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In This Issue of JAMA Dermatology
April 2017


JAMA Dermatol. 2017;153(4):245. doi:10.1001/jamadermatol.2016.1672


Actinic keratoses (AKs) require long-term management because a small proportion can evolve into squamous cell carcinoma (SCC). Spending on AK management was more than $1 billion in 2004. In this cohort study, Kirby et al demonstrate variability in AK management costs within and between regions. This variation is not fully explained by differences in patient characteristics and suggests an opportunity to investigate and improve the value of AK management.


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Physical pretreatment of the skin facilitates local uptake of photosensitizing agents and is recommended for treatment of AK with photodynamic therapy (PDT). Pretreatment preparations include curettage, microdermabrasion, microneedling, and ablative fractional laser (AFXL). In this randomized clinical trial, Bay et al compare these techniques and demonstrate that PPIX accumulation was most enhanced after AFXL, followed by microdermabrasion, microneedling, and curettage. Increasing the number of pretreatment passes and laser densities did not further augment PPIX accumulation.

The ugly duckling sign describes a nevus that obviously differs from others on an individual and is widely considered suspect for melanoma both visually and dermoscopically. To estimate the contribution of this kind of intrapatient comparative analysis (IPCA) to the diagnosis of melanoma, Gaudy-Marqueste et al used digital images of nevi of 80 patients. All melanomas were labeled ugly duckling nevi, and access to IPCA reduced the potential biopsy of nevi by a factor of 6.9. Introduction of IPCA using the ugly duckling sign may improve performance of computer-assisted diagnosis systems.

Many unresectable or metastatic basal cell carcinomas (BCCs) respond to targeted therapies such as those inhibiting the hedgehog pathway, but for those that do not, alternative treatment options are limited. Programmed cell death 1 (PD-1) inhibitors have proven effective therapy for many solid tumors, and in this cross-sectional study, Chang et al demonstrate high rates of programmed cell death ligand 1 (PD-L1) positivity in BCCs and tumor-infiltrating lymphocytes. Staining intensity for PD-L1 increased with the number of distinct prior treatment modalities. These data suggest that PD-1 inhibitor immunotherapy may have activity against BCCs, including those that have been previously treated.

Editorial and Related Articles 1 and 2


While early-stage cutaneous SCC (cSCC) has a good prognosis, treatment of unresectable or metastatic cSCC remains challenging. Cetuximab is a human-mouse chimeric monoclonal antibody that competitively inhibits the epidermal growth factor receptor (EGFR), which is highly expressed in cSCC. A lack of response to anti-EGFR therapy has been demonstrated in solid tumors harboring RAS mutations. In this study, Picard et al demonstrate no correlation of RAS mutations with response to cetuximab. Although mutational data may better define response to cetuximab among cSCC, looking for mutations in these genes is not useful.

Editorial and Related Articles 1 and 2