Misinformation in healthcare is at crisis level worldwide, with the internet as primary source of prevarication. Topical corticosteroids (TCS) are a safe and effective treatment used in multiple dermatological conditions. Nonadherence to prescribed TCS can be due to phobia secondary to misinformation. TCS phobia is a complex multifaceted phenomenon that exploits patients with skin disease, creates cognitive dissonance and can obstruct successful treatment. This study aimed to examine the content of TCS-related misinformation available online. A formal review of PubMed was performed using the terms ‘topical corticosteroids’ AND ‘misinformation’ OR ‘disinformation’ OR ‘conspiracy theory, along with an informal Google search using combinations of these terms and further targeted searches on social media applications including Facebook™, Twitter™, Instagram™ and TikTok™. ‘Topical steroid withdrawal’, ‘red skin syndrome’ or ‘TCS addiction’ is a particularly prevalent myth currently being propagated on social media, with most content suggesting that eczema is due to a ‘leaky gut’ or food intolerance and not to skin inflammation. The risks of potential adverse effects such as skin thinning and stunted growth/development are often exaggerated. Multiple websites promoting misinformation were frequently endorsed by companies advertising consultations or testing to identify ‘underlying causes’, or ‘natural’ products as alternative treatments, including ‘herbal’ remedies, which can contain significant quantities of corticosteroids or other potent ingredients. The dermatology community should be vigilant of the type of TCS-related misinformation online and be active in attempts to counteract it with evidence-based advice.
A 66-year-old woman receiving pembrolizumab for metastatic melanoma presented with tender red nodules on her shins and forearms. Biopsy was consistent with erythema nodosum (EN). The eruption responded to oral minocycline and potent topical steroids. Subsequent investigations detected bihilar lymphadenopathy, biopsied as granulomatous lymphadenitis, confirming the diagnosis of pembrolizumab-associated sarcoidosis. Pembrolizumab was stopped for two cycles and was restarted without recrudescence of EN or bihilar lymphadenopathy. Immunotherapy-associated sarcoidosis is a rare but recognized adverse event related to therapy with immune checkpoint inhibitors. EN is an uncommon manifestation of immunotherapy-induced sarcoidosis. New-onset bihilar lymphadenopathy in the context of immunotherapy requires prompt histological evaluation to differentiate between immunotherapy-associated sarcoidosis and metastatic progression. We review the literature related to immunotherapy-associated EN.
A 14-year-old boy was referred to dermatology with a new bleeding lesion on his right neck that had grown rapidly. There was no preceding history of trauma. Physical examination revealed a discrete eroded pink nodule measuring 10 × 9 mm on his right neck. Dermoscopic examination showed a central area of ulceration, with polymorphous vessels, white lines and multiple shades of pink and milky-white areas. This was excised. Histology confirmed the diagnosis of ulcerated superficial spreading malignant melanoma with a Breslow thickness of 4.8 mm (pT4b). BRAF v600e mutation was present. Initial staging with sentinel lymph node biopsy and whole-body positron emission tomography/computed tomography were clear, but 6 months after presentation, he developed right-sided cervical lymphadenopathy and a parotid mass that was confirmed to be metastatic disease. Following a right parotidectomy and neck dissection, he was commenced on adjuvant treatment with dabrafenib and trametinib. He remains under close follow-up. Less than 1% of all melanomas are diagnosed in patients younger than 20 years of age. Most paediatric cases occur in adolescence (between 15 and 19 years of age). The majority arise sporadically. Risk factors for melanoma in childhood include giant congenital melanocytic naevi, personal history of malignancy, family history of melanoma, multiple (> 50) melanocytic naevi, history of sunburn or tanning-bed use, immunosuppression or genodermatoses (e.g. xeroderma pigmentosum). Most clinicians are familiar with the ‘ABCDE’ tool (asymmetry, border irregularity, colour variegation, diameter > 6 mm, evolution) used to help with the recognition of melanomas; however, melanoma in children often presents in an atypical fashion. Paediatric melanomas often lack pigment (amelanotic) and are nodular, and so may be misdiagnosed. Because of this, diagnosis may be delayed and patients often present with thicker tumours and lymph node involvement. To facilitate earlier diagnosis, modified ABCD detection criteria have been proposed for paediatric melanoma (amelanosis, bleeding/bump, colour uniformity, de novo development) that can be used in conjunction with the established ABCDE approach. The CUP criteria have also been described (colour that is pink/red/changing, ulceration/upward thickness, pyogenic granuloma-like lesions/pop-up of new lesions). Evolution remains an important point to consider when suspecting melanoma in patients of any age. Management and staging of paediatric melanoma is adopted from the American Joint Committee on Cancer melanoma staging system guidelines for adult melanoma. Currently, there are no specific guidelines for the management of melanoma in children. The mainstay of treatment is surgical resection. Sentinel lymph node biopsy should be considered with ulceration or a Breslow thickness of > 0.75 mm. Patients with stage III and IV melanoma should be considered for adjuvant immunotherapy. All patients with melanoma should be followed-up with regular skin examinations.
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