Novel Use of Topical Ivermectin for the Prevention of Facial Insect Bites.

Options to prevent facial insect bites while sleeping are limited. Patients may prefer to avoid facial application of potentially neurotoxic insect repellants. Non-toxic “natural” repellants have limited efficacy, and netting may not be well-tolerated. Nightly facial application of 1% topical ivermectin (IVM) cream completely prevented overnight bites in 2 patients, both of whom reported recurrent bites after discontinuation, and a return to complete bite prevention after IVM resumption. Topical IVM may be an alternative facial mosquito bite prevention modality. J Drugs Dermatol. 2022;21(8):906-907. doi:10.36849/JDD.6432.

Vitamin K2 Awareness in Sun-Protected Patients Supplementing With Vitamin D.

Dermatologists often recommend vitamin D for sun-protected patients. Most patients are not aware of the key role vitamin K2 plays in vitamin D metabolism and do not receive sufficient dietary vitamin K2. A survey of 50 sun-protecting patients shows 4/50 understood the role of vitamin K2 and 1/50 was supplementing vitamin K2. Therefore, counseling on vitamin K2 supplementation may be of benefit to sun-protected dermatology patients. J Drugs Dermatol. 2021;20(2):228-229. doi:10.36849/JDD.5829.

Use of an adherent fenestrated drape to anchor an adjacent vertical sterile surgical towel.

Vertical surgical sites or those on reclining patients often present a challenge when establishing and securing a sterile field. The drape or towel most proximal to the physician is often vertically oriented. The forces of gravity and movements of surgery can shift or detach this vertical drape. Sterile clamps are not always available or are needed for securing other instruments. We present a method to secure this vulnerable drape using a central fenestrated adherent drape.

Use of a punch tool for paring plantar warts in an "awl-like" manner.

Paring is useful for both diagnosis and treatment of plantar warts. Paring techniques generally involve scalpel blades, abrasive tools, or curettes. However, these tools do not permit the use of an "awl-like" carving technique of the wart afforded by using a punch biopsy tool. We have found this technique to be associated with greater precision and safety, as well as potentially increased efficacy compared to traditional methods.

Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies.

New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a "value per life" basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize "unnecessary" biopsies may be economically counterproductive.

J Drugs Dermatol. 2016;15(5):527-532.

Glycopyrrolate-induced craniofacial compensatory hyperhidrosis successfully treated with oxybutynin: report of a novel adverse effect and subsequent successful treatment.

Hyperhidrosis, or abnormally increased sweating, is a condition that may have a primary or secondary cause. Usually medication- induced secondary hyperhidrosis manifests with generalized, rather than focal sweating. We report a 32-year-old woman with a history of palmoplantar hyperhidrosis for 15 years who presented for treatment and was prescribed oral glycopyrrolate. One month later, the palmoplantar hyperhidrosis had resolved, but she developed new persistent craniofacial sweating. After an unsuccessful trial of clonidine, oxybutynin resolved the craniofacial hyperhidrosis. To our knowledge, this is the first case of compensatory hyperhidrosis secondary to glycopyrrolate reported in the literature. The case highlights the importance of reviewing medication changes that correlate with new onset or changing hyperhidrosis. It also demonstrates a rare drug adverse effect with successful treatment.

Safe and efficacious use of intralesional steroids for the treatment of focally resistant mycosis fungoides.

Cutaneous T-cell lymphoma is a cancer of skin-homing T cells, of which mycosis fungoides (MF) is the most common variant. MF treatments range from topical steroids to systemic chemotherapy. Resistant cutaneous MF nodules can present a special challenge in that typical topical therapies may not penetrate thick lesions, and increasing systemic therapy brings added risk of side effects. We report successful use of intralesional steroids (ILS) for treatment-resistant MF, including tumor-stage plaques and nodules in 4 consecutive patients with focally resistant MF. ILS have been widely used to treat a broad range of cutaneous conditions such as alopecia areata and keloids. Side effects of ILS include hypopigmentation, atrophy, telangiectasias, lilac discoloration, acne, and striae. Rarely, and in circumstances involving unusually large doses, ILS may cause Cushing's syndrome, hypothalamus-pituitary-adrenal axis suppression, and reduced bone mineral density. The MF patients tolerated treatment well without any of the above side effects other than local hypopigmention in a single patient. These results point toward further exploration into ILS as a treatment for focally resistant MF.

Biopsy rates vary with patient profile across different physicians in an academic dermatology practice.

Current healthcare trends promote data-driven "benchmarking" to decrease cost and increase quality. Dermatologists perform 79% of skin biopsies and biopsy rate is an easily measured benchmark. To reduce the risk of a misguided "one size fits all" benchmark for biopsies, it will help to document the factors driving divergent biopsy rates.This letter compares biopsy rates and high-risk patient ratios for 1000 sequential patients from two academic dermatologists. Elevated biopsy rates (0.55 vs 0.42, p < 0.001) were associated with elevated ratios of high-risk patients (.52 versus .30, p< 0.001). Although limited by small sample size, this research takes a first step toward future efforts to improve accuracy of biopsy benchmarking.

Cutaneous adenosquamous carcinoma: a rare neoplasm with biphasic differentiation.

Cutaneous adenosquamous carcinoma (cASC) is an extremely rare malignant neoplasm. Due to its disputed pathophysiology, ambiguity of presentation, and lack of definitive clinical research, cASC is a commonly misdiagnosed skin lesion. Although it is not commonly encountered in clinical practice, it is essential for clinicians to correctly recognize and treat cASC because of its malignant and recurrent nature. The images provided in this case report depict classic and complete presentation of cASC. A review of the literature also was conducted to provide insight into this rare atypical lesion.