Julia A. Siegel

Downstream consequences of melanoma screening in a community practice setting: First results.

Population‐based screening for the early detection of melanoma holds great promise for reducing melanoma mortality, but evidence is needed to determine whether benefits outweigh risks. Skin surgeries and dermatology visits after screening were assessed to indicate potential physical, psychological, and financial consequences.

Chemoprevention of basal and squamous cell carcinoma with a single course of fluorouracil, 5%, cream: A randomized clinical trial

Importance Keratinocyte carcinoma (ie, cutaneous basal and squamous cell carcinoma) is the most common cancer in the United States. Objective To determine whether topical fluorouracil could prevent surgically treated keratinocyte carcinoma. Design, Setting, and Participants The Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial was a randomized, double-blind, placebo-controlled trial of topical fluorouracil for chemoprevention of keratinocyte carcinoma. Participants were recruited from May 2009 to September 2011 from 12 Veterans Affairs medical centers and followed until June 30, 2013. Participants were veterans (n = 932) with a history of at least 2 keratinocyte carcinomas in the past 5 years; almost all were white males and the median age was 70 years. Interventions Application of fluorouracil, 5%, (n = 468) or vehicle control cream (n = 464) to the face and ears twice daily for 2 to 4 weeks upon randomization. Main Outcomes and Measures Surgically treated keratinocyte, basal cell, and squamous cell carcinoma risk on the face and ears in the first year after enrollment; and time to first surgically treated keratinocyte, basal cell, and squamous cell carcinoma. The a priori hypothesis was that fluorouracil would be effective in preventing these cancers. Results Of 932 participants (916 men [98%]; 926 white [99%]; median age, 70 years), 299 developed a basal cell carcinoma end point (95 in year 1) and 108 developed a squamous cell carcinoma end point (25 in year 1) over 4 years (median follow-up, 2.8 years). Over the entire study, there was no difference between treatment groups in time to first keratinocyte, basal cell, or squamous cell carcinoma. During the first year, however, 5 participants (1%) in the fluorouracil group developed a squamous cell carcinoma vs 20 (4%) in the control group, a 75% (95% CI, 35%-91%) risk reduction (P = .002). The 11% reduction in basal cell carcinoma risk during year 1 (45 [10%] in the fluorouracil group vs 50 [11%] in the control group) was not statistically significant (95% CI, 39% reduction to 31% increase), nor was there a significant effect on keratinocyte carcinoma risk. However, a reduction in keratinocyte carcinomas treated with Mohs surgery was observed. Conclusions and Relevance A conventional course of fluorouracil to the face and ears substantially reduces surgery for squamous cell carcinoma for 1 year without significantly affecting the corresponding risk for basal cell carcinoma. Trial Registration clinicaltrials.gov Identifier: NCT00847912

Predictors of actinic keratosis count in patients with multiple keratinocyte carcinomas: A cross-sectional study

preoperatively in 3 NMSC studies (Supplemental Table I). The ASA, although not formally developed as a comorbidity index, was used for decades preoperatively to predict risk in patients undergoing general anesthesia, and performed comparably with formal indices as a comorbidity measure. An advantage of the ASA is its widespread use in patients who have undergone general anesthesia, many of whom may have this information documented in presurgical paperwork. The ACE-27 is a modification of the KaplanFeinstein Index and was used in 2 studies in the localized skin cancer population, showing superior performance to a standard medical interview in identifying comorbidity, and a correlation between more severe comorbidity and lower survival (Supplemental Table I). The ACE-27 includes more comorbid conditions than the CCI and was designed specifically for a cancer population. Both the CCI and the ACE-27 allow investigators to calculate scores retrospectively through medical chart review. They have also been adapted into the form of patientreported questionnaires for ease of data collection. Although 3 comorbidity measures were identified for theNMSCpopulation, studies are small and limited by significant heterogeneity. The ACE-27 captures more conditions and allows for comorbidity grading, which isnotpossiblewith theCCI.Perhaps theACE-27 will be more accurate in comorbidity assessment, however, larger studies are needed. As demographics shift to anolder populationover thenext 2decades, an evidence-based approach to management will depend on better understanding the impact of comorbidity and age on patient outcomes. Comorbidity tools may facilitate the decision-making process for physicians and patients, however, further studies are needed to better define their role.

Comparison of Contact Allergens in Bar Soaps and Liquid Body Washes

To the Editor: Allergic contact dermatitis (ACD) describes a delayed classic T-cellYmediated (type IV) hypersensitivity immune response to external substances that contact the skin. This often manifests as pruritus, erythema, and vesiculation that may progress to lichenification, xerosis, and fissuring. Identification and avoidance of specific allergens are key to adequate management and care. Although previous studies have investigated the presence of numerous contact allergens in cleansing products, limited research on the contact allergens of specific formulations of cleansing products currently exists. We aim to identify the difference between the number and types of contact allergens found in bar soaps versus liquid body washes. We examined the top 50 bar soaps and body washes listed on Amazon.com, sorting by ‘‘relevance’’ and filtering by ‘‘avg. customer review 4 stars and up’’ on October 6, 2016. Ingredient lists were almost entirely obtained from Amazon.com, but a few were collected from Target.com, Walgreens.com, and specific product Web sites. Allergens were selected from the American Contact Dermatitis Society core allergen series, with the expertise of a coauthor. W and Fisher exact tests were used to compare allergens in bar soaps versus body washes. Liquid body washes had far more preservative and surfactant allergens compared with bar soaps (P G 0.001, Table 1). No differences in fragrances existed between bar soaps and body washes. Of the preservatives studied, methylisothiazolinone, quaternium-15, sodium benzoate, methylchloroisothiazolinone/ methylisothiazolinone, DMDM hydantoin, phenoxyethanol, and iodopropynyl butylcarbamate were particularly prevalent in body washes compared with bar soaps. Of the surfactants studied, cocamidopropyl betaine and alkyl glucosides were ubiquitous in body washes and rarely seen in bar soaps. Polyethylene glycol was found in 38% of body washes but only in 8% of bar soaps (Table 1). A number of the most common contact allergens identified by the American Contact Dermatitis Society have been identified in soaps and cleansers; however, studies investigating these allergens in bar soaps and body washes are limited. Our study revealed a significantly higher number of preservative and surfactant allergens in body washes versus bar soaps. In recent years, bar soap sales have fallen by 2.2% despite a 2.7% rise in overall bath and shower product sales. Consumers younger than 65 years are primarily responsible. For example, only one third of consumers aged 25 to 34 years are willing to wash their face with bar soap compared with 60% of those older than 65 years. Potential explanations for this include the perceived inconvenience of storing bar soaps and the perceived uncleanliness of using them. However, in a study of 16 participants who washed their hands with bar soaps inoculated with gram-negative bacteria, none of the participants had detectable levels of bacterium on their hands after washing. Limitations include an inability to specify fragrances in all products because product labels are not required to report specific fragrance compounds. Second, ingredients obtained from retailers such as Amazon.com may be subject to error, although we limited this risk by cross-checking ingredient lists found on other Web sites. Because ACD often creates a treatment challenge, health care providers will benefit from an improved understanding of potential ingredients in products commonly associated with the condition. The use of bar soaps instead of body washes may alleviate symptoms and improve quality of life in some patients with ACD.