at the 50-mg dose; but, for hirsutism doses (200 mg/day) I check once at 4 to 6 weeks. For those patients with renal impairment, the drug should be used with caution, and patients should be warned about possible trimethoprim– sulfa interactions. Monthly labs for isotretinoin • If no bump in 6 to 8 weeks, there may be no role for repeat testing. LFTs for healthy people on terbinafine • Those with elevations are generally also symptomatic. Random TSH in vitiligo • Testing should be driven by signs or symptoms. • Counsel patients about signs and symptoms. Screening ANA for biologics CBC, metabolic panel for biologics • Even for TB, testing is not enough and patients must be asked about signs and symptoms. Immunizations in patients on tofacitinib 2 Most patients are able to mount a response to immunization while on tofacitinib.

Nonbullous pemphigoid 3 Erythematous, urticarial plaques are pres- ent in 52.3% of patients, and papules/ nodules are present in 20.5%. The mean age at presentation in this study was 74.9 years. CARD14-associated papulosquamous eruption 4 Suspect CARD14-associated papu- losquamous eruption in patients with papulosquamous disease with early-age onset; prominent involvement of the cheeks, chin, and ears; family history of psoriasis or pityriasis rubra pilaris; and min- imal response to conventional topical and systemic psoriasis therapies. Patients demonstrated improvement with ustekinumab. Pathologist characteristics associated with accuracy and reproducibility of melanocytic skin lesion interpretation 5 Rates of diagnostic reproducibility and accuracy were highest among patholo- gists with: • Board certification in dermatopathology. • 5 or more years of experience. Changing antimalarial agents after inefficacy or intolerance in patients with cutaneous lupus erythematosus 6 Of the patients changed because of inef- ficacy, 56% were responders at month 3; however, the response decreased over time. For patients switched because of adverse events, the second antimalarial agent was well-tolerated in 69% of cases.

Subclinical sensitization with diphenylcyclopropenone is sufficient for the treatment of alopecia areata 7 Of 159 patients, 46 (28.9%) showed a com- plete response and 59 (37.1%) showed a partial response. Dose escalation of doxepin for intractable pruritus 8 Optimal range in the plasma concentration was 150 to 250 g/L, with risk for toxicity at 500 g/L. In intractable pruritus when doxepin was considered a treatment failure, the researchers found that the dose could be titrated up to 300 mg/day by using trough plasma levels. Mycoplasma pneumoniae–associated erythema multiforme has a distinctive pres- entation with diffuse atypical targets and severe and extensive mucositis. • Histology is similar to toxic that of epi- dermal necrolysis. Anti-MDA5 dermatomyositis 10 The presence of mucocutaneous ulcer- ation, palmar papules, digital ulcers, nonscarring alopecia, panniculitis, and arthritis should suggest the diagnosis and Clinical and histologic features of mycoplasma pneumoniae-related erythema multiforme 9

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