PracticeUpdate Dermatology February 2019

VOL. 3 • NO. 1 • 2019

OUR EXPERTS. YOUR PRACTICE.

ISSN 2206-4702

More Top Stories 2018 Dermatologic Aesthetics Hope on the Horizon for Children with Severe Atopic Dermatitis

Expert Opinion Changing Perceptions of Pediatric Mastocytosis By Warren R. Heymann MD Platelet-Rich Plasma for the Treatment of Diabetic Foot Ulcers By Eliot N. MostowMD, MPH

JOURNAL SCANS The Value of Urgent Care Dermatology

e-Evaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients: A Retrospective Analysis

Clinical Features of Neutrophilic Dermatosis Variants Resembling Necrotizing Fasciitis

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4 out of 10 patients achieved PASI 100* 1

7 out of 10 patients achieved PASI 90* 1 9 out of 10 responders maintained their PASI response for up to 5 years * 1,2

*PASI 75/90/100 responses at Year 1 (88.9%, 68.5% and 43.8%, respectively) were sustained to Year 5 (88.5%, 66.4% and 41%) 1

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Abbreviations: PASI: Psoriasis Area and Severity Index. References: 1. Bissonnette R et al. J Eur Acad Dermatol Venereol 2018 Feb 14. doi: 10.1111/jdv.14878. 2. Bissonnette R, et al. Br J Dermatol 2017; 177:1033–42. Cosentyx is a registered trade mark of Novartis AG. Novartis Pharmaceuticals Australia Pty Limited. ABN 18 004 244 160. 54 Waterloo Road, Macquarie Park NSW 2113. Ph (02) 9805 3555. AU-6737. August 2018. NODE14051W/PUCc. Ward6

PRACTICEUPDATE DERMATOLOGY BOARD PracticeUpdate is guided by a world-renowned Editorial and Advisory Board that represents community practitioners and academic specialists with cross-disciplinary expertise. Editor-in-Chief Robert T. Brodell MD, FAAD Professor and Chair, Department of Dermatology, and Professor of Pathology, University of Mississippi Medical Center, Jackson, Mississippi; Instructor in Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, New York

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ABOUT For a complete listing of disclosures for each board member and editorial contributor, please refer to their profile on PracticeUpdate.com PracticeUpdate ’s mission is to help medical professionals navigate the vast array of available literature and focus on the most critical information for their patients and practice. All journal articles selected for PracticeUpdate receive a Take-Home Message designed to quickly summarize the key findings and explain the importance of that research within the specialty area. The most critical articles also receive Expert Commentaries from experts who are handpicked by the PracticeUpdate Editorial Board, providing additional context on that research for the reader. Expert Opinion pieces give special highlights to important topics and Conference Coverage captures relevant takeaways from a vast array of medical meetings throughout the year. PracticeUpdate Dermatology provides coverage of key research from leading international conferences, and a collection of top journal articles and accompanying expert commentaries in a convenient print periodical. These and more are also available online at PracticeUpdate.com PracticeUpdate and PracticeUpdate Dermatology are commercially supported by advertising, sponsorship, and educational grants. Individual access to PracticeUpdate.com is free. Premium content is available to any user who registers with the site. While PracticeUpdate is a commercially-sponsored product, it maintains the highest level of academic rigour, objectivity, and fair balance associated with all Elsevier products. No editorial content is influenced in any way by commercial sponsors or content contributors. DISCLAIMER PracticeUpdate Dermatology has been developed for specialist medical professionals. The ideas and opinions expressed in this publication do not necessarily reflect those of the Publisher. Elsevier will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Please consult the full current Product Information before prescribing any medication mentioned in this publication. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer. The printing and distribution of this publication has been made possible through paid advertising. The editorial content herein is independently produced by Elsevier with no involvement by the advertiser. It contains content published in accordance with the editorial policies of Elsevier’s PracticeUpdate.com. All content printed in this publication can be found on PracticeUpdate.com. CONTENT Abstracts are available when the publisher grants permission from MEDLINE/ PubMed, a database of the US National Library of Medicine. • NLM data are produced by a US Government agency and include works of the United States Government that are not protected by US copyright law but may be protected by non-US copyright law, as well as abstracts originating from publications that may be protected by US copyright law. • NLM assumes no responsibility or liability associated with use of copyrighted material, including transmitting, reproducing, redistributing, or making commercial use of the data. NLM does not provide legal advice regarding copyright, fair use, or other aspects of intellectual property rights. Persons contemplating any type of transmission or reproduction of copyrighted material such as abstracts are advised to consult legal counsel. SALES Matthew Buttsworth m.buttsworth@elsevier.com Linnea Mitchell-Taverner l.mitchell@elsevier.com PRODUCTION Content was originally published on PracticeUpdate.com Production of this issue was executed by: Editorial Manager A nne Neilson anne.neilson@elsevier.com Editorial Project Manager Carolyn Ng • Designer Jana Sokolovskaja Cover: Skin nutrition/gettyimages.com PracticeUpdate Dermatology is published by Elsevier Australia ISSN 2206-4702 (Print) ISSN 2206-4710 (Online)

Associate Editors

Ashish C. Bhatia MD, FAAD Assistant Professor, Clinical Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Medical Director, Dermatologic Research, DuPage Medical Group, Naperville, Illinois; Co-Director, Dermatologic, Laser and Cosmetic Surgery, The Dermatology Institute – Naperville,

DuPage Medical Group Eliot Mostow MD, MPH

Head, Dermatology Section, Northeast Ohio Medical University; Professor, Northeast Ohio Medical University, Dermatology Section, Rootstown, Ohio; Assistant Professor, Clinical Medicine, Department of Dermatology, Case Western Reserve College of Medicine, Cleveland, Ohio; Chief, Wound Care Research, Akron General Medical Center, Akron, Ohio

Advisory Board

Sarah L. Chamlin MD Professor of Pediatrics and Dermatology, Northwestern University Feinberg School of Medicine; Attending Physician, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois

Jane Grant-Kels MD Professor of Dermatology, Pathology and Pediatrics; Founding Department Chair Emeritus; Vice Chair of the Department of Dermatology; Founding Director Emeritus of the UCONN Dermatopathology Lab and Dermatology Residency program; Director of the Cutaneous Oncology and Melanoma Program; University of Connecticut Health Center and School of Medicine, Farmington, Connecticut Christen Mowad MD Director of Contact and Occupational Dermatitis Clinic; Clinical Director for Geisinger Dermatology, Geisinger Medical Center, Danville, Pennsylvania

Editorial Contributors

Caroline Crabtree MD Dermatology Resident, University of Mississippi Medical Center, Jackson, Mississippi

InYoung Kim MD, PhD Resident, Dermatology, Case Western University Hospital, Cleveland, Ohio

Caitlyn Reed MD Dermatology Resident, University of Mississippi Medical Center, Jackson, Mississippi

Editorial Boards:

Our specialty-focused KOLs meet weekly to review the Editorial Contributors’ selections and to discuss which content is truly the most impactful – identifying which items require additional expert context and commentaries.

Advisory Boards: Expert physician Advisory Boards oversee subspecialty areas within each broader topic and provide guidance and context for that content for each specialty area. Editorial Contributors: Each week these teams of specialty-specific physicians scan all of the available literature and hand-select the most impactful and practice changing content for the Editorial Boards to review.

ABN 70 001 002 357 475 Victoria Avenue Chatswood NSW 2067 Australia Locked Bag 7500 Chatswood DC NSW 2067 EMDN021901

VOL. 3 • NO. 1 • 2019

NEW

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Please review Product Information before prescribing available from www.ebs.tga.gov.au or Sun Pharma by calling 1800 726 229 ILUMYA tildrakizumab (rch) 100 mg/1 mL solution for injection in pre-filled syringe. Indications: treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy. Contraindications: Hypersensitivity to the active substance or excipients. Clinically important active infections (e.g. active tuberculosis). Precautions: Infections: Chronic or a history of recurrent infections; monitor patients if a serious infection develops Active tuberculosis (TB); evaluate for TB prior to treatment. Consider anti-TB therapy in patients with history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Monitor for TB during and after treatment. Hypersensitivity: Discontinue immediately if a serious reaction occurs and initiate appropriate therapy. Immunisations: Patients should not receive live vaccines during and for at least 17 weeks after treatment. Consider completion of immunisations prior to treatment initiation but if a live vaccine is received, wait at least 4 weeks prior to treatment initiation. Malignancy: Caution should be observed in patients with a history of malignancy or if this develops during therapy. Paediatric Use: not evaluated in under 18yr population. Interactions: Live vaccines. (See full PI). Pregnancy: (Category B1) Adverse effects: Common: diarrhoea, nausea, fatigue, injection site pain, nasopharyngitis, sinusitis, arthralgia, back pain and pain in extremity. Dosage and administration: subcutaneous injection (100mg) at weeks 0, 4 and every 12 weeks thereafter. See Consumer Medicines Information for instructions. Storage: store in refrigerator (2ºC-8ºC). Do not freeze. ILUMYA is stable for up to 30 days at 25ºC. Protect from light. Do not shake. Store in original container until ready for use. Date of preparation: August 2018 ▼ This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at https://www.tga.gov.au/reporting-problems References: 1. Approved Product Information 2. PBS. Schedule of Pharmaceutical Benefits - Effective 1 February 2019. Department of Health, Canberra. www.pbs.org.au. Sun Pharma ANZ Pty Ltd ABN 17 110 871 826, Macquarie Park NSW 2113. Ph: 1800 726 229. Fax: +61 2 8008 1639. Med Info and to report Adverse Events: adverse. events.aus@sunpharma.com or 1800 726 229. ILUMYA™ is a trade mark of Sun Pharma ANZ Pty Ltd. IL2019/02ELSpbs1. Date of preparation: February 2019.

CONTENTS 5

EXPERT OPINION 20 Takeaways From the Inaugural Integrative Dermatology Symposium, October 2018 By InYoung Kim MD, PhD 22 Changing Perceptions of Pediatric Mastocytosis By Warren R. Heymann MD 24 Dermatopathology Reports About Basal Cell Carcinoma Margins Cannot Be Marginal By Warren R. Heymann MD 25 Platelet-Rich Plasma for the Treatment of Diabetic Foot Ulcers By Eliot N. Mostow MD, MPH 26 Tetracycline, Nicotinamide, and Lesionally Administered Clobetasol as a Therapeutic Option to Prednisone in Patients With Bullous Pemphigoid By Misha A. Rosenbach MD TOP STORIES 2018 6 Dermatologic Aesthetics By Ashish C. Bhatia MD, FAAD 7 Hope on the Horizon for Children With Severe Atopic Dermatitis By Sarah L. Chamlin MD

RESEARCH Editor’s picks 8 A Smartphone Application Supporting

Patients With Psoriasis Improves Adherence to Topical Treatment Comments by Robert T. Brodell MD, FAAD and Steven R. Feldman MD, PhD

9 Reexamining the Role of SLN Biopsy in Melanoma 10 The Value of Urgent Care Dermatology Comment by Jeremy Jackson MD

11 Reevaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients Comment by Anna A. Wile MD 12 Comparing Swab With Biopsy for Obtaining Culture Results Comment by Robert S. Kirsner MD, PhD 13 Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections Comment by Eliot N. Mostow MD, MPH 14 Clinical Features of Neutrophilic Dermatosis Variants Resembling Necrotizing Fasciitis Comment by Lindy Fox MD

15 Trends in Oral Antibiotic Prescription in Dermatology 16 Opioid Prescribing for Acute Postoperative Pain After Cutaneous Surgery Comment by David G. Brodland MD 17 Effectiveness of Topical Fluorouracil vs Topical Imiquimod for the Treatment of Actinic Keratosis Comment by Martin Weinstock MD, PhD, Meghan E. Beatson BS and Angelica A. Misitzis MD

VOL. 3 • NO. 1 • 2019

Dermatologic Aesthetics By Ashish C. Bhatia MD, FAAD TOP STORIES 2018 6

I t has been a very interesting year in dermatologic aesthetics, with many great studies, not only looking at the procedures and techniques that we employ the most, but also looking at the impact that these interventions have on patients and their lives. Addition- ally, there have been some nice studies that provide evidence on how to recognize and best manage com- plications in this area. One article that I really enjoyed was " Perceptions Regarding Appearance After Perioral Rejuvenation With Hyaluronic Acid Fillers ." 1 The lower face is an area that we have been treating for many years in our practice. However, in training dermatologists and plas- tic surgeons, the focus has long been on nasolabial folds and cheeks as well as the upper face. The lower face has been largely neglected. This is mostly due to the fact that most neuromodulators and fillers have FDA clearances for upper face and midface, respec- tively. Since most of the trainings are on-labeI, most injectors train on the upper and midface first. We find that both dermatologists and patients greatly underestimate the impact of disproportionate aging of the lower face on the overall appearance and impres- sion of age from an observer’s perspective. When I point out signs of perioral aging on a patient during a patient consultation or when we are doing a patient assessment at a training session for practicing derma- tologists and residents, it is definitely not obvious to most observers. But when we cover up the top half of the face and then cover up the bottom half of the face and have the observer assess the perceived age of each area, it becomes very apparent. Aesthetics is not only about beauty, it is about harmony and balance. Disproportionate aging of different areas of the face is due to both genetic aging and external aging, and restoring harmony can have a great impact. This particular study evaluated the impact of rejuve- nating the lower face. The most dramatic results in this

study were the perceptions of the blinded evaluators relative to the treated perioral area. They perceived that individuals in the treated pictures had greater social skills, academic performance, dating success, occupational success, attractiveness, financial success, relationship success, and athletic success compared with pictures of untreated individuals. It is amazing that observers inferred so much about individuals who received minor corrections that can easily be achieved in a relatively quick and safe in-office procedure. The funny thing is that this study only looked at perioral rejuvenation with fillers. Today, there are so many other treatments that we can do nonsurgically and in the office to help improve the lower face. These include enhancement of jawline definition, reduction of masse- ter projection, enhancing chin projection, and reducing jowls. As aesthetic procedures become more commonplace, so do the complications. Just like in medical dermatol- ogy, one of the most important aspects of expanding one's repertoire of treatments for conditions is learn- ing to prevent, recognize, and treat complications of our therapies. This has been a good year for publi- cations addressing this. The first important article in this arena is entitled, " Vascular Injury After Deoxy- cholic Acid Injection ." 2 As deoxycholic acid injections are gaining popularity, not only for their on-label use in the submental area but also in off-label use in the jowls and in body contouring, we are likely to see more complications. This manuscript is a case report high- lighting two cases of what appear to be local vascular events after injection of deoxycholic acid. This can lead to tissue necrosis and tissue damage if not real- ized and treated early. Because deoxycholic acid is a solution, unlike some fillers, intravascular placement of the needle tip can be detected in most cases sim- ply by pulling back on the plunger prior to injection. This article is impactful because it is a complication

PRACTICEUPDATE DERMATOLOGY

TOP STORIES 2018 7

Hope on the Horizon for ChildrenWith Severe Atopic Dermatitis By Sarah L. Chamlin MD D upilumab received FDA approval for adults with atopic dermatitis (AD) in March of 2017, and approval for children with asthma 12 years and older was announced in October of 2018. FDA approval, published evidence of effi- cacy, and clinical experience for adult patients with atopic dermatitis strongly supports use of dupilumab. 1 In addition, this recent approval for a pediatric indication bodes well for children with AD, and phase III trials are underway for children with moderate to severe atopic dermatitis ages 6 months to 18 years of age. Unfortunately, due to insurance limitations and previous lack of a pediatric indication, few practi- tioners have experience using dupilumab off-label in children with AD. This private-practice group reported use in 6 children with severe AD with a mean age of 10.8 years. 2 All patients responded well, and 3 were almost clear (IGA of 1). This case series is a practical and real-world use of this drug in pediatric patients. The authors used a mean loading dose of 11.4 mg/kg and a mean biweekly dose of 5.7 mg/kg. Significant conjunc- tivitis was not reported in these patients, and the average duration of therapy was 8.5 months. Of these 6 patients, 5 had failed other systemic ther- apy, offering hope even for recalcitrant patients. Although the authors did not provide insight on how they were able to obtain insurance author- ization, this will be a significant hurdle to using dupilumab until FDA approval occurs. A labeled indication is likely many years away, and I hope to, very soon, partner with my allergy colleagues to gain experience using this for my patients with asthma and severe atopic dermatitis, the “kill two birds with one stone” approach. References 1. Seger EW, Wechter T, Strowd L, Feldman SR. Relative efficacy of systemic treatments for atopic dermatitis. J Am Acad Dermatol 2018 Oct 5. doi: 10.1016/j. jaad.2018.09.053. [Epub ahead of print.] 2. Treister AD, Lio PA. Long-term off-label dupilumab in pediatric atopic dermatitis: a case series. Pediatr Dermatol 2018 Oct 18. doi: 10.1111/pde.13697. [Epub ahead of print.] www.practiceupdate.com/c/76156

that has not been previously reported. Our commentary highlights some tips to recognize and prevent this. The second article in this realm, entitled, " Effectiveness of Low Doses of Hyaluronidase to Remove Hyaluronic Acid Filler Nodules ," was published in JAMA Dermatology this year. 3 The study evaluated the use of hyaluronidase for dissolving excess or improperly placed hyaluronic gels. Because hyaluronic acid gel injections are the most common filler injections globally, it is important to know the art and science of managing their complications and occasional unwanted outcomes. The authors share their findings regarding the concen- tration-dependent effect of hyaluronidase in dissolving unwanted hyaluronic acid filler. The accompanying commentary also addresses the more serious complication of impending vascular necrosis from intravascular injection of hyaluronic acid and the need for more concentration and large-volume use of hyaluronidase to manage those situations. A big shout out to my colleagues and mentors, Dr. Bob Brodell and Dr. Eliot Mostow, for allowing me to be part of this “comprehensive virtual journal club.” Also, a big thanks to our editorial board and our screeners and section edi- tors who do such a great job covering such a breadth of the most impactful findings in the dermatology literature and making them accessible to myself and our colleagues. I always look forward to our calls to discuss the literature and the impact on our specialty. Also, a big thanks to PracticeUpdate and the entire Elsevier team, who make the process so smooth and so much fun. References 1. Dayan SH, Bacos JT, Gandhi ND, et al. Assessment of the impact of perioral rejuvenation with hyaluronic acid filler on projected first impressions and mood perceptions. Dermatol Surg 2018 Jul 27. doi: 10.1097/DSS.0000000000001613. [Epub ahead of print.] 2. McKay C, Price C, Pruett L. Vascular injury after deoxycholic acid injection. Dermatol Surg 2018 May 9. doi: 10.1097/DSS.0000000000001550. [Epub ahead of print.] 3. Alam M, Hughart R, Geisler A, et al. Effectiveness of low doses of hyaluronidase to remove hyaluronic acid filler nodules: a randomized clinical trial. JAMA Dermatol 2018;154(7):765-772. www.practiceupdate.com/c/76155 " We find that both dermatologists and patients greatly underestimate the impact of disproportionate aging of the lower face on the overall appearance and impression of age from an observer’s perspective. "

VOL. 3 • NO. 1 • 2019

EDITOR’S PICKS 8

A Smartphone Application Supporting Patients With Psoriasis Improves Adherence to Topical Treatment The British Journal of Dermatology Take-home message • This randomized controlled trial evaluated the efficacy of a smartphone application (app) for improving treatment adherence in patients with psoriasis. In all, 122 patients completed the study. Each patient was given a medication canister containing calcipo- triol/betamethasone dipropionate cutaneous foam equipped with a chip which recorded the date and time of each application. Patients were instructed to apply the medication once daily. Patients in the intervention group were also given an app which sent daily reminders to their phone to apply their medication. At the end of 4 weeks, 65% of patients in the intervention group were compliant with the daily regimen (use of medication on greater than 80% of days) vs 38% of patients in the non-intervention group. • Patient adherence and psoriasis disease severity can be positively impacted using a smartphone app for daily reminder. Caitlyn T. Reed MD COMMENT By Robert T. Brodell MD, FAAD W hen I read this randomized study involving use of a smartphone app to remind patients to adhere to their topical treatment for psoriasis in a treatment and con-

longer one is on a drug, the less often the patient uses the drug.” Therefore, in this study, I would have expected that at longer time intervals (Weeks 8 and 24) there would have been MORE significant variance in the use of the topical product reflected in greater improvement and more favorable quality of life in the intervention group. This study showed a significant improvement only in week 4! Also, by my reading of this study, the adherence measures were only performed for the first 4 weeks of the trial. I believe that patients may become “bored” with the app and begin to ignore it over longer periods of time. Assuming that this is correct, we may need a more engaging, effective app…. and, another study could be done to demonstrate a scalable approach to overcoming patient adherence problems with adherence measured over a 24-week time frame. An alterna- tive explanation: the medication they chose to test may work so well, that missing more applications in the control group makes no difference in the eventual outcome based upon physician global assessment and quality of life measures. I have asked Steve Feldman to respond to this commentary! initial adherence, the app didn’t cause patients to develop a habit of using their treatment. Developing approaches – whether technological or psychosocial – that lead patients to develop solid medication use habits could be a profound way to improve the long-term outcomes of topical treatment for a wide range of skin diseases. I remember the tag line, “Better living through chemistry.” It may be that “Better living through psychology” describes an even more productive way of improving our patients’ outcomes.

trol group, I thought immediately of Steve Feldman. When I saw that memory caps on the foam canisters were used to judge adherence along with a secondary measure (weight of canisters brought in during visits) and that physician global assessment and quality of life measures were used in the study, I KNEW he must have a hand in this even though the study was performed at the University of South Denmark in Odense. Kudos are in order for the continued efforts of dermatologists from around the world that have been inspired by Dr. Feldman to perform research on the problem of adherence in dermatology that is experienced by ALL of our patients. There are findings in this study that did not match my hypotheses regarding patient adherence. I believe that tachyphylaxis (failure of a drug after prolonged use) is not primarily a pharmacologic phenomenon. In the setting of a topical product, it is not “the longer one uses a drug the less well it works” but, rather, “the By Steven R. Feldman MD, PhD S vendsen et al find that patients with psoriasis are not highly adherent to their topical treatment and that a reminder app can help increase their use of treatment. Their study, done in a Danish population who were sufficiently clever to use an English app and bothered enough by their disease to make regular visits to the dermatology office, shows that even well- educated patients with bothersome disease don’t use their topical medication. This study also shows that a simple, scalable app can help improve, but not altogether solve, the problem of poor adherence. In this study, the reminder app was only used for the first month. At 1 month, adherence and outcomes were better in patients who received the reminders. Although adherence was only measured for that month, only smaller differences – not statistically significant ones – remained in treatment outcomes at 8 and 12 weeks, suggesting that, although the app helped improve

Dr. Feldman is a Professor of Dermatology, Pathology & Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

PRACTICEUPDATE DERMATOLOGY

EDITOR’S PICKS 9

Reexamining the Role of SLN Biopsy in Melanoma Journal of the American Academy of Dermatology Take-home message • The Multicenter Selective Lymphad- enectomy Trials indicated that there are no overall or melanoma-specific survival advantages to performing sentinel lymph node (SLN) biopsy fol- lowed by an immediate completion lymph node dissection in patients with positive SLNs compared with wide excision and observation. In this commentary, the authors express concerns that SLN biopsy may solely be a staging procedure that stratifies patients into trials or to receive adjuvant therapy and which comes at a high cost of significant patient morbidity. • The authors suggest that the role of SLN biopsy in the management of melanoma patients should be reex- amined, considering that the potential marginal benefit of SLN biopsy has not been well-established. InYoung Kim MD, PhD Abstract The Multicenter Selective Lymphadenectomy Trials (MSLT) were practice changing rand- omized, controlled trials. MSLT-I demonstrated that in patients with cutaneous melanoma wide excision and sentinel lymph node biopsy (SLNB) followed by immediate completion lymph node dissection (ICLND) for patients with positive sentinel nodes did not provide overall or mel- anoma specific survival advantage over wide excision and observation. MSLT-II demonstrated that ICLND did not increase overall or melano- maspecific survival compared to close clinical observation and delayed CLND even among patients with melanoma and positive senti- nel-nodes. These results indicate that SLNB followed by ICLND has no survival value and SLNB should now be regarded solely as a stag- ing procedure. Its role as a staging procedure in the management of patients with melanoma deserves reappraisal. Time to Reconsider the Role of Sentinel Lymph Node Biopsy in Melanoma. J Am Acad Derma- tol 2018 Nov 21;[EPub Ahead of Print], M Bigby, S Zagarella, M Sladden, CM Popescu. www.practiceupdate.com/c/76993

Abstract BACKGROUND Adherence to topical psoriasis treatments is low, which leads to unsatisfac- tory treatment results. Smartphone applications (apps) for patient support exist but their poten- tial to improve adherence has not been systematically evaluated. OBJECTIVES To evaluate whether a study-spe- cific app improves adherence and reduces psoriasis symptoms compared with standard treatment. METHODS We conducted a randomized con- trolled trial (RCT, clinicaltrials.gov registration: NCT02858713). Patients received once-daily medication [calcipotriol/betamethasone dipro- pionate (Cal/BD) cutaneous foam] and were randomized to no app (n = 66) or app inter- vention (n = 68) groups. In total, 122 patients (91%) completed the 22-week follow-up. The primary outcome was adherence, which was defined as medication applied ≥ 80% of days during the treatment period and assessed by a chip integrated into the medication dispenser. Secondary outcomes were psoriasis severity measured by the Lattice System Physician's Global Assessment (LS-PGA) and quality of life, measured using the Dermatology Life Quality Index (DLQI) at all visits. RESULTS Intention-to-treat analyses using regression was performed. More patients in the intervention group were adherent to Cal/ BD cutaneous foam than those in the non- intervention group at week 4 (65% vs. 38%,

P = 0·004). The intervention group showed a greater LS-PGA reduction than the noninter- vention group at week 4 (mean 1·86 vs. 1·46, P = 0·047). A similar effect was seen at weeks 8 and 26, although it did not reach statistical significance. CONCLUSIONS This RCT demonstrates that the app improved short-term adherence to Cal/ BD cutaneous foam treatment and psoriasis severity. A Smartphone Application Supporting Patients With Psoriasis Improves Adherence to Topi- cal Treatment: A Randomized Controlled Trial. Br J Dermatol 2018 Nov 01;179(5)1062-1071, MT Svendsen, F Andersen, KH Andersen, et al. the long-term outcomes of topical treatment for a wide range of skin diseases. " " Developing approaches – whether technological or psychosocial – that lead patients to develop solid medication use habits could be a profound way to improve

www.practiceupdate.com/c/76554

VOL. 3 • NO. 1 • 2019

EDITOR’S PICKS 10

The Value of Urgent Care Dermatology International Journal of Dermatology Take-home message

COMMENT By Jeremy Jackson MD U rgent care dermatology clinics provide patients rapid access to dermatologists who are the most qualified to treat conditions of the skin. This article shows that there are several potential benefits to seeing patients in the setting of an urgent care dermatology clinic versus waiting for a general dermatology clinic appointment or being seen in an emergency room. These benefits include lower no-show rates compared with general derma- tology clinics, shorter wait times when compared with emergency room vis- its, and significantly decreased costs to the healthcare system when com- pared with emergency room visits. This study was performed at a tertiary care academic medical center where it is likely less difficult to implement than in a private practice setting. However, in the current healthcare environment, where quality measures and value are increasingly emphasized, this article supports the benefits of implementing urgent care dermatology clinics to pro- vide high-quality access to our patients. At the University of Mississippi, we have had a rapid access clinic (RAC) for a lit- tle over a year. There are barriers! The RAC must refer to "regular" clinics for follow-up care to keep openings avail- able for urgent and emergent patients. The RAC dermatologist loses continuity of care with many of these patients. Still, it has been a great success and won friends for our department, including emergency room personnel, primary care physicians, and private practicing dermatologists who often need to send patients "right now!!"

• The authors of this study from the University of Utah established an urgent care dermatology clinic which offered same-day dermatology (SDD) appointments to better serve patients with acute skin diseases who would otherwise have presented to their primary care doctor or the emergency department (ED) and to determine if urgent-care dermatology adds value to healthcare. Over the study period of 3 months, 542 patients were seen in SDD. Compared with similar patients from ED, patient encounters in SDD took less time (58 minutes in SDD vs 163 minutes in ED), and patients were charged less than half the cost of an ED visit. The no-show rate for SDD was less than half that of a general dermatology clinic (2.5% vs 5.7%, respectively). Patients in SDD were more likely to be insured by Medicaid or self-pay than those in a general dermatology clinic. • As wait times for dermatology appointments continue to increase, patients with acute skin problems often resort to visiting the ED, resulting in significant wait times, high costs, and treatment by a provider with no formal dermatology training. Urgent-care dermatology clinics can greatly increase the value of care for patients with acute skin issues through quality specialist care and lower costs compared with ED. Caitlyn T. Reed MD

Abstract OBJECTIVE To determine whether urgent care dermatology adds value (service + quality/cost) to healthcare. METHODS A retrospective cross-sectional chart review of dermatologic patients in three service settings was compared: an urgent care derma- tology clinic (same day dermatology [SDD]), the emergency department (ED), and a general dermatology clinic. Study period was July 1-Sep- tember 30, 2014, for ED and SDD patients and August 2014 for general dermatology patients. ED patients had diagnoses of dermatitis (629.9) or rash (782). Final diagnoses, visit length, and no-show rates were determined. Cost and charge data for patients seen in SDD versus the ED were provided by the university, without raw data available for publication. RESULTS For matched diagnoses, ED visits were 105 (95% CI: 68.7-152.4, P < 0.001) min- utes longer than SDD visits. Compared to SDD,

no-shows in the general dermatology clinic were 2.24 times more likely (95% CI: 1.0003-5.02, P = 0.045). The odds for an SDD patient to be diag- nosed with a code that was also seen in the ED was 13.0 (95% CI: 8.0-21.2, P < 0.01) times higher than the odds for the same diagnosis to be given to patients seen in the general derma- tology clinic. ED visits cost 25% more than SDD visits. Patient charges for an ED visit are 207% more than for an SDD visit. CONCLUSIONS Urgent care dermatology clinic adds value to the healthcare system by pro- viding quality care and excellent service at low cost. Dermatologists better utilize their skills by seeing acute, often-serious patients who would have otherwise been seen in the ED. The Value of Urgent Care Dermatology. Int J Dermatol 2019 Jan 01;58(1)80-85, J Sempler,

Dr. Jackson is an Assistant Professor of Dermatology at the University of Mississippi Medical Center in Jackson, Mississippi.

F Thomas, J Pettit, SZ Klein. www.practiceupdate.com/c/77694

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Reevaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients Journal of the American Academy of Dermatology Take-home message • This retrospective study included 903 patients using isotretinoin for acne (62.9% women), with a mean age of 28.6 years. Patients were started on twice-daily isotretinoin 10 to 20 mg and increased to a maximum dose of 40 to 80 mg twice daily for a duration of 4 to 9 months. There was no clinically significant anemia, thrombocytopenia, or leukopenia observed. Elevations in triglycerides, ALT, and AST resolved at follow-up upon completion of isotretinoin treatment. Risk factors for increased triglyceride levels included obesity (BMI >30), increased baseline triglyceride levels, and concomitant medications. Increases in both ALT and AST occurred in 7 patients, which were all attributed to concomitant alcohol use. • Given that transient alterations of lipid and liver aminotransferases levels tend to be clinically insignificant, and repeated laboratory monitoring may cause financial and emotional burden for patients, the authors recommend reducing the tests to baseline, at 2 to 3 months, and upon completion of the isotretinoin treatment course. InYoung Kim MD, PhD

COMMENT By Anna A. Wile MD A growing body of evidence argues against monthly laboratory monitor- ing for patients on isotretinoin. The authors of this article support this notion after evaluating 903 patients treated with isotretinoin. No clinically significant ane- mia, thrombocytopenia, or leukopenia was noted in the study, and elevated ALT or AST was uncommon. However, elevated triglycerides were seen in 21.8% of patients, which, in my opinion, is common. Similar findings were cited in two recent articles, “Laboratory Monitoring During Isotretinoin Therapy for Acne: A Systematic Review and Meta-Analysis,” by Lee et al and “Standard- ized Laboratory Monitoring with Use of Isotretinoin in Acne,” by Hansen et al. 1,2 All three articles conclude that monthly labora- tory monitoring for isotretinoin is excessive. Changing old standards of care may be

but forgo a full cholesterol panel? Maybe even drop CBCs altogether? Despite ini- tial unease, I believe we can challenge ourselves to find a new laboratory monitor- ing regimen that is based in evidence and proven to keep patients safe. References 1. Lee YH, Scharnitz TP, Muscat J, et al. Laboratory monitoring during isotretinoin therapy for acne: A systematic review and meta-analysis. JAMA Dermatol 2016;152(1):35-44. 2. Hansen TJ, Lucking S, Miller JJ, et al. Standardized laboratory monitoring with use of isotretinoin in acne. J Am Acad Dermatol 2016;75(2):323-328.

uncomfortable, but it may be appropri- ate. Any dermatologist would likely find the study well-designed and the evidence sound. However, when it comes to translat- ing the article’s recommendations to daily practice, many will hesitate. I admit, I like the security and reassurance that monthly laboratory monitoring offers. I even find myself using it as a tactic to reassure anx- ious parents. However, our discomfort is not an excuse to ignorewarranted changes that save healthcare dollars and decrease patient discomfort. Even if we are not yet comfortable with the article’s recommenda- tion of “testing at 2–3months, after reaching the peak dose, and upon completion of the treatment course,” we could consider other judicious changes. Couldwe checkASTand ALT every other month instead of monthly? Could we continuemonitoring triglycerides

Dr. Wile is a Dermatologist at Rush Health System in Meridian, Mississippi.

Abstract Oral isotretinoin, a vitamin A derivative, is a very effective treatment for acne vulgaris. Routine labo- ratorymonitoring has become part of the standard regimen for isotretinoin use due to concerns for the development of transaminitis, leukopenia, thrombocytopenia, and lipid abnormalities. This retrospective analysis identified 1,015 patients who were diagnosed with acne vul- garis and had mention of systemic isotretinoin therapy in their medical record from 2010-2017 at Massachusetts General Hospital and Brigham and Women’s Hospital. e-Evaluating the Need for Routine Laboratory Monitoring in Isotretinoin Patients: A Retrospec- tive Analysis. J Am Acad Dermatol 2018 Oct 10;[EPub Ahead of Print], R Shah, D Kroshinsky.

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Comparing SwabWith Biopsy for Obtaining Culture Results Wound Repair and Regeneration Take-home message

COMMENT By Robert S. Kirsner MD, PhD C hronic wounds harbor bacteria and many heal despite 3 or more bacteria being present. The mere presence of bacteria in a chronic wound does not equate to a wound infection. Rather, wound infection is diagnosed by a clinician based on clinical features such as redness, warmth swelling, pain, and loss of function. Therefore, chronic wound infections are a clinical, not a microbiologic, diagnosis. However, wound cultures play a role in patient care. After a wound infection is diagnosed, clinicians should imple- ment empiric antibiotic therapy based on evidence-based algorithms or local community or hospital antibioticograms. When a patient returns in follow-up, if the infection has not improved, cul- tures help to direct further antibiotics therapy. Therefore, the findings of this article are quite important because they lend confidence to clinicians that taking a swab (as opposed to a more invasive tissue culture) is beneficial for choice of antibiotic and by helping predict which bacteria may be present deeper in the wound. As technology improves, it may still prove to be important to obtain tissue cultures for bacteria, especially if the ability to perform quantitative cultures becomes routine in a clinical setting, which currently it is not. Quantitating the amount of bacteria in tissue may aid fur- ther in helping clinicians decide if and what antibiotics are needed in the care of a patient with a chronic wound.

• This study compared samples obtained by swab and biopsy in clinical practice by including a variety of wounds and using standard sampling and culture procedures. Wound cultures from 180 patients were analyzed, and samples obtained with biopsies were compared with samples from swabs using the Levine technique. While skin flora was more frequently cultured from swabs, similar recovery rates were obtained when excluding skin flora. Swabs identified all microorganisms cultured from biopsies in 131 wounds (72.8%). • Wound swabs have been avoided with the presumption that they capture microor- ganisms from the skin surface only. When human skin flora was excluded from the comparison, 72.8% of all wounds had identical culture results in this study. Thus, swabs may be considered as an initial diagnostic tool, keeping in mind that neither biopsy nor swab can consistently identify all microorganisms present in the wound. InYoung Kim MD, PhD

Abstract The question remains whether wound swabs yield similar culture results to the traditional gold standard, biopsies. Swabs are not invasive and easy to perform. However, they are believed to capture microorganisms from the surface rather than microorganisms that have invaded tissue. Several studies compared swabs and biopsies using different populations and sampling meth- ods, complicating the ability to draw conclusions for clinical practice. This study aimed to compare swab and biopsy in clinical practice, by including a variety of wounds and using standard sam- pling and culture procedures. Swabs (Levine technique) and biopsies were taken for microbi- ological culture in a standardized manner from the same location of one wound for each patient. Statistical analyses were performed to determine overall agreement, and observed agreement and kappa for specific microorganisms. A variety of

wounds of 180 patients from different healthcare facilities in The Netherlands were included. Skin flora was more frequently cultured from swabs, resulting in similar recovery rates when excluding skin flora (1.34 vs 1.35). Swabs were able to iden- tify all microorganisms cultured from biopsies in 131 wounds (72.8%) wounds. Most frequently iden- tified organisms were Staphylococcus aureus, Pseudomonas aeruginosa, and beta-haemolytic streptococci species. Observed agreement and kappa for these organisms varied between 87.2 and 97.8% and 0.73 and 0.85, respectively. This study demonstrates that swabs and biopsies tend to yield the same culture results when taken from the same location. For frequently occurringmicro- organisms, agreement between the twomethods was even higher. Therefore, there seems to be no direct need for invasive biopsy in clinical practice.

Dr. Kirsner is Chief of Dermatology at University of Miami Hospital, and Chairman of Dermatology at the Department of Dermatology and

Cutaneous Surgery, University of Miami Miller School of Medicine in Miami, Florida.

Wound Swab and Wound Biopsy Yield Similar Culture Results. Wound Repair Regen 2018 Mar 01;26(2)192-199, M Haalboom, MHE Blokhuis- Arkes, RJ Beuk, et al. www.practiceupdate.com/c/76115

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Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections JAMA Dermatology Take-home message • This study measured the rate of laboratory test abnormalities in 4985 healthy adults and children using terbinafine or griseof- ulvin for dermatophyte infections. Elevated ALT, AST, anemia, lymphopenia, and neutropenia were infrequent, and rates were comparable to the baseline rates. Most (93.4%) of the abnormalities that occurred were grade 1. The grade 2 or higher laboratory abnormalities detected with terbinafine consisted of 4 cases of ALT elevations (0.2%), 1 case of AST elevation (0.1%), 1 case of anemia (0.1%), and 5 cases of lymphopenia (0.7%). The rate of laboratory abnormalities for griseofulvin microsize was low, with 3 patients with grade 2 neutropenia (4%) and 1 patient with grade 2 lymphopenia (1%), all of whom continued the treatment course uneventfully. There was only 1 patient with a grade 1 AST elevation with griseofulvin ultra-microsize, and no cases of ALT measurement elevation, anemia, neutropenia, or lymphopenia were identified. • Given the low rates of abnormalities, routine interval laboratory test result monitoring appears to be unnecessary in healthy adults and children taking oral terbinafine or griseofulvin for dermatophyte infections. Caroline K. Crabtree MD

Abstract IMPORTANCE Terbinafine hydrochloride and griseofulvin are effective oral treatments for der- matophyte infections but have been associated with hepatic and hematologic abnormalities. The prevalence of alanine aminotransferase eleva- tions, aspartate aminotransferase elevations, anemia, lymphopenia, and neutropenia among adults and children taking terbinafine and gri- seofulvin is unclear. OBJECTIVE To measure the rate of laboratory test result abnormalities in healthy adults and children taking terbinafine or griseofulvin for dermatophyte infections. DESIGN, SETTING, AND PARTICIPANTS This retro- spective study assessed adults and children taking terbinafine or griseofulvin for derma- tophyte infections from January 1, 2006, to December 31, 2016. Data were collected from one Midwest health care system. Exclusion cri- teria were preceding diagnosis of hepatic or hematologic condition and preceding or con- current use of oral ketoconazole, amphotericin, or itraconazole. MAIN OUTCOMES AND MEASURES The rates of ele- vated alanine aminotransferase measurements, elevated aspartate aminotransferase measure- ments, anemia, lymphopenia, and neutropenia in adults and children taking terbinafine, griseof- ulvin microsize, or griseofulvin ultramicrosize were calculated. Secondary measures included rates of baseline abnormalities, frequency of laboratory test results that required additional testing or discontinued use of medication, and laboratory test result monitoring practices. RESULTS This study included laboratory data from 4985 patients (mean [SD] age, 42.8 [20.3] years; 2288 [45.9%] female) receiving 4309 courses of terbinafine, 634 courses of griseof- ulvin microsize, and 159 courses of griseofulvin ultramicrosize. We identified a low rate of labo- ratory test result abnormalities in patients taking

" …this study assists us in counseling patients and

Utility of Laboratory Test Result Monitoring in Patients Taking Oral Terbinafine or Griseofulvin for Dermatophyte Infections. JAMA Dermatol 2018 Oct 17;[EPub Ahead of Print], DA Stolmeier, HB Stratman, TJ McIntee, EJ Stratman. www.practiceupdate.com/c/74959 binafine. I think we all want to protect ourselves from malpractice suits, and the concept of defensive medicine can sometimes still be good medical practice; however, this study assists us in counseling patients and parents that good care does not have to be as invasive, especially for children. When I prescribe relatively short courses of terbinafine to children and adoles- cents, I offer blood work monitoring, telling them what my usual protocol is for adults, but give them the chance to decline it while explaining “my sense” that the risks of problems in children are less (and perhaps overrated in adults too)....and I document the conversation in my notes (my defense, if needed?). Almost all decline the offer to monitor. Now I have more data to support my clinical care and what constitutes good medical care. COMMENT By Eliot N. Mostow MD, MPH T his study was impressive in that it used data from 4985 patients receiving 4309 courses of ter-

parents that good care does not have to be as invasive, especially for children. "

terbinafine or griseofulvin. When laboratory test result abnormalities occurred, most were low grade (212 [93.4%] grade 1) and did not require subsequent laboratory test result evaluation or discontinued use of medication (15 051 [99.9%]). Elevations in alanine aminotransferase meas- urements were detected infrequently and were comparable to baseline detection rates (61 [3.5%] vs 95 [3.6%] for terbinafine, 2 [2.1%] vs 3 [3.7%] for griseofulvin microsize, and 0 vs 2 [5.0%] for griseofulvin ultramicrosize). Rates of elevated aspartate aminotransferase measure- ments, anemia, lymphopenia, and neutropenia were also infrequent and comparable to base- line rates. CONCLUSIONS AND RELEVANCE In this study. the rates of alanine aminotransferase elevations, aspartate aminotransferase elevations, ane- mia, lymphopenia, and neutropenia in adults and children taking terbinafine or griseoful- vin were low and equivalent to the baseline rates of abnormalities in this population. Rou- tine interval laboratory test result monitoring appears to be unnecessary in adults and chil- dren without underlying hepatic or hematologic conditions taking terbinafine or griseofulvin for dermatophyte infections. Abandoning frequent laboratory monitoring can decrease unneces- sary health care spending, decrease patient psychological angst associated with blood draws, and allow for expanded use of these effective oral medications.

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