Improving systemic therapy selection for inflammatory skin diseases: A clinical need survey.

Background: Empirical decisions to select therapies for psoriasis (PSO) and atopic dermatitis (AD) can lead to delays in disease control and increased health care costs. However, routine molecular testing for AD and PSO are lacking. Objective: To examine (1) how clinicians choose systemic therapies for patients with PSO and AD without molecular testing and (2) to determine how often the current approach leads to patients switching medications. Methods: A 20-question survey designed to assess clinician strategies for systemic treatment of AD and PSO was made available to attendees of a national dermatology conference in 2022. Results: Clinicians participating in the survey (265/414, 64% response rate) ranked "reported efficacy" as the most important factor governing treatment choice (P < .001). However, 62% (165/265) of clinicians estimated that 2 or more systemic medications were typically required to achieve efficacy. Over 90% (239/265) of respondents would or would likely find a molecular test to guide therapeutic selection useful. Limitations: To facilitate ease of recall, questions focused on systemic therapies as a whole and not individual therapies. Conclusion: Clinicians want a molecular test to help determine the most efficacious drug for individual patients.

Incorporating a Prognostic Gene Expression Profile Test into the Management of Cutaneous Squamous Cell Carcinoma: An Expert Consensus Panel Report.

BACKGROUND:  Cutaneous squamous cell carcinoma (cSCC) is a growing health concern with a rapidly increasing incidence. Disease-specific mortality is typically preceded by a metastasis, but current staging systems have significant limitations in predicting this event. The 40-gene expression profile (40-GEP) test is a validated method of further stratifying patients based on the risk of regional or distant metastasis, but limited guidelines exist for incorporating this test into clinical practice. OBJECTIVE:  To review the available literature on the use of gene expression profile (GEP) testing to assess prognosis in cSCC and create consensus statements to guide dermatology clinicians on its use. METHODS:  A comprehensive literature search of PubMed, EMBASE, and Scopus was completed for English-language original research articles on the use of GEP testing to assess cSCC prognosis. A panel of 8 dermatologists with significant expertise in diagnosing and managing cSCC gathered to review the articles and create consensus statements. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned using the Strength of Recommendation Taxonomy (SORT) criteria. RESULTS:  The literature search produced 157 articles that met the search criteria. A thorough screening of the studies for relevance to the research question resulted in 21 articles that were distributed to the panelists for review prior to the roundtable discussion. The panel unanimously voted to adopt 7 consensus statements and recommendations, 6 of which were given a strength of "A" and 1 of which was given a strength of "C". CONCLUSION:  The 40-GEP test provides accurate and independent prognostic information beyond standard staging systems that only incorporate pathologic data. Incorporation of GEP testing into national guidelines can help further stratify patients based on risk of metastasis and thus may improve morbidity and mortality. J Drugs Dermatol. 2023;22(12):54-60.   doi:10.36849/JDD.7691.

Incorporating a Prognostic Gene Expression Profile Test into the Management of Cutaneous Squamous Cell Carcinoma: An Expert Consensus Panel Report.

BACKGROUND: Cutaneous squamous cell carcinoma (cSCC) is a growing health concern with a rapidly increasing incidence. Disease-specific mortality is typically preceded by a metastasis, but current staging systems have significant limitations in predicting this event. The 40-gene expression profile (40-GEP) test is a validated method of further stratifying patients based on the risk of regional or distant metastasis, but limited guidelines exist for incorporating this test into clinical practice. OBJECTIVE: To review the available literature on the use of gene expression profile (GEP) testing to assess prognosis in cSCC and create consensus statements to guide dermatology clinicians on its use. METHODS: A comprehensive literature search of PubMed, EMBASE, and Scopus was completed for English-language original research articles on the use of GEP testing to assess cSCC prognosis. A panel of 8 dermatologists with significant expertise in diagnosing and managing cSCC gathered to review the articles and create consensus statements. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned using the Strength of Recommendation Taxonomy (SORT) criteria. RESULTS: The literature search produced 157 articles that met the search criteria. A thorough screening of the studies for relevance to the research question resulted in 21 articles that were distributed to the panelists for review prior to the roundtable discussion. The panel unanimously voted to adopt 7 consensus statements and recommendations, 6 of which were given a strength of "A" and 1 of which was given a strength of "C". CONCLUSION: The 40-GEP test provides accurate and independent prognostic information beyond standard staging systems that only incorporate pathologic data. Incorporation of GEP testing into national guidelines can help further stratify patients based on risk of metastasis and thus may improve morbidity and mortality. J Drugs Dermatol. 2023;22(12): doi:10.36849/JDD.7691e.

Acneiform Eruption Secondary to Over-the-Counter Vitamin B12.

Treating an acneiform eruption requires the discovery of its etiology. Often, the removal of the offending agent can lead to the resolution of the eruption, resulting in an excellent prognosis. Herein, we present a rare case of a vitamin B12-induced acneiform eruption occurring in a 68-year-old female due to an over-the-counter supplement.

Integrating Precision Medicine into Medical Dermatology Clinical Practice: An Expert Consensus Panel.

BACKGROUND: Precision medicine utilizes an individual’s genomics to improve diagnosis, prognosis, and therapy. The joint American Academy of Dermatology and National Psoriasis Foundation 2019 guidelines recognized the need to identify biomarkers that can predict the optimal biologic agent for an individual patient. This paper examines the current state of precision medicine in dermatology and how its use can improve outcomes in psoriasis. METHODS: A search of PubMed/MEDLINE using the terms precision medicine, personalized medicine, biomarkers, genomics, and dermatology was performed to identify relevant publications. An expert consensus panel was then convened to assign levels of evidence to each article using strength of recommendation taxonomy and create consensus statements requiring a two-thirds supermajority for agreement utilizing a modified Delphi approach. RESULTS: Thirteen articles met inclusion and exclusion criteria and were assigned levels of evidence. The panel created 10 consensus statements on how precision medicine can improve patient outcomes, all of which received a unanimous (6/6) vote. CONCLUSION: Choosing a biologic medication for psoriasis often relies on patient preference, provider preference, and a trial-and-error approach. Utilizing precision medicine tests such as Mind.Px can help providers identify biomarkers unique to a patient’s pathophysiology and choose the optimal medication through a targeted and evidence-based approach. Zakria D, Brownstone N, Armstrong AW, et al. Integrating precision medicine into medical dermatology clinical practice: an expert consensus panel. J Drugs Dermatol. 2023;22(6):588-593. doi:10.36849/JDD.7432.

Lichen Sclerosus of the Lip.

In this case report, we outline a case of a 36-year-old woman who presented to the dermatology clinic with a history of a hypopigmented macule on her lip. After conducting hepatitis C antibody testing and a shave biopsy, the patient was diagnosed with lichen sclerosus. Because of the increased risk for squamous cell carcinoma, she underwent an anogenital exam, where no lesions were found.

How to successfully handle the initial encounter with a delusional infestation patient.

Managing a delusional patient is one of the most challenging situations experienced by dermatologists. This is exacerbated by the scarcity of psychodermatology training offered in residency and similar training programs. A few practical management tips can be easily employed in the initial visit to avoid an unsuccessful encounter. We highlight the most important management and communication techniques needed for a successful first encounter with this traditionally tricky patient population. Topics such as diagnosing primary versus secondary delusional infestation, how to prepare before entering the exam room, how to write the initial patient note, and when is the ideal time to introduce pharmacotherapy are discussed. Tips on preventing clinician burnout and creating a stress-free therapeutic relationship are reviewed.

Electrical impedance spectroscopy significantly enhances correct biopsy choice for pigmented skin lesions beyond clinical evaluation and dermoscopy.

The purpose of this study was to investigate whether EIS technology can further improve correct biopsy choices beyond clinical and dermoscopic evaluation for melanoma (MM), severe dysplastic nevi (SDN) and benign PSLs. Images of 49 MMs, SDNs and benign PSLs were randomly selected from a prior study and were provided in a reader-type survey study to dermatologists to evaluate for biopsy. A total of 33,957 biopsy decisions were analyzed. Respondents significantly improved on the correct biopsy choice with the addition of dermoscopy versus clinical image alone for melanoma and severely dysplastic nevi. Respondents also showed a statistically significant improvement in correct biopsy choice beyond their dermoscopic evaluation when integrating the EIS score versus dermoscopy with clinical images for MM, SDN and benign lesions. Respondents also made fewer incorrect biopsy choices with the addition of the EIS score versus dermoscopy and clinical image for MM and benign lesions. Sub-analyses of biopsy choices were also conducted based on experience and practice type. The findings from this study demonstrate that the integration of EIS technology into PSL biopsy decisions has the potential to significantly improve the accuracy of lesion selection for biopsy beyond clinical and dermoscopic evaluation alone.

Dermatology Match Preference Signaling Tokens: Impact and Implications.

BACKGROUND: The dermatology residency application process implemented a new system of preference signaling tokens (PSTs) in the 2021-2022 cycle to allow applicants to express a higher level of interest in specific programs. Limited data are available on the utilization and impact of these tokens. OBJECTIVE: To determine the impact of PSTs on the application process and where in the process PSTs had the greatest influence. MATERIALS AND METHODS: A 14-question survey was sent to 62 ACGME-accredited dermatology residency programs. Primary outcomes were PST impact on 2021-2022 applications. Variables were evaluated using open-ended questions, yes/no responses, and importance ratings from 0 to 100. RESULTS: An average of 7.1% of applicants were offered interviews, but 21.1% of applicants that submitted PSTs were interviewed versus 3.7% of nonsubmitters. 22.5% of ranked applicants and 19% of matched applicants submitted a PST to that program. LIMITATIONS: Not all programs responded, and PST submission restrictions could not be assessed. CONCLUSION: The greatest PST impact was on the interview decision but had minimal subsequent impact. Given PSTs cannot be submitted to home programs or in-person away rotations, the actual impact was probably greater than found. Programs will continue to implement PSTs in future cycles.

The Koo-Brownstone staging system as a tool to assist in the management of patients with a possible diagnosis of dermatological delusions: an experts suggestion.

BACKGROUND: Delusional infestation (DI) is one of the most challenging situations dermatologists and other dermatology providers may face in their practice. Dermatologists must know how to properly communicate with these patients. The process of acquiring delusional states can be a gradual development and not all delusional patients in dermatology are the same. OBJECTIVE: The objective of this manuscript is to introduce the 'Koo-Brownstone Staging System' for Delusional Infestation (Morgellons disease) with the goal of improving communication and management for these patients. METHODS: This staging system has been derived based on more than three decades of experience of the senior author supported by additional years of experience of the first author. RESULTS: The following stages are presented and explained: formication only (stage 1), overvalued ideation of parasitosis (stage 2), pre-delusional (stage 3), delusional (stage 4) and terminally delusional (stage 5). LIMITATIONS: This staging system has been derived based on expert clinical experience rather than a direct reporting from this patient population themselves. CONCLUSIONS: This staging system will enhance awareness on the part of the health providers to enable them to categorize a given patient, which becomes critical in optimizing communications and management.

Knowledge Gaps Among Dermatologists Regarding Immunotherapy for Non-melanoma Skin Cancer.

Background: Advanced nonmelanoma skin cancer (NMSC) is a sometimes unrecognized public health burden. The development of immune checkpoint inhibitors (ICIs), such as those affecting programmed cell death protein-1 (PD-1), have dramatically changed the management of advanced NMSC. Dermatologists need to be knowledgeable about these therapies given their key role in diagnosing, treating, and comanaging NMSC. The purpose of this study was to assess the knowledge base and identify knowledge gaps that dermatologists may have regarding ICIs and assess advanced NMSC referral patterns. Methods: A 10-question survey was emailed to United States-based dermatologists in July 2021 assessing knowledge of ICI therapy and referral patterns for metastatic cutaneous squamous cell carcinoma (mcSCC) or locally advanced basal cell carcinoma (laBCC) management. Results: At their current knowledge level, respondents averaged 40.6 out of 100 (95% CI [35.1, 46.0]) when asked how comfortable they feel counseling a patient on the risks and benefits of an ICI. Seventy-one percent reported that having more information about treatment for mcSCC or laBCC would be helpful in their practice. Being in practice for less than 10 years was not significantly associated with desiring more information about treatment. The respondents reported that the highest number of annual average referrals out for mcSCC or laBCC were made to Mohs surgeons. Fifty-four percent of respondents received referrals for mcSCC or laBCC, and of the providers receiving referrals, 40 percent of them came from general dermatology. Conclusion: These results demonstrate that a knowledge gap exists for dermatologists in treating mcSCC and laBCC with immunotherapy. There is a need among all dermatologists, regardless of years in practice, to receive this information.