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Managing a delusional patient is one of the most challenging situations experienced by dermatologists. This is exacerbated by the scarcity of psychodermatology training offered in residency and similar training programs. A few practical management tips can be easily employed in the initial visit to avoid an unsuccessful encounter. We highlight the most important management and communication techniques needed for a successful first encounter with this traditionally tricky patient population. Topics such as diagnosing primary versus secondary delusional infestation, how to prepare before entering the exam room, how to write the initial patient note, and when is the ideal time to introduce pharmacotherapy are discussed. Tips on preventing clinician burnout and creating a stress-free therapeutic relationship are reviewed. [ABSTRACT FROM AUTHOR]

This article introduces to the dermatology provider two medications for the treatment of tardive dyskinesia (TD), which were the first medications approved by the US FDA specifically for the treatment of TD. In addition to describing these two new medications, this article will also provide a focused review of the pathogenesis of TD, as well as non-FDA-approved treatments, which have been tried prior to the advent of these medications. A PubMed search was conducted and articles were reviewed by the senior authors and included if they were relevant for dermatologists regarding etiology, symptoms, risk, and treatment of TD. One of the most widely accepted explanations of TD involves the concept of 'dopamine receptor hypersensitivity state.' There are several other less well substantiated proposed pathogenic pathways of TD. The clinical manifestation is characterized by involuntary movements. Prevention includes switching to a 2nd generation agent or using the lowest dose possible for the shortest amount of time. Two new FDA-approved medications for TD are also discussed and reviewed. TD now has FDA-approved medications for treatment. Now, there is even more reason for the dermatologist to have increased confidence when treating delusions of parasitosis (DOP) with antipsychotic agents. [ABSTRACT FROM AUTHOR]

The outbreak of the novel coronavirus known as SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) causing COVID-19 was first reported in late December 2019. Many patients with psoriasis on biologic therapy have asked their medical providers about the effect of biologics on COVID-19. However, it is currently unknown how biologic therapy for psoriasis might impact patients with psoriasis and COVID-19. In this article, we report on the clinical course of two patients on biologic medication for psoriasis who developed COVID-19 and successfully recovered from SARS-CoV-2 infection. Both patients presented with fever and respiratory symptoms, but neither patient required hospitalization. While more research is needed, it is reassuring to know that successful recovery is possible after COVID-19 infection in patients on biologic therapy for psoriasis. [ABSTRACT FROM AUTHOR]

Easily accessible office-based procedures that require minimal resources may facilitate timely surgical management of hidradenitis suppurativa (HS). This review focuses on excision and unroofing as two surgical HS treatments that can be tailored to the outpatient setting. Fifty-five articles were included in our review, representing 3914 patients. The majority were retrospective studies (58%, n = 32), and the studies reported data both across patients and by number of treated lesions. Recurrence rates for unroofing (14.5%) were found to be half that of excision (30%) across patients (p = 0.015) and slightly lower across lesions [20% recurrence vs 26% for excision (p = 0.023)]. Complication rates at the lesion level were also significantly associated with procedure, with rates after excision more than double those after roofing (26% vs. 12%, p < 0.001). The complication rate after combined medical and surgical therapy did not differ between procedures. Studies also suggest that continuing medical therapy in the perioperative period may be associated with improved recurrence rates, although delayed wound healing with biologic therapy has been reported. The existing data are limited by low-quality uncontrolled studies with small sample sizes, variable reporting of outcomes, and lack of uniform definitions for recurrence and remission. Further systematic prospective studies are needed to better compare complication and recurrence rates across these procedures in HS, especially in the context of concomitant medical therapy. [ABSTRACT FROM AUTHOR]

With the emergence of the novel coronavirus disease (COVID-19) viral pandemic, there is uncertainty whether biologic agents for psoriasis may place patients at a higher risk for infection or more severe disease course. This commentary offers patient counseling recommendations based on the current available evidence. While there are currently no specific data for psoriasis biologics and COVID-19, data are presented here from phase III clinical trials of psoriasis biologics on rates of upper respiratory infection, influenza, and serious infection. Overall these data reveal that on the whole, psoriasis biologics do not show major increases in infection risk compared to placebo during the course of these trials. However, as the COVID-19 virus is a novel pathogen that is associated with mortality in a subset of patients, a cautious approach is warranted. We discuss factors that may alter the benefit–risk ratio of biologic use during this time of COVID-19 outbreak. Ultimately, treatment decisions should be made on the basis of dialogue between patient and provider, considering each patient's individualized situation. Once this pandemic has passed, it is only a matter of time before a new viral disease reignites the same issues discussed here. [ABSTRACT FROM AUTHOR]

A common treatment for a rare condition: Narrowband-Ultraviolet B (NB-UVB) phototherapy for the treatment of a recalcitrant acquired port wine stain A port-wine stain is a capillary vascular malformation. 2015; 8: 27 - 33. https://doi.org/10.2147/CCID.S53118 7 van Raath MI, Chohan S, Wolkerstorfer A, van der Horst C, Storm G, Heger M. Port wine stain treatment outcomes have not improved over the past three decades. [Extracted from the article]

This letter published in the Journal of Dermatological Treatment discusses the management of dysplastic nevi (DN) and presents the results of a survey conducted among US dermatologists. The survey aimed to assess the practice trends for DN evaluation and management over a 20-year period. The study found significant differences in certain aspects of DN management between the years 2015 and 2021, including the use of technology for evaluation, recommendations for ophthalmologic exams, and the re-excision of severe DN with negative margins. The findings provide insights into the evolving practices in the field of dermatology. The study examines the current management practices of dermatologists in the United States regarding dysplastic nevi (DN), a type of mole that can be a risk factor for melanoma. The study found that while dermatologists still believe there is additional risk for melanoma in DN patients, fewer dermatologists attempt total removals to achieve clear margins. Average surgical margins have increased over time. The study also found that there were changes in the decision to re-excise DN with positive and negative margins. The use of dermoscopy and technology has grown, and there have been changes in screening practices and influences on management decisions. The study suggests that further research is needed to better educate dermatologists on this topic. [Extracted from the article]

BACKGROUND: The dermatology residency application process implemented a new system of preference signaling tokens (PSTs) in the 2021-2022 cycle to allow applicants to express a higher level of interest in specific programs. Limited data are available on the utilization and impact of these tokens. OBJECTIVE: To determine the impact of PSTs on the application process and where in the process PSTs had the greatest influence. MATERIALS AND METHODS: A 14-question survey was sent to 62 ACGME-accredited dermatology residency programs. Primary outcomes were PST impact on 2021-2022 applications. Variables were evaluated using open-ended questions, yes/no responses, and importance ratings from 0 to 100. RESULTS: An average of 7.1% of applicants were offered interviews, but 21.1% of applicants that submitted PSTs were interviewed versus 3.7% of nonsubmitters. 22.5% of ranked applicants and 19% of matched applicants submitted a PST to that program. Limitations: Not all programs responded, and PST submission restrictions could not be assessed. CONCLUSION: The greatest PST impact was on the interview decision but had minimal subsequent impact. Given PSTs cannot be submitted to home programs or in-person away rotations, the actual impact was probably greater than found. Programs will continue to implement PSTs in future cycles. [ABSTRACT FROM AUTHOR]

Background: Advanced nonmelanoma skin cancer (NMSC) is a sometimes unrecognized public health burden. The development of immune checkpoint inhibitors (ICIs), such as those affecting programmed cell death protein-1 (PD-1), have dramatically changed the management of advanced NMSC. Dermatologists need to be knowledgeable about these therapies given their key role in diagnosing, treating, and comanaging NMSC. The purpose of this study was to assess the knowledge base and identify knowledge gaps that dermatologists may have regarding ICIs and assess advanced NMSC referral patterns.Methods: A 10-question survey was emailed to United States-based dermatologists in July 2021 assessing knowledge of ICI therapy and referral patterns for metastatic cutaneous squamous cell carcinoma (mcSCC) or locally advanced basal cell carcinoma (laBCC) management.Results: At their current knowledge level, respondents averaged 40.6 out of 100 (95% CI [35.1, 46.0]) when asked how comfortable they feel counseling a patient on the risks and benefits of an ICI. Seventy-one percent reported that having more information about treatment for mcSCC or laBCC would be helpful in their practice. Being in practice for less than 10 years was not significantly associated with desiring more information about treatment. The respondents reported that the highest number of annual average referrals out for mcSCC or laBCC were made to Mohs surgeons. Fifty-four percent of respondents received referrals for mcSCC or laBCC, and of the providers receiving referrals, 40 percent of them came from general dermatology.Conclusion: These results demonstrate that a knowledge gap exists for dermatologists in treating mcSCC and laBCC with immunotherapy. There is a need among all dermatologists, regardless of years in practice, to receive this information. [ABSTRACT FROM AUTHOR]

Even if the patient happens to develop TD, it is good for dermatologists to be aware that valbenazine and deutetrabenazine were approved for treatment of TD in 2017. Again, we commend the authors on discussing this important topic but would like to offer this pearl with the goal of making the dermatologist more comfortable and successful with the pharmacological treatment of delusional patients. [Extracted from the article]

Introduction: Achievement of remission in psoriasis is a key goal for patients and providers, yet definitions of remission may vary. Some treat-to-target initiatives in psoriasis have focused on degree of skin involvement, while others have also incorporated quality of life (QoL) measures. The goal of this study is to identify factors associated with patient-reported psoriasis remission. Methods: The National Psoriasis Foundation conducted a survey of a random stratified sample of 1570 individuals with psoriatic disease in the USA. The survey contained questions regarding provider diagnosis of psoriasis and/or psoriatic arthritis, as well as comorbid conditions and participant demographics. Psoriasis severity was assessed using the Patient Report of Extent of Psoriasis Involvement (PREPI), a validated self-reported measure of body surface area (BSA). Dermatologic-related quality of life was assessed using the Dermatology Life Quality Index (DLQI). Individuals reporting BSA ≤ 3% were asked if they believed their psoriasis was in remission. Multivariate logistic regression was used to identify factors associated with remission. Results: Of 930 participants reporting BSA ≤ 3%, 479 (51.7%) believed their psoriasis was in remission, with an average remission duration of 31 months. Of those in remission, 79.1% reported current treatment. Multivariate regression revealed that psoriasis remission was independently associated with female sex, lower BSA, less impairment in the Dermatology Life Quality Index and global QoL, biologic use, and concomitant diagnosis of psoriatic arthritis. There was no association with age, race, body mass index, or number of comorbidities. Conclusion: Overall, patient perception of psoriasis remission was not solely associated with BSA, but also with sex, quality of life, and treatment type. [ABSTRACT FROM AUTHOR]

Dermatologists are often ill-equipped to promptly identify and manage patients with personality disorders. Patients with borderline personality disorder (BPD) and narcissistic personality disorder (NPD) frequently present to dermatology clinics, particularly those that provide esthetic services. Although dermatologists should ideally utilize specific management strategies when working with these patients, there is a lack of awareness and availability of resources on how to do so. Here, we review the psychiatry, plastic and reconstructive surgery, and dermatology literature to provide recommendations on tangible management strategies for dermatologists to avoid common mistakes that are made while managing patients with BPD and NPD. Additionally, we also discuss common dermatologic manifestations of BPD and NPD to improve providers' ability to identify patients with these conditions in their practices. [ABSTRACT FROM AUTHOR]

Background: Prognostic assessment of cutaneous melanoma relies on historical, clinicopathological, and phenotypic risk factors according to American Joint Committee on Cancer(AJCC) and National Comprehensive Cancer Network (NCCN) guidelines but may not account for a patient's individual additional genetic risk factors. Objective: To review the available literature regarding commercially available gene expression profile (GEP) tests and their use in the management of cutaneous melanoma. Methods: A literature search was conducted for original, English-language studies or meta-analyses published between 2010 and 2021 on commercially available GEP tests in cutaneous melanoma prognosis, clinical decision-making regarding sentinel lymph node biopsy, and real-world efficacy. After the literature review, the Skin Cancer Prevention Working Group, an expert panel of dermatologists with specialized training in melanoma and non-melanoma skin cancer diagnosis and management, utilized a modified Delphi technique to develop consensus statements regarding prognostic gene expression profile tests. Statements were only adopted with a supermajority vote of > 80%. Results: The initial search identified 1064 studies/meta-analyses that met the search criteria. Of these, we included 21 original articles and meta-analyses that studied the 31-GEP test (DecisionDx-Melanoma; Castle Biosciences, Inc.), five original articles that studied the 11-GEP test (Melagenix; NeraCare GmbH), and four original articles that studied the 8-GEP test with clinicopathological factors (Merlin; 8-GEP + CP; SkylineDx B.V.) in this review. Six statements received supermajority approval and were adopted by the panel. Conclusion: GEP tests provide additional, reproducible information for dermatologists to consider within the larger framework of the eighth edition of the AJCC and NCCN cutaneous melanoma guidelines when counseling regarding prognosis and when considering a sentinel lymph node biopsy. [ABSTRACT FROM AUTHOR]

Doxepin, a tricyclic antidepressant, is the most efficacious antipruritic available to dermatologists; however its use is often suboptimal because of significant interindividual variability in doxepin plasma levels and clinical response between patients taking the same dose. As result, the Food and Drug Administration approves a maximum dose of 300 mg of doxepin per day and a 10 mg per cc liquid doxepin concentrate. These allow patients to significantly increase or decrease their dose, due to either a lack of clinical efficacy or side effects at typical dermatologic doses (often 10–25 mg per day). This review initially discusses the unique advantages of doxepin in dermatology. Then, it explores internal and external reasons why doxepin plasma levels and clinical response vary so significantly between patients, including genetic polymorphisms, drug interactions, comorbidities, sex, and ethnicity. Blood level monitoring is introduced, a tool dermatologists can use to optimize doxepin dosing in patients responding subtherapeutically to typical dermatologic doses. Without blood level monitoring, patients initially unresponsive to treatment could be labeled treatment failures when in fact they may be cases of inadequate dosing. Blood level monitoring allows for safe dose adjustments in these individuals to maximize patients' chances of achieving therapeutic success with this agent. [ABSTRACT FROM AUTHOR]

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self‐induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient‐perceived stigma and lack of educational opportunities for dermatology providers. This two‐part series highlights the most up‐to‐date evidence‐based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin‐picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics. [ABSTRACT FROM AUTHOR]

Pediatric psychodermatologic conditions encompass both primary dermatologic conditions with psychiatric comorbidities and primary psychiatric conditions with self‐induced dermatologic manifestations. Detection, diagnosis, and management of primary psychiatric conditions with dermatologic manifestations are challenging due to patient‐perceived stigma and lack of educational opportunities for dermatology providers. This two‐part series highlights the most up‐to‐date evidence‐based data and management techniques of some of the more common dermatoses of primary psychiatric conditions in children. Part I includes trichotillomania, skin picking disorder, and onychophagia, and part II covers dermatitis artefacta, body dysmorphic disorder, and delusions of parasitosis by proxy, with special considerations for family dynamics. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic significantly impacted clinical research in dermatology and practices around the country transitioned to teledermatology amid physical distancing requirements. Despite their growing use in teledermatology and clinical care, dermatology applications have not been studied extensively in the research space. The use of mobile applications has the potential to improve the experience of study subjects and physicians and increase the pool of individuals willing to participate in research beyond the pandemic. We discuss the various pros and cons of mobile apps, as well as the necessary components they require to successfully conduct research. [ABSTRACT FROM AUTHOR]

The association between psoriasis, metabolic syndrome, and cardiovascular disease is well established. The shared pathways between psoriasis, metabolic syndrome, and atherosclerosis suggest that treatments targeting the inflammatory pathways of psoriasis may also be beneficial in the treatment of associated cardiometabolic comorbidities. This paper reviews the most recent data regarding the impact of systemic psoriasis treatments on comorbid cardiovascular and metabolic disease. Data from randomized clinical trials with systemic and biologic agents are presented. Overall, studies demonstrate beneficial effects on several cardiometabolic markers and risk factors in psoriasis patients; however, longer randomized controlled trials to characterize the direct benefit for cardiovascular outcomes are needed. [ABSTRACT FROM AUTHOR]

Genital and inverse psoriasis can develop in more than one-third of patients who have psoriasis. Psoriatic plaques in the genital and intertriginous skin are challenging to treat because the skin is thin and often occluded, making it more sensitive to certain therapies. Traditional guidelines indicate topical therapies, such as corticosteroids, topical calcineurin inhibitors (TCI), and vitamin D analogs as first-line recommendation in treating genital and inverse psoriasis. There have been developments in the treatment of genital and inverse psoriasis using systemic therapies, including IL-17 inhibitors and PDE-4 inhibitors. [ABSTRACT FROM AUTHOR]

Nail psoriasis has a prevalence that ranges from 10 to 82% and can significantly impact the quality of life of patients. Nail psoriasis is one of the most challenging areas to treat, and multiple therapies have been explored. Topical and injectable therapies are recommended for few-nail disease. Systemic therapies, including biologics, can be considered for patients with multiple and resistant nail disease, impaired quality of life, and severe skin and joint involvement, due to their long-term efficacy. Although outcome data are difficult to compare, interleukin (IL)-17 inhibitors may have superior short-term efficacy when compared to IL-23 inhibitors and tumor necrosis factor (TNF)-alpha inhibitors, although long-term efficacy is similar to TNF-alpha inhibitors. IL-23 inhibitors and TNF-alpha inhibitors have a similar efficacy for nail psoriasis. [ABSTRACT FROM AUTHOR]

The scalp is one of the most commonly affected regions in psoriasis. However, scalp psoriasis can be difficult to treat because of challenges in the delivery of therapy. Effective therapeutic regimens for scalp psoriasis are essential to improving the quality of life of patients. Recent data on topical therapies, phototherapy, systemic agents, and complementary therapy have demonstrated that it is possible to achieve and maintain significant improvement in scalp psoriasis. In this review, efficacy data for these modalities and an algorithm for the practical management of scalp psoriasis are presented. [ABSTRACT FROM AUTHOR]

Machine learning (ML) has the potential to improve the dermatologist's practice from diagnosis to personalized treatment. Recent advancements in access to large datasets (e.g., electronic medical records, image databases, omics), faster computing, and cheaper data storage have encouraged the development of ML algorithms with human-like intelligence in dermatology. This article is an overview of the basics of ML, current applications of ML, and potential limitations and considerations for further development of ML. We have identified five current areas of applications for ML in dermatology: (1) disease classification using clinical images; (2) disease classification using dermatopathology images; (3) assessment of skin diseases using mobile applications and personal monitoring devices; (4) facilitating large-scale epidemiology research; and (5) precision medicine. The purpose of this review is to provide a guide for dermatologists to help demystify the fundamentals of ML and its wide range of applications in order to better evaluate its potential opportunities and challenges. [ABSTRACT FROM AUTHOR]

Background: Clostridium difficile (CD) is a common cause of healthcare-associated infectious colitis that complicates about 1% of all hospital stays in the U.S. The impact of CD on outcomes after coronary artery bypass grafting (CABG) and valvular surgery (VS) is not well known. Methods: The Nationwide Inpatient Sample (2002-2009) was queried to identify CABG and VS patients utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Rates of CD, post-operative endocarditis and mediastinitis, hospital mortality rate, and resource utilization were evaluated. Results: We identified 421,294 and 90,923 patients of age 40 yrs and older who underwent CABG and VS, respectively. The CD infection was more likely to develop in patients undergoing VS than in those having CABG (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.64-1.92) and was more likely after urgent or emergency admission than after elective admission (OR 1.8; 95% CI 1.68-1.94). There was a greater likelihood of mediastinitis in patients with CD after CABG than in non-complicated cases without CD, both by univariable (OR 6.0; 95% CI 3.07-11.62) and multivariable analysis with adjustment for patient age, gender, race, type of admission, and co-morbidities (OR 3.1; 95% CI 1.49-6.51). The infection thus was most likely a result of the antibiotics used to treat mediastinitis, as the patients treated for mediastinitis were most likely to develop CD. There was a significant association in patients with CD and endocarditis who underwent VS but not in patients who did not have CD. The CD infection in these patients thus was most likely a result of the antibiotics used to treat endocarditis. Endocarditis and CD developed 3.2 times (95% CI 2.65-3.97) as often as in patients without CD, a finding that was confirmed by multivariable analysis (OR 2.2; 95% CI 1.70-2.84). At the same time, in patients having VS, there was no significant association of CD and mediastinitis. Clostridium difficile infection affected the hospital mortality rate significantly after both CABG (OR 2.0; 95% CI 1.65-2.35) and VS (OR 1.9; 95% CI 1.51-2.39). Development of CD increased median hospital length of stay and cost dramatically after both CABG (from 7 d to 19 d and from $33,105 to $65,535, respectively; p<0.0001 for both) and VS (from 8 d to 24 d and from $41,876 to $95,699, respectively; p<0.0001 for both). Conclusions: The development of CD worsened significantly the outcomes of adult patients undergoing cardiac surgery. There was a greater risk of CD in patients with either mediastinitis or endocarditis. The infection was associated with a higher hospital mortality rate, longer hospital stays, and greater cost after both CABG and VS. [ABSTRACT FROM AUTHOR]