Antifungal Selection for the Treatment of Onychomycosis: Patient Considerations and Outcomes.

Onychomycosis, a common fungal nail infection, affects >20% of adults over age 60 and >50% of people over age 70. Onychomycosis may cause pain, psychosocial problems, and secondary infections, therefore meriting treatment. This review describes the range of treatment modalities, including FDA-approved systemic drugs and topical therapies. Additionally, new and emerging oral and topical therapies are discussed. We emphasize the importance of tailoring onychomycosis therapy to individual patient characteristics, comorbidities, preferences, extent of nail involvement, and fungal species, such that physicians may optimize treatment outcomes, patient satisfaction, and safety.

Nail lichen planus treatment safety.

AREAS COVERED: Topical therapies for nail lichen planus (clobetasol propionate, topical tacrolimus, bath-PUVA), intralesional treatment (triamcinolone), and systemic treatment (corticosteroids, retinoids, small molecule inhibitors (jak/stat inhibitors)), TNF-alpha inhibitors (etanercept), systemic immunomodulators (oral calcineurin inhibitors, mycophenolate mophetil), and antimalarials (chloroquine), each with unique safety profiles and considerations. Herein, we discuss common and uncommon adverse events, as well as utilization for special populations, including pregnant and pediatric patients.

Minimizing Bias in Alopecia Diagnosis in Skin of Color Patients.

Alopecia is one of the most common dermatologic conditions affecting black patients, with a significantly negative impact on quality of life.1,2 Timely and accurate diagnosis is therefore critical in order to reverse or halt progression of disease.3 Unfortunately, lack of representation of skin of color (SOC) patients in the current literature may contribute to misdiagnosis as providers may be unfamiliar with the clinical spectrum of alopecia presenting in darker scalps.4 Some scarring alopecia subtypes such as Central Centrifugal Cicatricial Alopecia (CCCA) are more prevalent in certain racial groups. However, focusing solely on patient demographics and gross clinical findings may obscure accurate diagnoses. To distinguish alopecia findings in Black patients, a dedicated approach using a combination of clinical exam findings and patient history, along with trichoscopy and biopsy, is essential to prevent misdiagnosis and improve clinical and diagnostic outcomes. We present three cases of alopecia in patients of color which the initial suspected clinical diagnosis did not correspond with trichoscopic and biopsy results. We challenge clinicians to reexamine their biases and fully evaluate patients of color with alopecia. An examination should include a thorough history, clinical examination, trichoscopy, and potentially a biopsy, particularly when findings do not correlate. Our cases highlight the challenges and disparities that exist in diagnosis of alopecia in Black patients. We emphasize the need for continued research regarding alopecia in skin of color and the importance of a complete workup for alopecia to improve diagnostic outcomes.Balazic E, Axler E, Nwankwo C, et al. Minimizing bias in alopecia diagnosis in skin of color patients. J Drugs Dermatol. 2023;22(7):703-705. doi:10.36849/JDD.7117.  .

The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis.

OBJECTIVE: To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP). DATA SOURCES: PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021. REVIEW METHODS: All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination. RESULTS: The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, -7.48 to -1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46-29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination. CONCLUSION: The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2046-2054, 2023.

Pentoxifylline in dermatology.

BACKGROUND: Pentoxifylline was initially marketed for use in patients with intermittent claudication due to chronic occlusive arterial disease of the extremities but has since been shown to have several off-label uses in dermatology. AIMS: The aim of this review is to increase awareness of the several applications of pentoxifylline in the field of dermatology. METHODS: A comprehensive PubMed search was conducted in May 2022 using the following phrases "dermatology" AND "pentoxifylline." Our search period spanned 34 years from 1988 to 2022. All available literature was reviewed. Reference lists of identified articles were included. Studies were excluded if they were not in English and if the study was out of scope. Eighty-one articles were included in this review. RESULTS: Pentoxifylline has been used to treat various dermatological conditions including peripheral vascular disease, vasculitis and vasculopathies, chilblains, pigmented purpuric dermatosis, granuloma annulare, necrobiosis, keloids, lichen sclerosis et atrophicus, scars, radiation-induced fibrosis, vitiligo, alopecia areata, leishmaniasis, and leprosy. CONCLUSIONS: Pentoxifylline's use in dermatology is growing. However, there are limited larger studies and randomized control trials on the use of pentoxifylline in dermatology and more investigation is needed to evaluate its use for many dermatologic conditions. Pentoxifylline's unique mechanism of action as well as its good tolerability, cost-effectiveness, and minimal drug interactions make it a convenient primary or adjunctive option in many dermatological conditions.

Risk assessment for indeterminate pulmonary nodules using a novel, plasma-protein based biomarker assay.

BACKGROUND: The increase in lung cancer screening is intensifying the need for a noninvasive test to characterize the many indeterminate pulmonary nodules (IPN) discovered. Correctly identifying non-cancerous nodules is needed to reduce overdiagnosis and overtreatment. Alternatively, early identification of malignant nodules may represent a potentially curable form of lung cancer. OBJECTIVE: To develop and validate a plasma-based multiplexed protein assay for classifying IPN by discriminating between those with a lung cancer diagnosis established pathologically and those found to be clinically and radiographically stable for at least one year. METHODS: Using a novel technology, we developed assays for plasma proteins associated with lung cancer into a panel for characterizing the risk that an IPN found on chest imaging is malignant. The assay panel was evaluated with a cohort of 277 samples, all from current smokers with an IPN 4-30 mm. Subjects were divided into training and test sets to identify a Support Vector Machine (SVM) model for risk classification containing those proteins and clinical factors that added discriminatory information to the Veteran's Affairs (VA) Clinical Factors Model. The algorithm was then evaluated in an independent validation cohort. RESULTS: Among the 97 validation study subjects, 68 were grouped as having intermediate risk by the VA model of which the SVM model correctly identified 44 (65%) of these intermediate-risk samples as low (n=16) or high risk (n=28). The SVM model negative predictive value (NPV) was 94% and its sensitivity was 94%. CONCLUSION: The performance of the novel plasma protein biomarker assay supports its use as a noninvasive risk assessment aid for characterizing IPN. The high NPV of the SVM model suggests its application as a rule-out test to increase the confidence of providers to avoid aggressive interventions for their patients for whom the VA model result is an inconclusive, intermediate risk.