What's new in dermatology

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ACNE AND ROSACEA

Spironolactone versus doxycycline for acne vulgaris (May 2024)

Spironolactone is an oral antiandrogen hormonal therapy commonly used to treat females with acne that is not adequately controlled by topical therapy. In a blinded, randomized trial of 133 adult females with moderate acne who were receiving topical benzoyl peroxide, individuals were assigned to add spironolactone (six-month course) or doxycycline (three-month course) [1]. At six months, individuals in the spironolactone group were more likely to have reduced acne severity compared with the doxycycline group. Adverse effects (primarily menstrual irregularity) were more common in the spironolactone group but were well tolerated. The dose of spironolactone administered was relatively high and patients did not receive topical retinoid therapy (a preferred treatment), which limits the generalizability of these findings. Nevertheless, this study supports the efficacy of spironolactone; we use it for treatment of selected female patients with moderate to severe acne. (See "Acne vulgaris: Management of moderate to severe acne in adolescents and adults", section on 'Administration and efficacy'.)

Updated guidelines for the management of acne vulgaris (May 2024)

The American Academy of Dermatology published updated guidelines for the management of acne vulgaris [2]. The guidelines continue to support multiple treatment measures, such as combined use of topical agents with different mechanisms of action; limited duration of antibiotic treatment; topical or systemic antibiotic treatment only in conjunction with topical benzoyl peroxide; and oral isotretinoin treatment for severe acne, acne that has not responded adequately to standard oral or topical treatment, and acne associated with psychosocial burden or scarring. (See "Acne vulgaris: Overview of management", section on 'Treatment principles'.)

ATOPIC DERMATITIS AND OTHER DERMATITIS

Dupilumab for recalcitrant chronic hand eczema (February 2024)

Treatment of severe chronic hand eczema (CHE) is challenging and may require systemic immunosuppressants or oral alitretinoin (a retinoid not available in the United States) or phototherapy. In a small randomized trial, 29 adults with severe CHE were assigned to treatment with dupilumab (an interleukin [IL] 4/IL-13 inhibitor approved for the treatment of atopic dermatitis) or placebo [3]. At week 16, more patients in the dupilumab group than in the placebo group achieved 75 percent improvement in the Hand Eczema Severity index (95 versus 33 percent). Treatment was well tolerated. Ocular pruritus occurred in three patients in the dupilumab group and was the only treatment-associated adverse effect. These findings indicate dupilumab as a valuable option for recalcitrant CHE, although it is not yet approved for this indication. (See "Chronic hand eczema", section on 'Dupilumab'.)

Topical roflumilast for seborrheic dermatitis (January 2024)

Seborrheic dermatitis is a chronic, relapsing dermatitis involving areas rich in sebaceous glands (eg, scalp, face) that requires repeated or long-term maintenance treatment with topical anti-inflammatory agents. In a randomized trial that included 226 adults with moderate to severe seborrheic dermatitis, topical roflumilast, a potent phosphodiesterase-4 inhibitor with anti-inflammatory properties, was more effective than vehicle in achieving an Investigator Global Assessment score of clear/almost clear at eight weeks (74 versus 41 percent, respectively) [4]. Treatment was generally well tolerated. These findings contributed to approval by the US Food and Drug Administration of roflumilast 0.3% foam for the treatment of seborrheic dermatitis in adults and children older than nine years [5]. (See "Seborrheic dermatitis in adolescents and adults", section on 'Topical anti-inflammatory agents'.)

AUTOIMMUNE AND SYSTEMIC DISEASES

Features of drug-induced dermatomyositis (April 2024)

Drug-induced dermatomyositis can present with cutaneous features similar to idiopathic dermatomyositis. In a systematic review that identified 165 patients with possible drug-induced dermatomyositis, the most commonly reported inciting therapies were hydroxyurea, immune checkpoint inhibitors, statins, penicillamine, and tumor necrosis factor inhibitors [6]. The median time between initial drug exposure and disease development was 60 days. Although the strength of the drug association varied broadly among the 134 included articles, this study highlights drug-induced dermatomyositis as a consideration when evaluating patients with the cutaneous features of this disease. (See "Clinical manifestations of dermatomyositis and polymyositis in adults", section on 'Skin findings in dermatomyositis'.)

PEDIATRIC DERMATOLOGY

Second primary cancers in pediatric and young adult survivors of cutaneous melanoma (March 2024)

In an analysis of data from the Surveillance, Epidemiology, and End Results Program that included over 7100 patients aged 0 to 29 years diagnosed with a first primary cutaneous melanoma between 2000 to 2018, 632 (9 percent) developed a second primary cancer, with an overall fivefold increased risk of any cancers compared with the general population [7]. Of note, 77 percent of second primary cancers were melanomas. These findings highlight the importance of frequent total body skin examination in pediatric and young adult survivors of cutaneous melanoma. (See "Melanoma in children", section on 'Risk of second primary cancers'.)

PSORIASIS AND OTHER PAPULOSQUAMOUS DISORDERS

Oral apremilast for pediatric plaque psoriasis (April 2024)

Apremilast (a phosphodiesterase 4 inhibitor) is an established oral therapy for plaque psoriasis in adults. However, efficacy data in children have been limited. In the first phase 3 trial to assess efficacy of apremilast in children, 245 children (ages 6 to 17 years) with moderate to severe plaque psoriasis were randomly assigned to treatment with either apremilast or placebo [8]. At week 16, children treated with apremilast were more likely to have clear or almost clear status and at least a two-point improvement from baseline (based on the five-point static Physician Global Assessment scale) than children in the placebo group (33 versus 12 percent). Apremilast therapy was generally well tolerated. The most commonly reported adverse events were diarrhea, nausea, and abdominal pain. These findings support apremilast as an additional oral treatment option for pediatric plaque psoriasis. (See "Psoriasis in children: Management of chronic plaque psoriasis", section on 'Apremilast'.)

SKIN CANCER

Second primary cancers in pediatric and young adult survivors of cutaneous melanoma (March 2024)

In an analysis of data from the Surveillance, Epidemiology, and End Results Program that included over 7100 patients aged 0 to 29 years diagnosed with a first primary cutaneous melanoma between 2000 to 2018, 632 (9 percent) developed a second primary cancer, with an overall fivefold increased risk of any cancers compared with the general population [7]. Of note, 77 percent of second primary cancers were melanomas. These findings highlight the importance of frequent total body skin examination in pediatric and young adult survivors of cutaneous melanoma. (See "Melanoma in children", section on 'Risk of second primary cancers'.)

OTHER DERMATOLOGY

New guidelines for protoporphyria (March 2024)

Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are rare cutaneous porphyrias that cause severe, nonblistering photosensitivity and liver disease; their rarity makes evidence-based management challenging. Two new guidelines from the Rare Diseases Clinical Research Network are available to help guide diagnosis and management of EPP and XLP:

●Consensus guidelines discuss use of biochemical and genetic testing, use of afamelanotide, avoidance of ineffective therapies, methods of sun protection, and prevention of liver disease [9].

●Liver-specific guidelines discuss screening, prevention, and treatment of liver disease, including liver and hematopoietic stem cell transplantation for advanced disease [10].

●(See "Erythropoietic protoporphyria and X-linked protoporphyria", section on 'Management'.)

Risankizumab for dissecting cellulitis of the scalp (November 2023)

Oral antibiotics, oral isotretinoin, biologic tumor necrosis factor-alpha inhibitors, and surgical excision are the mainstays of treatment for dissecting cellulitis of the scalp (DCS), a debilitating form of scarring alopecia that can be challenging to treat. In a report of two patients with oral antibiotic-refractory DCS treated with risankizumab (a biologic interleukin [IL] 23 inhibitor), marked clinical improvement occurred within 4 to 13 months [11]. These findings add to other isolated reports suggesting benefit of biologic IL-23 inhibition for DCS. While promising, more evidence regarding safety and efficacy are needed. (See "Dissecting cellulitis of the scalp", section on 'Other therapies'.)