The Surface by PSOLVE+, Issue #8, November 2021
Issue #8, November 2021

In this issue of The Surface, we feature publications on a variety of dermatologic disorders, including melanoma and non-melanoma skin cancer, warts, nail psoriasis, and atopic dermatitis.. View archived issues of The Surface at

Intralesional injections of Candida antigen and bivalent HPV vaccine for common wart treatment

Nassar and colleagues compared traditional cryotherapy, intralesional Candida antigen, intralesional bivalent HPV vaccine, and intralesional saline as a control to treat common warts in 105 patients. The potential benefits of intralesional Candida and HPV vaccine include response at both injected and non-injected warts, whereas cryotherapy must be applied to each wart individually.
Complete clearance of warts was reported in 63.3% of the Candida antigen group, 50% of the bivalent HPV vaccine group, 20% of the cryotherapy group, and 0% of the control group. The differences were significant between each intralesional treatment and cryotherapy, but the difference between Candida and HPV vaccine treatments was non-significant. Complete resolution of distant, noninjected warts was observed in 71.4% of the Candida antigen group and 41.2% of the bivalent HPV vaccine group through induction of a systemic immune response.

Read more: [Sosido link] Nassar A, Alakad R, Essam R, Bakr NM, Nofal A. Comparative efficacy of intralesional Candida antigen, intralesional bivalent human papilloma virus vaccine, and cryotherapy in the treatment of common warts [published online ahead of print, 2021 Aug 28]. J Am Acad Dermatol. 2021;S0190-9622(21)02384-7. doi:10.1016/j.jaad.2021.08.040


Consensus panel exercise on the practical management of AD with dupilumab

Papp and colleagues report on a consensus panel exercise to address the practical aspects of dupilumab use for atopic dermatitis (AD). The panel consisted of 12 key dermatology experts from across Canada, many of whom are active in the PSOLVE+ community. A series of clinical statements was posed to the panel, with each statement being reviewed, revised, and voted on by authors to provide their level of agreement and degree of uncertainty for each statement. Agreements of > 80% were achieved for each statement. The publication lists the statements, Bayesian estimates of the level of agreement of the panel, and the clinical data that support the statements. 

The panel addressed the following clinical areas of dupilumab use: treatment and initiation (such as tapering concurrent systemic therapy, evaluation of dupilumab therapy response and non-responders), special populations (including statements on COVID-19 infection and vaccination), and the management of adverse events. The situations covered in the article represent frequently encountered clinical situations.

Read more: [Sosido link] Papp KA, Hong CH, Lansang MP, et al. Practical Management of Patients with Atopic Dermatitis on Dupilumab. Dermatol Ther (Heidelb). 2021;11(5):1805-1828. doi:10.1007/s13555-021-00586-w


Intramatricial secukinumab injections for patients with nail psoriasis

He and colleagues report on a small (n = 6) study of intramatricial injection of low-dose secukinumab for the treatment of nail psoriasis. Recruited patients had mainly received topical therapy for their skin psoriasis, and none had received systemic conventional or biologic therapy in the three months prior to study entry. Patients were treated first with local anaesthesia to the proximal nail fold before secukinumab injections. Three digits one the left hand were treated with different concentrations of secukinumab (7.5, 15 and 30 mg/mL). Injection volume was 0.05 mL per nail. Patients were treated every two weeks for 5 or 6 treatments. Corresponding digits on the right hand were left untreated as controls. Nail Psoriasis Severity Index (NAPSI) was scored at baseline and every two weeks of the study, with a final follow-up at week 24.
At week 24, there was significant difference in mean NAPSI between the treated and untreated nails (mean improvement of 73.2% vs 18.3%, p < 0.01). All three concentrations appeared to yield similar results. Significant improvements were seen in both the nail bed and nail matrix, and overall clinical efficacy in the nail bed was superior to nail matrix. Injection pain was the most commonly reported adverse event.

Read more: [Sosido link] He F, Long FY, Zhang ZQ, Xia RY, Lu Y, Yin ZQ. Intramatricial injection of anti-interleukin-17A antibody for six patients with nail psoriasis [published online ahead of print, 2021 Sep 12]. Clin Exp Dermatol. 2021;10.1111/ced.14933. doi:10.1111/ced.14933


Reflexive BRAF mutational testing for suspected advanced melanoma

Zhou and colleagues recommend that dermatologists can play an enhanced role in ordering BRAF mutational testing in cases of suspected advanced melanoma, so that patients who may benefit from BRAF/MEK inhibitors can receive timely access. They provide the example of reflex mutational testing in non-small cell lung cancer (NSCLC), where pathologists have been able to reduce the median time to treatment initiation by three weeks with reflexively ordered biomarker tests upon pathologic confirmation of NSCLC. With melanoma, it would be ideal if the BRAF biomarker testing was complete before the first appointment with medical oncology.

The letter discusses the different guidelines for recommending BRAF testing in melanoma, and ultimately recommend ordering molecular testing in cases where the dermatologist suspects stage IIB or higher disease.

Read more: [Sosido link] Zhou S, Sivachandran S, Sikorski D, et al. Reflex Molecular Testing in Melanoma Diagnosis: When Should BRAF Mutation Testing Be Ordered and Who Should Order It? [published online ahead of print, 2021 Sep 8]. J Cutan Med Surg. 2021;12034754211045380. doi:10.1177/12034754211045380


Relative risk of skin cancers with different thiazides and thiazide-like diuretics

First-line treatments for hypertension include thiazides and thiazide-like diuretics (TZs), calcium channel blockers (CCBs) and renin–angiotensin–aldosterone system inhibitors. TZs are photosensitizing due to their sulfonamide moieties, but the relative risks of different TZs is unclear. Previous data suggested that hydrochlorothiazide (HCTZ) may have a greater risk than other TZs. The authors leveraged the UK-based Clinical Practice Research Datalink GOLD database to conduct a cohort study on the risks and incidences of skin cancer in patients starting TZs (n = 271,154) and CCBs (n = 275,263). 

The weighted incidence rate ratio (IRR) for squamous cell carcinoma with long term use of HCTZ was 1.95 (95% CI, 1.87-2.02) compared to CCBs, representing an absolute excess risk of 87.4 SCC diagnoses per 100 000 patient-years of long-term HCTZ use. There was no increased risk found for basal cell carcinoma or cutaneous malignant melanoma. Long-term use of indapamide was associated with an increased risk of cutaneous malignant melanoma [IRR, 1.43 (95% CI, 1.35-1.50)]. Bendroflumethiazide was not associated with increased risk of any type of skin cancer. 

The authors conclude that with risks of skin cancer, that bendroflumethiazide appears to be the safest option for TZ therapy.

Read more: [Sosido link] Schneider R, Reinau D, Stoffel S, Jick SS, Meier CR, Spoendlin J. Risk of skin cancer in new users of thiazides and thiazide-like diuretics: a cohort study using an active comparator group. Br J Dermatol. 2021;185(2):343-352. doi:10.1111/bjd.19880


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