Dermatopathology

WEDNESDAY, Jan. 31, 2024 -- Patients with chronic inflammatory skin diseases (CISD) starting systemic immunomodulatory treatment often do not receive recommended pretreatment testing, according to a study published online Jan. 31 in JAMA Dermatology.Maria C. Schneeweiss, M.D., from Brigham and Women's Hospital in Boston, and colleagues conducted a descriptive analysis of U.S. commercial insurance claims databases to examine the prevalence of pretreatment testing that is recommended for patients with CISD. Data were included for 122,308 adult patients with CISD (psoriasis, hidradenitis suppurativa, or atopic dermatitis) who started an immunomodulatory agent.The researchers found that the most common test, performed in 31 to 69 percent of individuals before initiating treatments, was complete blood count. Tuberculosis screening within six months before treatment was performed in 11 to 59 percent of patients, and 3 to 26 percent had updated tests one year later. Before treatment, between 13 and 41 percent had hepatitis panels. Low pretreatment testing levels, seen before apremilast (15 to 45 percent), persisted one year into treatment (9 to 36 percent) and were similar to testing levels for dupilumab (11 to 41 percent and 3 to 25 percent, respectively)."Collaboration between federal and professional associations would be greatly beneficial to update laboratory screening/monitoring guidelines for therapies on a scheduled basis," write the authors of an accompanying editorial. "This will likely help to unify our practice while keeping patients safe."Several authors disclosed ties to the pharmaceutical industry.

Between 11 and 59 percent of patients had tuberculosis screening within six months before treatment

Pretreatment Testing Often Omitted in Chronic Inflammatory Skin Disease

WEDNESDAY, Nov. 8, 2023 -- Specialty training in dermatopathology is associated with an increased tendency to diagnose atypical melanocytic proliferations as pT1a melanomas, according to a study published online Nov. 8 in JAMA Dermatology.Kathleen F. Kerr, Ph.D., from the University of Washington in Seattle, and colleagues conducted an exploratory study using data from two nationwide studies to identify pathologist characteristics associated with tendencies to diagnose melanocytic lesions as higher grade versus lower grade. A total of 338 pathologists were included: 113 general pathologists, 74 dermatopathologists from the Melanoma Pathology study, and 151 dermatopathologists from the Reducing Errors in Melanocytic Interpretations study.The researchers found that specialist training in dermatopathology was the predominant factor associated with rendering more severe diagnoses. Compared with pathologists without this training, those with this training interpreting the same case were more likely to render higher-grade diagnoses and to diagnose invasive melanoma (odds ratios, 2.63 and 1.95, respectively). The observed difference in diagnosis of invasive melanoma was due to nonmitogenic pT1a diagnoses; when these lesions were grouped with the less severe diagnoses, no association was observed. Among dermatopathologists, higher-grade diagnoses were more likely to be assigned by those with a higher caseload of melanocytic lesions (odds ratio for trend, 1.27)."We hypothesize that this could in part play a role in the rising incidence of early-stage melanoma with low risk of progression or patient morbidity, thereby contributing to increasing rates of overdiagnosis," the authors write.

Specialty training linked to increased tendency to diagnose atypical melanocytic proliferations as pT1a melanomas

Does Specialty Training in Dermatopathology Lead to More Severe Diagnoses?

WEDNESDAY, Oct. 4, 2023 -- For patients with Kaposi sarcoma (KS), Black race is independently associated with worse overall survival, according to a study published in the September issue of SKIN.Michelle S. Swedek, from the Creighton University School of Medicine in Omaha, Nebraska, and colleagues examined the effects of socioeconomic and demographic factors on survival among patients with KS diagnosed from 2004 to 2017. Overall survival was analyzed among all patients and in a propensity score-matched cohort, where White patients were matched to Black patients for demographic factors and comorbidities in a 1:1 ratio.The researchers found that advanced age, Black race, HIV-positive status, and Charlson-Deyo score ≥1 were independently associated with reduced overall survival among the 4,034 KS patients. There was a survival benefit seen for Spanish/Hispanic ethnicity, private insurance, residence in areas of high educational attainment, and treatment at academic centers. Median survival was 99 and 140 months for Black and White patients, respectively. Black patients had poorer overall survival compared with White patients after propensity score matching (119 versus 136 months)."We highlight significant racial disparities with poor survival outcomes in Black patients with KS, which persisted even after controlling for socioeconomic features and other surrogate markers of health care access," the authors write. "We call for greater efforts in promoting access to health care and providing equitable medical care to all KS patients."

Survival benefit seen for Spanish/Hispanic ethnicity, private insurance, residence in areas of high educational attainment

Black Race Linked to Worse Survival in Kaposi Sarcoma

Dermatopathology: Challenges and Solutions

In this highly anticipated session, Clay J. Cockerell, MD, MBA, provided the audience with tips and updates from the world of dermatopathology. Starting with dysplastic nevi, Dr Cockerell reiterated a previously published call for change to the currently accepted 3-tiered grading of dysplastic nevi instead of “mild,” “moderate,” and “severe.” Due to poor inter-rater concordance on what is a “moderately dysplastic nevus,” Dr Cockerell recommended using a “low-grade” and “high-grade” system to simplify management decisions for clinicians. Severely dysplastic nevi are often true melanomas and should be treated with conservative re-excision. Dr Cockerell also reminded listeners that nevi in special sites can have atypical features but often do not represent true dysplastic nevi and that the threshold to diagnose a malignant melanoma in special sites should be higher. New techniques are available to help diagnose melanoma, such as gene expression profiling. These tests should be used with caution as they are easy to overinterpret.&nbsp; &nbsp; Later, Dr Cockerell presented some interesting clinicopathologic cases, highlighting important pearls on Wong-type dermatomyositis and invasive aspergillosis, among others.&nbsp;&nbsp; Changing topics, Dr Cockerell educated the audience on the history of and legal implications of starting a trust. A trust may be chosen over a will for estate planning purposes. Benefits of trusts include avoiding probate court and ensuring privacy is maintained since a trust is not subject to probate and cannot be contested. Trusts can also include incapacity provisions allowing them to be used prior to death. Dr Cockerell encouraged the audience to check with estate planning attorneys to discuss further. To conclude, Dr Cockerell touched on how clinicians can improve diagnostic accuracy and implored those listening to be accurate and thorough on requisition forms; he also highlighted how helpful clinical photos can be when submitted with biopsy specimens.&nbsp;

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Dermatopathology: Challenges and Solutions

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