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In This Issue of JAMA Dermatology
October 2017


JAMA Dermatol. 2017;153(10):959. doi:10.1001/jamadermatol.2016.1714


Because of its low cost, infrequent dosing, and favorable adverse effect profile, methotrexate sodium is widely used for severe psoriasis. However, methotrexate therapy is associated with hepatic fibrosis, which occurs at excess even among patients who are carefully prescreened for alcohol use and chronic viral hepatitis. Liver biopsy is the current standard for detecting and monitoring hepatic fibrosis among patients receiving long-term methotrexate therapy, but this invasive procedure carries important risks. In this cohort study, Bauer et al demonstrate the utility of a noninvasive test for nonalcoholic steatohepatitis (NASH), which may significantly reduce the need for liver biopsies.

Nonmelanoma skin cancer (NMSC) risk factors include white race, male sex, and sun exposure. The major etiologic agent for NMSC is UV-B, but UV-B also induces cutaneous vitamin D production, which exerts protective effects in several cancer types. More than 60 single-nucleotide polymorphisms (SNPs) in the vitamin D receptor have been detected. In this case-control study, Burns et al demonstrate that patients with the BsmI SNP were twice as likely to develop NMSC. Screening for BsmI may emphasize the need for early skin cancer prevention in individuals with this SNP.

Total body nevus count and the presence of atypical nevi are among the strongest known risk factors for melanoma. The Study of Nevi in Children (SONIC) is a population-based study designed to prospectively document the evolution of individual nevi in children using clinical and dermoscopic photography. In this cohort study, Xu et al demonstrate that baseline total nevus count and variability in nevus dermoscopic pattern in early adolescence were significantly associated with a mole-prone phenotype in late adolescence. These clinical factors may facilitate early identification of a population at risk for melanoma and enhance targeting of melanoma prevention efforts.

Continuing Medical Education

The significance of the BAP1 gene was originally established when inactivating BAP1 mutations were found in aggressive uveal melanoma tumors. BAP1 deficiency has been associated with a syndrome that includes increased renal cell carcinoma and melanoma risk. Some patients develop numerous skin-colored, dome-shaped papules, referred to as melanocytic BAP1-mutated atypical intradermal tumors (MBAITs). In this case series, Haugh et al demonstrate that the histopathology of MBAITs is highly characteristic and that these lesions have a relatively early age of onset compared with other associated tumors. Patients with BAP1 syndrome identified by dermatologists should be referred to geneticists and to specialized pulmonary and nephrology centers.

Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neuroendocrine neoplasm with a high risk of recurrence following resection. Adjuvant radiotherapy is considered for larger tumors, close resection margins, lack of sentinel lymph node biopsy, or in immunocompromised patients. In this cohort study, Patel et al demonstrate that radiotherapy doses from 40 Gy to under 50 Gy for localized MCC of the trunk or extremities may be appropriate to achieve survival equivalent to that achieved with higher doses, and with perhaps fewer toxic effects.