Rural Health Disparities in Skin Cancer Amplified Among Skin of Color.

Limited studies explore the role social determinants of health have on urban-rural health disparities, particularly for Skin of Color. To further evaluate this relationship, a cross-sectional study was conducted on data from five states using the 2018 to 2021 Behavior Risk Factor Surveillance Survey, a national state-run health survey. Prevalence of skin cancer history and urban/rural status were evaluated across these social determinants of health: sex, age, race, insurance status, number of personal healthcare providers, and household income. Overall, rural counterparts were significantly more likely to have a positive skin cancer history across most social determinants of health. Rural populations had a higher prevalence of skin cancer history across all races (P<.001). Rural non-Hispanic Whites had greater odds than their urban counterparts (OR=1.40; 95% CI 1.34 - 1.46). The odds were approximately twice as high for rural Black (OR=1.74; 95% CI 1.14 - 2.65), Hispanic (OR=2.31; 95% CI 1.56 - 3.41), and Other Race, non-Hispanic (OR=1.99; 95% CI 1.51 - 2.61), and twenty times higher for Asians (OR=20.46; 95% CI 8.63 - 48.54), although no significant difference was seen for American Indian/Alaskan Native (OR=1.5; 95% CI 0.99 - 2.28). However, when household income exceeded $100,000 no significant difference in prevalence or odds was seen between urban and rural settings. Despite increasing awareness of metropolitan-based health inequity, urban-rural disparities in skin cancer prevalence continue to persist and may be magnified by social determinants such as income and race. J Drugs Dermatol. 2024;23(6):480-484.    doi:10.36849/JDD.8094.

Immune checkpoint inhibitor associated epidermal necrosis, beyond SJS and TEN: a review of 98 cases.

Immune checkpoint inhibitor (ICI) therapies carry the risk of major immune-related adverse events (irAEs). Among the most severe irAEs is epidermal necrosis that may clinically mimic Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis (TEN). The aim of this study was to provide a summary of the clinical and histological features of ICI-associated epidermal necrosis, with a special focus on factors associated with fatal outcomes in cases of extensive disease. A total of 98 cases, 2 new cases and 96 reported on PubMed and in the literature, of ICI-associated epidermal necrosis were assessed. Development of epidermal necrosis occurred between 1 day and 3 years after starting ICI therapy, with an average onset of 13.8 weeks for patients with limited (< 30% BSA) and 11.3 weeks for those with extensive (≥ 30% BSA) involvement, and a median onset of 5.8 weeks and 4 weeks respectively. A preceding rash was seen in 52 cases and was more common in extensive cases. Mucosal involvement was only reported in 65% of extensive cases but was significantly associated with fatal reactions. Co-administration of cytotoxic chemotherapy was associated with more extensive disease. Recovery was observed in 96% and 65% of those with limited and extensive involvement respectively and no specific therapy was associated with improved survival. Young age was significantly associated with poor outcomes in extensive disease, the average age of surviving patients was 64.5 years old versus 55.1 years old for deceased patients, p < 0.01. Both superficial perivascular and interface/lichenoid inflammatory infiltrates were commonly seen. These findings suggest that ICI-associated epidermal necrosis should be considered a distinct clinical entity from drug-induced SJS/TEN.

Assessing Time of Onset for Interstitial Lung Disease in Anti-MDA5 Antibody-Positive Dermatomyositis.

This cohort study seeks to describe the time interval between interstitial lung disease and anti­melanoma differentiation-associated gene 5 antibody-positive dermatomyositis diagnoses.

Telangiectasias induced by combination tucatinib and ado-trastuzumab emtansine in a patient with metastatic breast cancer.

BACKGROUND: Tucatinib is a tyrosine kinase inhibitor currently used in salvage therapy for human epidermal growth factor receptor 2 (HER2)-positive breast and colorectal cancer. The use of tucatinib alone or in combination with ado-trastuzumab emtansine (T-DM1) in the treatment of advanced HER2-positive cancers is rapidly expanding. OBJECTIVE/METHODS: We report the case of a 66-year-old female who presented to the dermatology clinic with a one-year history of widespread telangiectasias that began after initiation of combination chemotherapy with tucatinib and T-DM1 for metastatic HER2-positive invasive ductal carcinoma. RESULTS: The patient's lesions regressed upon cessation of combination therapy and reappeared in the setting of tucatinib re-initiation, with gradual improvement over the following four months following electrocautery to the affected regions. CONCLUSIONS: We postulate that telangiectasias may be a previously unreported dermatologic side effect of combination treatment with tucatinib and T-DM1. Electrocautery is a safe and effective procedure to reduce the appearance of telangiectasias and improve patient satisfaction during chemotherapy.

Epigenetic mechanisms driving the pathogenesis of systemic lupus erythematosus, systemic sclerosis and dermatomyositis.

Autoimmune connective tissue disorders, including systemic lupus erythematosus, systemic sclerosis (SSc) and dermatomyositis (DM), often manifest with debilitating cutaneous lesions and can result in systemic organ damage that may be life-threatening. Despite recent therapeutic advancements, many patients still experience low rates of sustained remission and significant treatment toxicity. While genetic predisposition plays a role in these connective tissue disorders, the relatively low concordance rates among monozygotic twins (ranging from approximately 4% for SSc to about 11%-50% for SLE) have prompted increased scrutiny of the epigenetic factors contributing to these diseases. In this review, we explore some seminal studies and key findings to provide a comprehensive understanding of how dysregulated epigenetic mechanisms can contribute to the development of SLE, SSc and DM.

Toxic Ingredients in Personal Care Products: A Dermatological Perspective.

Environmental dermatology is the study of how environmental factors affect the integumentary system. The environment includes natural and built habitats, encompassing ambient exposure, occupational exposures, and lifestyle exposures secondary to dietary and personal care choices. This review explores common toxins found in personal care products and packaging, such as bisphenols, parabens, phthalates, per- and poly-fluoroalkyl substances, p-phenylenediamine, and formaldehyde. Exposure to these toxins has been associated with carcinogenic, obesogenic, or proinflammatory effects that can potentiate disease. In addition, these compounds have been implicated as endocrine-disrupting chemicals that can worsen dermatological conditions such as acne vulgaris, or dermatitis. Certain pollutants found in personal care products are not biodegradable and have the potential to bioaccumulate in humans. Therefore, even short-term exposure can cause long-lasting issues for communities. The skin is often the first point of contact for environmental exposures and serves as the conduit between environmental toxins and the human body. Therefore, it is important for dermatologists to understand common pollutants and their acute, subacute, and chronic impact on dermatological conditions to better diagnose and manage disease.

Approach to diagnosis, evaluation, and treatment of generalized and nonlocal dysesthesia: A review.

Dysesthesia is an abnormal sensation in the skin that occurs in the absence of any extraordinary stimulus or other primary cutaneous disorders, excluding any delusions or tactile hallucinations. Clinicians have characterized dysesthesias to include sensations such as burning, tingling, pruritus, allodynia, hyperesthesia, or anesthesia. The etiology and pathogenesis of various generalized dysesthesias is largely unknown, though many dysesthesias have been associated with systemic pathologies including malignancy, infection, autoimmune disorders, and neuropathies. Dermatologists are often the first-line clinicians for patients presenting with such cutaneous findings, thus it is crucial for these physicians to be able to methodically work-up generalized dysesthesias to build a working differential diagnosis, follow up with key labs and/or imaging, and offer patients evidence-based treatment to relieve their symptoms. This broad literature review is an attempt to centralize key studies, cases, and series to help guide dermatologists in their assessment and evaluation of complaints of abnormal cutaneous sensations.

Insurance delays in the approval of biologic medications for patients with psoriasis and psoriatic arthritis.

Biologics are the most effective treatment for moderate-to-severe psoriasis. Insurance approval and need for prior authorization continue to be a barrier to care for many patients with psoriasis and psoriatic arthritis. We sought to determine whether race/ethnicity, insurance type, and provider specialty affect biologic approval times. Records from the University of Miami Health System were reviewed, and 101 patients were included. Need for a prior authorization was significantly associated with long waits (p = 2.4 × 10-5). We did not identify a significant difference in wait times between non-Hispanic Whites and non-Whites. The average wait time for biologic approval for Whites was 29.7 days and for non-Whites was 27.2 days. Biologics were approved the same day for 23.7% of HMO carriers, 11.5% of PPO carriers, 63% of Medicare carriers, and 40% of Medicaid carriers (p < 0.001). There was no difference in the biologic type prescribed based on insurance type. Medicaid (p < 0.05) and the need for prior authorization (p = 2.4 × 10-5) significantly predicted approval wait time in our multilinear regression model. Patients with Medicare had the shortest wait time with a mean of 7.3 days. Medicaid patients waited a mean of 11.3 days. Private insurance patients waited the longest, regardless of whether they had a PPO (37 days) or HMO (41.3 days).

An Approach to Hypereosinophilic Syndrome Presenting With Cutaneous Features.

Hypereosinophilic syndrome (HES) is a heterogeneous group of disorders characterized by persistent peripheral hypereosinophilia and eosinophilia-mediated tissue damage. Hypereosinophilic syndrome can have life-threatening effects on multiple organ systems but may initially, or in some cases solely, present with skin lesions. The clinical presentation of HES in the skin represents a diagnostic challenge for the dermatologist, because cutaneous manifestations are highly variable and may be mistaken for several dermatologic conditions. Once peripheral and tissue eosinophilia is diagnosed, the differential diagnosis is quite broad, spanning hematoproliferative disorders, infectious diseases, drug reactions, and many others. Workup and management may also present a challenge, because the prospect for organ system involvement in those with apparent skin-limited disease is unclear. This article provides a dermatology-centered approach to HES and provides a reference for the differential diagnosis, workup, and management of this complex disorder.

Malignancy risk of non-biologic immunosuppressive therapies: A review of the literature with evidence-based treatment recommendations.

Non-biologic immunosuppressive therapies are a mainstay in the treatment of various dermatologic conditions. However, the use of these therapies has been scrutinized for potentially increasing risk of haematologic or solid-organ malignancies. Currently, there are no evidence-based guidelines stratifying the risk of malignancy in patients receiving these immunosuppressive agents for the treatment of dermatologic disease. In our review, we evaluate the risk of solid organ and haematologic malignancies in patients receiving non-biologic immunosuppressant therapy for dermatologic indications. A literature search was conducted on PubMed/MEDLINE. Search terms included commonly prescribed non-biologic immunosuppressants and common dermatologic conditions for which non-biologic immunosuppressants are typically prescribed. Levels of evidence and grades of recommendation were used for guidelines. All immunosuppressants evaluated, with the exception of cyclophosphamide, demonstrated low solid-organ or haematologic malignancy potential. Co-morbidities may play a role in malignancy risk in the context of immunosuppressant treatment, including autoimmune disease, which have been associated with increased risk of malignancy and confound overall risk. Duration and/or dosage of treatment may influence this risk as well. Limitations of the review include that the majority of studies were of small sample size, retrospective in nature, and there was lack of direct comparison trials.

Drug interactions of natural supplements in dermatology: a review.

Limited information is available on the drug-drug interactions of natural supplements in dermatology. Many natural supplements are available over the counter, but drug-drug interactions can occur. This study reviews the clinical use and drug interactions of six natural supplements commonly recommended in dermatology: nicotinic acid (nicotinamide), polypodium leucotomos (heliocare), turmeric, horse chestnut seed extract, zinc, and N-acetylcysteine. We reviewed the drug-drug interactions of each supplement using the PubMed database and IBM Micromedex. For nicotinic acid, zinc, horse chestnut, and N-acetylcysteine, IBM Micromedex generated 11, 23, one, and two results, respectively. Further review of literature from PubMed identified two drug interactions with polypodium leucotomos, two with turmeric, and two more with zinc. Notable interactions included an increased risk of myopathy and rhabdomyolysis when nicotinic acid is taken by patients using statins, an increased risk of bleeding associated with horse chestnut seed, especially when used in combination with warfarin, and reduced plasma concentration in many drugs when taken with zinc. Furthermore, N-acetylcysteine may interfere with concentrations of other medications used in the psychiatric setting, and polypodium leucotomos and turmeric may interfere with the CYP metabolic pathway, which may affect drugs metabolized by this pathway. Prior to recommending a treatment, dermatologists should foster awareness of these interactions. In order to advance the practice as a whole, research should continue to evaluate the drug interactions of these natural supplements.

A Case Report of a Patient with Turner Syndrome, Multiple Comorbidities, and Pustular Psoriasis: Correlation or Coincidence?

Turner syndrome (TS) is one of the most common chromosomal abnormalities. Patients with TS are at an increased risk for the development of metabolic syndrome, hypertension (HTN), diabetes mellitus type II (DM2), hyperlipidemia (HLD), obesity, and cardiovascular disease. The association between psoriasis and the aforementioned conditions including metabolic syndrome, HTN, HLD, obesity, and cardiovascular disease has also been established. Although the mechanism for heightened risk in TS patients is yet to be elucidated, patients suffering from TS and cardiometabolic diseases are likely to be at an even higher risk for developing psoriasis than patients suffering from TS alone. We present a case of a 53-year-old Hispanic woman with a mosaic TS and multiple comorbidities who presented with pustular psoriasis. For this patient, management can be challenging considering her numerous medical comorbidities and the presence of both TS and psoriasis.

The Safe Management of Acne Vulgaris in Lupus Erythematosus: A Systematic Review with Evidence-Based Treatment Recommendations.

BACKGROUND: To date, there have been no studies that have specifically investigated which medications can and cannot be safely used to treat acne vulgaris in patients who have lupus erythematosus (LE). These patients require a highly individualized treatment approach, as the use of certain acne medications may exacerbate LE symptomology, such as photosensitivity and hypercoagulability. OBJECTIVE: In this systematic review, we examine safety outcomes associated with commonly prescribed oral acne medications, specifically in the context of LE. METHODS: A literature search, conducted on PubMed/MEDLINE, revealed 146 studies, of which 13 met the criteria. We assigned a level of evidence to each study and sought to determine evidence-based recommendations for each class of drug; each recommendation was then assigned a corresponding grade. RESULTS: There were very few high-quality studies available on this topic. Although we determined recommendations based on the existing literature, the grading was occasionally unfavorable due to the low-quality nature of the evidence supporting the recommendation. However, our recommendation against the use of combined oral contraceptive pills and in favor of spironolactone for the treatment of acne, in the setting of LE, received a satisfactory grading (grade A). CONCLUSION: While no definitive recommendations for the treatment of acne in LE can be made based on the existing quality and quantity of studies available, this article aims to provide a comprehensive overview and analysis of oral acne medication safety in patients with LE, while emphasizing the immense need for higher quality studies and distinct acne treatment guidelines for this vulnerable patient population.

Dermatological manifestations of fungal infection in patients with febrile neutropaenia: A review of the literature.

Febrile neutropaenia (FNP) is a common cause of morbidity and mortality in immunocompromised patients. Although most infections are caused by bacterial pathogens, fungal infections are becoming increasingly more common. Due to its rarity, the diagnosis of fungal infections in febrile neutropenic patients is often delayed. To provide current clinical features, epidemiology, aetiology, diagnosis and treatment of cutaneous involvement of fungal infection in patients with FNP. A retrospective literature review of PubMed was performed, with no language or publishing data restrictions, yielding 116 results. We queried each case for cutaneous lesions associated with fungal pathogens in FNP. We found 54 publications with 215 reported cases of cutaneous manifestations of fungal injury in patients with FNP. This study is limited in that it is a literature review of a disease that is likely underreported. Cutaneous lesions caused by yeasts such as Candida and Trichosporon manifest as diffuse erythematous papules and usually do not develop central necrosis or eschar, while moulds will present as tender nodules that subsequently develop eschar and necrosis. Recognising the cutaneous manifestations of fungal disease can assist in the diagnosis and management of these infections.