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In This Issue of JAMA Dermatology
July 2017


JAMA Dermatol. 2017;153(7):623. doi:10.1001/jamadermatol.2016.1693


Photodynamic therapy (PDT) with aminolevulinic acid (ALA) is an effective and cosmetically favorable treatment for actinic keratoses (AKs). However, the shallow penetration depth of ALA, prolonged incubation times, and treatment-associated pain limit widespread use of PDT as standard field therapy for AK. In this randomized clinical trial, Petukhova et al demonstrate that microneedle pretreatment before a 20-minute incubation of ALA resulted in an AK clearance rate of 76%, comparable to conventional PDT. In addition to expediting the protocol, microneedle treatment was virtually painless. This protocol may shorten treatment time and achieve greater patient satisfaction without compromising efficacy.


External store-and-forward (SAF) teledermatology systems typically operate outside of electronic health records (EHRs), and limitations include care fragmentation, inadequate communication among clinicians, and privacy and security concerns. Internal SAF systems within existing EHRs should be the standard for large health care organizations. In this case series, Carter et al demonstrate that, compared with traditional in-person dermatology referrals, an internal SAF system with Epic EHR improved access to dermatologic care by reducing the time to evaluation and time to treatment. After implementation, a greater percentage of referred patients were actually treated by a dermatologist than in the prior year.

Histiocytoid Sweet syndrome (HSS) is a rare histopathologic variant of Sweet syndrome with a mononuclear cell dermal infiltrate thought to be composed of immature myeloid cells. The myeloid nature of this infiltrate has been questioned recently, but in this case series, Alegría-Landa et al used double immunostaining in 33 cases of HSS to confirm the immature myeloid cell type of most of the cells. Histiocytes were found in most cases as only a minor component of the infiltrate. While HSS should not be interpreted as leukemia cutis, it is associated with hematologic malignancy with the same frequency as classic neutrophilic Sweet syndrome.

Vitiligo is a common, chronic, acquired cutaneous depigmentation disorder. Although many interventions are available, no gold standard for treatment has emerged. Phototherapy, including psoralen–UV-A and narrowband UV-B (NBUVB), constitutes the principal treatment for generalized vitiligo, whereas excimer laser therapy and topical agents are used to treat localized disease. In this meta-analysis, Bae et al demonstrate that NBUVB treatment of vitiligo produced at least a mild response after 6 months of treatment. The greatest response was demonstrated after long-term NBUVB on the face and neck, while response to treatment of the hands and feet was disappointing.

The inherent limitations of image recognition make the visual assessment of pigmented lesions by even experienced dermatologists challenging, and early melanomas may go undetected. Dermoscopy or computer-aided image analysis may reduce, but not overcome, these limitations. In this case study, Ferris et al demonstrate that a noninvasive adhesive patch biopsy-based 2-gene expression test significantly improved biopsy specificity while maintaining sensitivity. This tool may increase the number of early melanomas biopsied and reduce the number of benign lesions biopsied.

Continuing Medical Education