Low-dose Psoralen–UV-A maintenance therapy prolongs disease-free remission rates in mycosis fungoides patients

A clinical decision report using Vieyra-Garcia P, Fink-Puches R, Porkert S, et al. Evaluation of Low-Dose, Low-Frequency Oral Psoralen–UV-A Treatment With or Without Maintenance on Early-Stage Mycosis Fungoides. JAMA Dermatology. 2019;155(5):538. https://doi.org/10.1001/jamadermatol.2018.5905 for a patient weighing whether to continue treatment in light of socioeconomic circumstances

Publication rates on the topic of racial and ethnic diversity in dermatology versus other specialties

Background: The population of the U.S. is becoming more diverse every year. The field of dermatology is not following the same trend. Objective: To assess the promotion of diversity in the field of dermatology by analyzing publications focused on diversity, compared to other specialties. Methods: The PubMed database was systematically searched to identify publications focused on diversity from January 2008 to July 2019. The search criteria were as follows: dermatology/radiology/ophthalmology/ anesthesiology/orthopedic surgery/family medicine/ internal medicine/general surgery AND diversity/ diverse/racial/race/ethnic/ethnicity/cultural/culture/competency/competence. Comparisons were made using single-factor ANOVA and two-group t-tests. A qualitative analysis was performed for publications in the field of dermatology. Results: From January 2016 to July 2019, there were 25 publications focused on diversity in dermatology (Mean=6.25, SD=2.06), compared to 6 in radiology (Mean=1.50, SD=1.29, P=0.01), two in ophthalmology (Mean=0.50, SD=0.58, P=0.01), two in anesthesiology (Mean=0.50, SD=1.00, P=0.01), 12 in orthopedic surgery (Mean=3.00, SD=1.41, P=0.04), 23 in family medicine (Mean=5.75, SD=2.22, P=0.75), 9 in internal medicine (Mean=2.25, SD=1.71, P=0.02), and 7 in general surgery (Mean=1.75, SD=0.50, P=0.02). Conclusions: Although the field of dermatology has suffered from a lack of racial/ethnic diversity, efforts to promote diversity via increased publications in the last four years have been stronger in dermatology compared to many other fields

Analyzing China’s contributions to major dermatologic journals from the past 20 years

Background: Over the past 20 years, China has experienced an increased popularity of Western medicine. The impact of Western medicine in China on the field of dermatology is not well characterized. Objective: To assess the impact China has had on the field of dermatology by analyzing the total publications to six dermatological journals, compared to two other Asian countries: Japan and Korea. Methods: PubMed was utilized to search for publications from China, Japan, and Korea within the past 20 years. Descriptive statistics were used to determine the average percentage change in publications during this 20-year period, and the average annual increase in total number of publications from each country. Comparisons were made using one-way ANOVA and two-group t-tests. Results: From 1998 to 2019, there was a 24% average annual increase in publications from China (M=24.4, SD=24.5), compared to a 6% increase from Japan (M=5.6, SD=25.4, P=0.02) and 8% increase from Korea (M=7.8, SD=23.4, P=0.03). Conclusion: For the past 20 years, there has been a strong positive trend regarding the total number of publications from China. This finding might be related in part to an increased acceptance of Western medicine, which follows a similar trend during the time period we analyzed

A case of new-onset vitiligo in a patient on tofacitinib and brief review of paradoxical presentations with other novel targeted therapies

With recent advancements in the understanding of vitiligo pathogenesis, Janus kinase (JAK) inhibitors have emerged as a promising new treatment modality, but their effects remain incompletely elucidated. Tofacitinib, an oral JAK 1/3 inhibitor approved for the treatment of rheumatoid arthritis, has previously been shown to induce significant re-pigmentation in vitiligo. However, as with other novel targeted therapies, cutaneous adverse effects have been observed. We report a 36-year-old woman with a history of rheumatoid arthritis, refractory to multiple pharmacotherapies, who was initiated on tofacitinib and subsequently developed progressive depigmented patches consistent with new-onset vitiligo. Although definitive causation cannot be established in this case without additional studies, it is important to note that many targeted therapies have the potential to induce paradoxical effects, that is, the occurrence or exacerbation of pathologic conditions that have been shown to respond to these medications. Paradoxical findings with other targeted therapies include the occurrence of melanoma during treatment with BRAF inhibitors, keratoacanthomas with PD-1 inhibitors, vitiligo and psoriasis with TNF-alpha inhibitors, and hidradenitis suppurativa with various biologic agents. Although JAK inhibitors hold therapeutic promise in the treatment of inflammatory skin disorders, further research is warranted to more fully comprehend their effects

Dupilumab for bullous pemphigoid with intractable pruritus

Bullous pemphigoid (BP) is an autoimmune blistering disorder that predominantly affects the elderly. Treatment regimens typically include topical and systemic immunosuppressive medications. Although effective, systemic corticosteroids are sometimes poorly tolerated in the elderly patient, contributing to the overall morbidity and mortality of BP. Dupilumab is a monoclonal antibody targeting interleukin 4 receptor alpha (IL4R?), approved for the treatment of atopic dermatitis, as well as moderate to severe asthma and chronic rhinosinusitis with nasal polyposis. In recent reports, dupilumab has been successfully used off-label to treat a variety of pruritic disorders, including chronic spontaneous urticaria [1], anal and genital itch [2], allergic contact dermatitis [3], and prurigo nodularis [4, 5]. We report here a case of an elderly patient with refractory BP whose symptoms of pruritus and blistering became well-controlled with the addition of dupilumab to the treatment regimen

Challenges to smartphone applications for melanoma detection

This commentary addresses the emerging market for health-related smartphone applications. Specific to dermatology, there has been a significant increase not only in applications that promote skin cancer awareness and education but also in those meant for detection. With evidence showing that 365 dermatology-related applications were available in 2014--up from 230 in 2012--and that 1 in 5 patients under the age of 50 have used a smartphone to help diagnose a skin problem, there is clearly a large subset of patients participating in this growing trend. Therefore, we are obligated to take a closer look into this phenomenon. Studies have shown that applications are inferior to in-person consultations with one study showing that 3 out of 4 applications incorrectly classified 30% or more melanomas as low-risk lesions. Although the FDA gained regulatory oversight over mobile health applications in 2012 and recently released their statement in 2015, their reach only extends to cover a selected portion of these applications, leaving many unregulated as they continue to be marketed toward our patients. Dermatologists should be updated on our current situation in order to properly counsel patients on the risks and benefits of these applications and whether they are acceptable for use. © 2016 by the article author(s)

Diagnosis of cutaneous T-cell lymphoma by insurance type before and after the Affordable Care Act: a national database study

The Affordable Care Act (ACT) was implemented to increase health care access and reduce the uninsured in the age group between pediatric and Medicare populations (18-64). The association of the ACA with insurance type upon diagnosis (uninsured, Medicaid, non-Medicaid) has been investigated for otolaryngologic, gynecologic, and the top five non-skin malignancies. Such studies for cutaneous malignancies are lacking. We conducted a retrospective analysis of the prospective National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) cancer database to assess the impact of the ACA on new diagnoses of cutaneous T-cell lymphoma (CTCL) by insurance type. Unlike prior studies of other malignancies, we did not observe significant differences between rate of diagnosis of CTCL by insurance type before and after full implementation of the ACA in all states, expansion states, and non-expansion states. Skin cancers do not have screening guidelines and CTCL is an uncommon malignancy, both of which may contribute to these findings. However, Medicaid-expansion states were much closer to reducing the percentage of newly diagnosed uninsured patients with CTCL than non-expansion states. As such, it may be prudent to investigate intrinsic socioeconomic barriers to care in Medicaid patients to improve their access to care to decrease the uninsured population and improve outcomes

Topical timolol for treatment of persistent granulation tissue in the setting of severe hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a potentially debilitating dermatological disease that negatively impacts patients' quality of life. Severe cases can be further complicated by persistent granulation tissue at the ostia of sinus tracts, which may prove recalcitrant to standard interventions. Herein we report such a case in which a patient experienced significant improvement from severe HS but was left with persistent granulation tissue that complicated his course of recovery. When standard interventions failed, we elected to begin treatment with topical timolol. After three months, the majority of the granulation tissue had regressed and has remained quiescent after 12 months of follow up. The patient has tolerated the treatment well and continues to use topical timolol daily as needed for flares. We believe that topical timolol can provide a practical and painless alternative to current invasive and expensive therapies for persistent granulation tissue associated with severe HS

Bill to Restrict Indoor Tanning for Minors in The State of Maine

Background: Melanoma is the deadliest and the most common type of cancer in individuals age 15 to 29. Evidence has shown that ultraviolet radiation overexposure at younger ages significantly increases the risk of developing non-melanoma and melanoma skin cancer in later years. Despite these concerns, approximately 1.6 million minors under the age of 18 participate in the use of indoor tanning devices annually. The high prevalence of skin cancer in the United States continues to be a public health issue that warrants continued preventative and regulatory action. In spite of the health risks associated with indoor tanning, the state of Maine does not restrict the use of tanning devices for minors, as 18 states now do. Therefore, the aim of this DNP project was to implement a health policy change initiative with the goal of restricting access to commercial indoor tanning devices for minors. Methods:The policy process framework and population health framework were used as models for implementing the health policy initiative. The population health framework was used to develop an argument for the public health implications of excessive ultraviolet (UV) radiation and provides rationale for restricting UV exposure among minors. The policy process framework was used to guide and evaluate the legislative work of this project. The legislative work was accomplished in collaboration with Maine Representative Anne Perry and other stakeholders. Purpose/Implementation Plan: The purpose of this DNP project was to implement a substantive health policy change, that being the restriction of minors under the age of 18 from the use of commercial indoor tanning devices. The health policy change process included the following steps: 1. Create awareness of long-term health risks of indoor tanning devices among key legislators, constituents, and interest groups, 2. Work with legislators to bring a bill forward to restrict access to indoor tanning devices, 3. Evaluate the process and develop a proposal for sustainable action, if the legislation fails. The overall objective of this initiative was to decrease the risk of skin cancer among Maine’s youth. Results:A proposal for the policy change was presented to stakeholders and was developed in support of the initiative. LD #1297, An Act to Reduce Youth Cancer Risk was introduced through the efforts of the coalition. The first public hearing for LD #1297 was held on April 3, 2019 with the Health and Human Services Committee (HHS) in Augusta, Maine with support from the stakeholders. A work session was held on April 16, 2019 where the bill was voted “ought to pass” 7 to 3 by members of the HHS committee. Conclusion:The population health framework and application of the policy process framework to guide legislative efforts, resulted in greater support for LD #1297 by the HHS committee. Policy engagement to address the upstream causes of disease such as skin cancer is a professional responsibility of doctorally prepared nurse practitioners. This can be achieved by engaging in coalition building and enacting legislative initiatives for public health challenges such as the serious public health threat of indoor tanning by minors. Key Words: skin neoplasms, skin cancer, ultraviolet radiation, indoor tanning, artificial tanning, basal cell carcinoma, squamous cell carcinoma, melanom

Barriers and Facilitators to Use of a Clinical Evidence Technology in the Management of Skin Problems in Primary Care: Insights from Mixed Methods

Objective: Few studies have examined the impact of a single clinical evidence technology (CET) on provider practice or patient outcomes from the provider’s perspective. A previous cluster-randomized controlled trial with patient-reported data tested the effectiveness of a CET (i.e., VisualDx) in improving skin problem outcomes but found no significant effect. The objectives of this follow-up study were to identify barriers and facilitators to the use of the CET from the perspective of primary care providers (PCPs) and to identify reasons why the CET did not affect outcomes in the trial. Methods: Using a convergent mixed methods design, PCPs completed a post-trial survey and participated in interviews about using the CET for the management of patients’ skin problems. Data from both methods were integrated. Results: PCPs found the CET somewhat easy to use but only occasionally useful. Less experienced PCPs used the CET more frequently. Data from interviews revealed barriers and facilitators at four steps of evidence-based practice: clinical question recognition, information acquisition, appraisal of relevance, and application with patients. Facilitators included uncertainty in dermatology, intention for use, convenience of access, diagnosis and treatment support, and patient communication. Barriers included confidence in dermatology, preference for other sources, interface difficulties, presence of irrelevant information, and lack of decision impact. Conclusion: PCPs found the CET useful for diagnosis, treatment support, and patient communication. However, the barriers of interface difficulties, irrelevant search results, and preferred use of other sources limited its positive impact on patient skin problem management