1282 Research Letters J AM ACAD DERMATOL

DECEMBER 2023

Correspondence to: JiaDe Yu, MD, MS, Department of tuberculosis, and the human immunodeficiency vi-
Dermatology, Massachusetts General Hospital, rus among dermatology patients at our institution
Boston, MA 02114 from January 1, 2018, to January 1, 2023. A total of
14,362 eligible patients were identified (Table I).
E-mail: [email protected]
The highest rate of positivity was for HAV (13.1%)
Conflicts of interest and the lowest was for human immunodeficiency virus
None disclosed. (0.588%). The high rate of HAV IgG/immunoglobulin M
positivity may reflect past infection and vaccination as
REFERENCES well as active disease. There were 2150 HAV screens, 8
1. Yadav G, Yeung J, Miller-Monthrope Y, et al. Unmet need in
people with psoriasis and skin of color in Canada and the
(0.37%) of which came from positive immunoglobulin
United States. Dermatol Ther (Heidelb). 2022;12(11):2401-2413. M titers, indicating a low rate of acute HAV infection or
https://doi.org/10.1007/s13555-022-00811-0 testing shortly after vaccination. Adequate screening for
2. Alexis AF, Blackcloud P. Psoriasis in skin of color: epidemi- HBV infection requires testing for hepatitis B surface
ology, genetics, clinical presentation, and treatment nuances. antigen, usually as part of an acute hepatitis panel, as
J Clin Aesthet Dermatol. 2014;7(11):16-24.
3. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ,
well as for total hepatitis B core antibody.1 We found a
Griffiths CEM. Psoriasis prevalence in adults in the United 3.35% positive screening rate for HBV. In such patients,
States. JAMA Dermatol. 2021;157(8):940-946. https://doi.org/10. tumor necrosis factor alpha biologics are contraindi-
1001/jamadermatol.2021.2007 cated.2 For chronic hepatitis B, the American
4. Hsu DY, Gordon K, Silverberg JI. The inpatient burden of Gastroenterological Association recommends antiviral
psoriasis in the United States. J Am Acad Dermatol. 2016;75(1):
33-41. https://doi.org/10.1016/j.jaad.2016.03.048
prophylaxis 12 to 18 months before and after high-risk
5. Levy H, Janke A. Health literacy and access to care. J Health immunosuppressant therapy, and 6 to 12 months for
Commun. 2016;1(21Suppl):43-50. https://doi.org/10.1080/10 low-to-medium-risk therapies.3 For resolved HBV,
810730.2015.1131776 guidelines advise beginning prophylaxis, 12 to
18 months before and after high-risk immunosuppres-
https://doi.org/10.1016/j.jaad.2023.08.011 sant therapy only.2,3 Ultraqualtitative polymerase chain
reaction should be used to monitor viral load.
A retrospective cohort review of A positive antibody to HCV (anti-HCV) shows
infectious disease findings in current, previous, or latent HCV infection. Currently,
patients screened before no vaccine exists against HCV, and there is limited
immunosuppressant therapy pre- or postexposure prophylaxis available. We found
To the Editor: Dermatologists often prescribe immu- a 2.49% positive screening rate among patients
nosuppressive therapy for the treatment of severe screened for HCV. In sharp contrast to HBV, tumor
dermatoses, but they are potentially associated with necrosis factor agents (especially etanercept) can
reactivation of latent infectious diseases. improve manifestations of HCV infection and are
We performed a retrospective cohort review to not contraindicated, but the viral load should be
determine the positive screening rates for hepatitis A assessed, and the patient referred for antiviral
(HAV), hepatitis B (HBV), hepatitis C (HCV), therapy.4

Table I. Positive screening rates for infectious disease components

Number of Total number Positive
Infectious disease Screened component positive screen screened screening rate
Hepatitis A virus Hepatitis A IgM antibody, hepatitis A IgG 281 2150 13.1%
antibody, hepatitis A total antibody
Hepatitis B virus Hepatitis B surface antigen, anti-hepatitis 213 6353 3.35%
B core IgM, anti-hepatitis B core IgG,
anti-hepatitis B total core
Hepatitis C virus Hepatitis C antibody 254 10,291 2.49%
Tuberculosis QuantiFERON gold 135 3865 3.49%
Human immunodeficiency virus HIV-1 antibodies, HIV-2 antibodies 58 9872 0.588%

HIV, Human immunodeficiency virus; IgG, immunoglobulin G; IgM, immunoglobulin M.

ª 2023 by the American Academy of Dermatology, Inc.

J AM ACAD DERMATOL Research Letters 1283
VOLUME 89, NUMBER 6

Of the patients tested for tuberculosis with reactivation during immunosuppressive drug therapy. Gastro-
QuantiFERON Gold, we found a 3.49% positive enterology. 2015;148(1):215-219.
4. Zein NN, Etanercept Study Group. Etanercept as an adjuvant
screening rate. Such patients should be screened to interferon and ribavirin in treatment-naive patients with
for pulmonary and gut infections and referred for chronic hepatitis C virus infection: a phase 2 randomized,
treatment. double-blind, placebo-controlled study. J Hepatol. 2005;42:
The overall rate of positive screening for infec- 315-322. https://doi.org/10.1016/j.jhep.2004.11.025
tious diseases was roughly 23%; 10% if HAV is 5. Snast I, Atzmony L, Braun M, Hodak E, Pavlovsky L. Risk for
hepatitis B and C virus reactivation in patients with psoriasis
excluded. This suggests that at minimum 1 in 10 on biologic therapies: a retrospective cohort study and
patients we treat with immunosuppressive agents systematic review of the literature. J Am Acad Dermatol.
may be at risk for reactivation or exacerbation of an 2017;77(1):88-97.e5. https://doi.org/10.1016/j.jaad.2017.01.037
underlying infection. A prior study from a tertiary
medical center noted hepatitis B and C rates of https://doi.org/10.1016/j.jaad.2023.07.1033
14.49% in a study restricted to psoriasis patients.5
These rates are higher than publicly available data
Perianal and anal skin cancers
collected by the Center for Disease Control. The
treated with Mohs micrographic
retrospective nature of our study and the single
surgery and interdisciplinary care:
tertiary medical center used to collect data may
Local recurrence rates and patient-
limit the generalizability of the findings.
reported outcomes
Nonetheless, this study reinforces the importance
of screening patients prior to beginning To the Editor: Perianal and anal skin cancers treated
immunosuppressive therapy and familiarity with with conventional excision have high local recur-
current guidelines for treatment of those with rence rates.1 Excision of perianal skin cancers may
positive screening results. cause fecal incontinence and negatively impact pa-
tient quality of life.2 Mohs micrographic surgery
Nicholas Strat, MSCR,a Lauren Sattele, BS,a and (MMS) may reduce local recurrence and preserve
Dirk Elston, MDb function, yet National Comprehensive Cancer
Network guidelines are unclear about indications
From the College of Graduate Studies, Medical for MMS of perianal skin cancer. This study evaluated
University of South Carolina, Charleston, SCa; local recurrence rates, patient-reported outcomes
and Department of Dermatology & Dermatologic (PROs), and the frequency of interdisciplinary care
Surgery, Medical University of South Carolina, for perianal skin cancers treated with MMS.
Charleston, SC.b A retrospective case series was conducted for
Funding sources: None. patients with perianal or anal skin cancers treated
with comprehensive or modified peripheral margin
IRB approval status: Exempt. MMS (Supplementary Figure 1-2, available via
Patient consent: Not applicable. Mendeley at https://data.mendeley.com/datasets/
xn3dkjjjkj/1) at an academic medical center between
Key words: biologics; dermatology; hepatitis; immu- 2009 and 2021. Consistent with National
nosuppression; infectious disease; tuberculosis. Comprehensive Cancer Network definitions, tumors
Correspondence to: Nicholas Strat, MSCR, 135 were classified as the ‘‘anal canal location’’ if they
Rutledge Ave, 11th floor, Charleston, SC, 29425 involved mucosa proximal to the anal verge and were
inaccessible by gently pressing the buttocks, or as
E-mail: [email protected] ‘‘perianal location’’ if they involved skin within a
Conflicts of interest 5-cm radius of the anal verge.3 MMS or a modified
None disclosed. MMS (‘‘moat’’ technique) was performed as previ-
ously described.4 The primary outcome was local
REFERENCES recurrence, defined as recurrence contiguous with
1. Elston D. Hepatitis B reactivation in patients on biologics: a
the scar of MMS. Local recurrence was determined via
perfect storm. J Am Acad Dermatol. 2022;86(1):37-38.
2. Akiyama S, Cotter TG, Sakuraba A. Risk of hepatitis B virus medical record review or telephone calls. Secondary
reactivation in patients with autoimmune diseases undergo- outcomes included PROs, evaluated via a telephone
ing non-tumor necrosis factor-targeted biologics. World J survey, and the frequency of interdisciplinary care.
Gastroenterol. 2021;27(19):2312-2324. https://doi.org/10.3748/ Patient-reported fecal incontinence was measured
wjg.v27.i19.2312
3. Reddy KR, Beavers KL, Hammond SP, Lim JK, Falck-Ytter YT.
American Gastroenterological Association Institute guideline
on the prevention and treatment of hepatitis B virus ª 2023 by the American Academy of Dermatology, Inc.