Juliana Berk-Krauss

Melanoma risk after in vitro fertilization: A review of the literature

Background: The role of female sex hormones in the pathogenesis of malignant melanoma (MM) remains controversial. Although melanocytes appear to be hormonally responsive, the effect of estrogen on MM cells is less clear. Available clinical data does not consistently demonstrate that increased endogenous hormones from pregnancy or increased exogenous hormones from oral contraceptive pills and hormone replacement affect MM prevalence and outcome. Objective: We sought to examine potential associations between in vitro fertilization (IVF) and melanoma. Methods: A literature review was conducted. Primary outcomes were reported as associations between IVF and melanoma risk compared with the general population. Secondary outcomes included associations stratified by type of IVF regimen and subgroup, such as parous versus nulliparous patients. Results: Eleven studies met our inclusion criteria. Five studies found no increased risk for MM among IVF users compared with the general population. Two studies found an increase in MM in clomiphene users, and 4 studies found an increase in MM among patients who were gravid or parous either before or after IVF. Conclusion: The reviewed studies do not reveal consistent patterns of association between IVF and MM among all infertile women. However, the data indicates a potential increased risk for MM in ever‐parous patients treated with IVF. High‐quality studies including a large number of MM cases that control for well‐established MM risk factors are needed to adequately assess the relationship between IVF and MM, particularly among ever‐parous women.

Bullous disorders associated with anti-PD-1 and anti-PD-L1 therapy: A retrospective analysis evaluating the clinical and histopathologic features, frequency, and impact on cancer therapy

Background: Bullous disorders associated with anti–programmed cell death 1 (PD‐1)/programmed cell death ligand 1 (PD‐L1) therapy are increasingly reported and may pose distinct therapeutic challenges. Their frequency and impact on cancer therapy are not well established. Objective: To evaluate the clinical and histopathologic findings, frequency, and impact on cancer therapy of bullous eruptions due to anti–PD‐1/PD‐L1 therapy. Methods: We retrospectively reviewed the medical records of patients evaluated by the oncodermatology clinic and consultative service of Yale New Haven Hospital from 2016 to 2018. Results: We identified 9 of 853 patients who developed bullous eruptions (˜1%) that were treated with an–PD‐1/PD‐L1 therapy at our institution during the study period: 7 presented with bullous pemphigoid, 1 presented with bullous lichenoid dermatitis, and 1 presented with linear IgA bullous dermatosis in the context of vancomycin therapy. In all, 8 patients required systemic steroids, 5 required maintenance therapy, and 8 required interruption of immunotherapy. All 9 patients had an initial positive tumor response or stable disease, but 4 went on to develop disease progression. Limitations: This was a retrospective study from a single tertiary care center. Conclusions: Bullous disorders developed in approximately 1% of patients treated with anti–PD‐1/PD‐L1 therapy at our institution and frequently resulted in interruption of immune therapy and management with systemic corticosteroids and occasionally steroid‐sparing agents.

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce. Objective To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme. Design, Setting, and Participants This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists. Main Outcomes and Measures Active US dermatologist and physician density. Results In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities. Conclusions and Relevance Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

An immunosuppressed man with an isolated necrotic plaque on the chest

A 54-year-old man on systemic immunosuppressive therapy for 1 month after a liver transplant for hepatitis C virus presented with a 5-day history of a solitary plaque on the chest. Physical examination found an indurated, violaceous 53 3-cm tender plaque studded with pustules. Over the following days, the plaque became more purulent and developed a central erosion with necrosis (Fig 1). Punch biopsy found a nodular and diffuse dermal mixed cell infiltrate with multinucleated histiocytes and neutrophils (Fig 2, A). Fungal organisms with nonseptated hyphae and right angle branching were identified by Gomori methenamine silver stain (Fig 2, B).

Eczematous reaction to IVIG for the treatment of dermatomyositis

The use of high-dose intravenous immunoglobulin (IVIG) is an accepted therapy for patients with refractory dermatomyositis. Cases of eczematous reactions to IVIG have been reported in the literature, but to our knowledge, none in patients being treated for dermatomyositis. We report on the cases of two female patients with refractory dermatomyositis who developed pruritic, scaly pink plaques after receiving high-dose IVIG. This diffuse eczematous skin reaction to high-dose IVIG is a rare adverse event that most often occurs days after administration of therapy. Practitioners should be aware of this entity because the eczematous eruption may be extensive and can commonly worsen with subsequent re-exposure to IVIG.

Pregnancy and Melanoma: Recommendations for Clinical Scenarios

Managing pregnant patients with a history of melanoma or with a melanoma diagnosis can be daunting and confusing for dermatologists. We present three clinical scenarios that raise questions about the safety of pregnancy in patients with a history of melanoma, skin biopsies during pregnancy, and excisions and sentinel lymph node biopsies during pregnancy. Our recommendations incorporate the most up-to-date clinical data to help guide clinicians when faced with pigmented lesions and melanoma in a pregnant patient.

Mole Mapping for Management of Pigmented Skin Lesions

Identifying new or changing melanocytic lesions, particularly in patients with numerous or atypical nevi, can be challenging. Total-body photography and sequential digital dermoscopy imaging, together known as digital follow-up, are 2 prominent forms of noninvasive imaging technology used in mole mapping that have been found to improve diagnostic accuracy, detect earlier-stage melanomas, and reduce costs. Digital follow-up, in combination with direct-to-consumer applications and teledermatology, is already revolutionizing the ways in which physicians and patients participate in melanoma surveillance and will likely continue to enhance early detection efforts.