Search

Background The ItchyQoL is an itch-specific patient-reported outcome measure used to assess quality of life in patients with chronic pruritus (CP). Objectives We aimed to assess and extend the psychometric properties of the ItchyQoL using classical test theory (CTT) and item response theory (IRT). Methods Item characteristic curves were analysed to investigate whether the response categories were functioning optimally. Confirmatory factor analyses were carried out on the ItchyQoL prior to and after rescoring of the response categories. We conducted a Rasch analysis for the ItchyQoL with revised response options and assessed the mean fit residuals in addition to the assumptions of unidimensionality and local independence. Results In total, 551 patients with CP from nine European countries completed the 22 items of the ItchyQoL. IRT analysis supported the revision of response options from five points to three. This revision was supported by excellent structural validity using CTT. The overall fit to the Rasch model was adequate. Unidimensionality was supported by the ItchyQoL overall scale and by the single subscales; however, local independence was violated in eight cases. Conclusions We suggest a revision of the response categories of the ItchyQoL from a 5-point to a 3-point scale. When this revision was applied, the ItchyQoL showed excellent structural validity according to CTT and IRT/Rasch. The calculation of an overall ItchyQoL sum score is allowed.

Background Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that severely impairs patients’ quality of life (QoL). Instruments such as the 10-item Dermatology Life Quality Index and 16-item Skindex-16 have been used to assess QoL in HS; however, it is unknown whether the shorter 3-item Skindex-mini can also provide an accurate assessment of skin-related QoL in patients with HS. Objectives The aim was to assess how well the Skindex-16 correlates with its shorter adaptation, the Skindex-mini, in capturing QoL among patients with HS. Methods This retrospective cross-sectional study included all HS patients seen in the HS Clinic at The Emory Clinic between January 1, 2019, and August 16, 2019. We compared the correlation between the symptom, emotion, and function domains of the Skindex-16 and Skindex-mini using Pearson correlation coefficients (CC). Secondary outcome measures included individual survey item analysis, ItchyQuant scores, and numeric rating scale of pain. Results We identified 108 encounters among 75 unique hidradenitis suppurativa patients (43 black/African American, 18 white, 5 Asian/Pacific Islander, 3 Latino, 4 Other, 2 unknown). Pearson CC between the Skindex-16 and Skindex-mini domain scores for all encounters were 0.770 ( P < .001), 0.787 ( P < .001), and 0.801 ( P < .001) for the symptom, emotion, and function domains, respectively. The mean pain and ItchyQuant scores were 4.14 (SD 3.31) and 3.55 (SD 3.34), respectively. Conclusions The Skindex-mini correlated highly with the Skindex-16 in a racially diverse group of patients with HS. The Skindex-mini is a streamlined QoL instrument that could be practically implemented into routine clinical care among diverse patients presenting to dermatology.

Actinic keratoses (AK) diagnosis, billing, and pharmacy codes have not been validated among people living with human immunodeficiency virus (HIV), preventing use in epidemiologic and clinical research. We aimed to calculate the positive predictive value (PPV) of AK diagnosis codes, procedural codes for destruction of pre-malignant lesions, and pharmacy codes for topical 5-fluorouracil.Patients diagnosed with HIV within the Infectious Disease clinic at the Atlanta Veterans Affairs Medical Center from 1/1/2002 to 8/5/2017 were eligible. Patients were included if they had any of the following: encounters with a diagnosis for AK (International Classification of Diseases [ICD]-9: 702.0; ICD-10: L57.0), procedural codes for destruction of premalignant lesions (Current Procedural Terminology [CPT]: 17000, 17003, and 17004), and prescriptions for topical 5-fluorouracil. PPV and binomial 95% confidence intervals were calculated.PPV was 91.9% (89.1-94.7) for 369 encounters with an AK diagnosis. For procedural codes, PPV was 52.6% (48.1-57.2) for 454 encounters with destruction of 1 pre-malignant lesion, 63.7% (58.4-68.9) for 322 encounters with destruction of 2-14 lesions, and 57.7% (38.7-76.7) for 26 encounters with destruction of 15+ lesions. PPV was 72.9% (63.5-82.4) for 85 encounters with a prescription of topical 5-fluorouracil.AK diagnosis codes are appropriate to use in epidemiologic and health policy research among people living with HIV and may be more reliable than destruction of pre-malignant lesion CPT codes.

Cutaneous melanomas are the fifth most common cancer in the United States and the United Kingdom, with a 5-year relative survival of 87-93%.1,2 Targeted and immune checkpoint therapies have further expanded the number of advanced melanoma survivors. Cancer survivorship recommendations have been published by Macmillan Cancer Support; yet programs for melanoma survivors in the US are still in their infancy.3 We aimed to explore experiences and challenges that US patients diagnosed with melanoma experienced in a tertiary cancer centre using in-depth interviews.

Background Timely treatment for melanoma may affect survival, and characterizing the predictors of delay may inform intervention strategies. Objective To determine characteristics associated with the interval between diagnosis and surgery in melanoma. Methods The National Cancer Database was used to examine factors associated with the interval between diagnosis and surgery among 213 146 patients with stage I, II, or III cutaneous melanoma. Results Among privately insured patients, time to surgery was longer for patients aged 50 to 70 years (hazard ratio [HR], 0.96) and older than 70 years (HR, 0.83) compared with those younger than 50 years. In contrast, patients without private insurance experienced a shorter surgical wait time if older (HR for age 50-70 years, 1.07; HR for age >70 years, 1.05). Other factors associated with longer surgical interval included nonwhite race, less education, higher comorbidity burden, advanced stage, and head or neck melanoma location. Limitations Use of zip code–level data for income and education level. Conclusion Patients with melanoma experience disparities in timely receipt of surgery.

BACKGROUND/OBJECTIVES Validated pruritus-specific quality of life and self-reported severity instruments exist primarily for adults. Clinical trials to develop therapeutics for children with chronic pruritus are hampered by the paucity of appropriate outcome measures. To address this gap, we aimed to develop validated instruments to measure itch-specific quality of life and self-reported severity in children. METHODS We conducted in-depth, open-ended interviews of itchy children and generated concepts to develop TweenItchyQoL. We administered TweenItchyQoL, ItchyQuant, a cartoon-annotated self-reported pruritus severity numeric rating scale (NRS), and a non-cartoon NRS to 175 itchy children aged 8-17 years. We analyzed the data for feasibility, preference, reliability, construct validity, and responsiveness. RESULTS Average completion time was 4.8 minutes for TweenItchyQoL and 33 seconds for ItchyQuant. The majority of patients either preferred ItchyQuant or found no difference between ItchyQuant and the NRS. Cronbach's alpha for TweenItchyQoL total and subscales ranged from 0.84 to 0.95. Test-retest reliability coefficients were ≥0.7 for TweenItchyQoL and 0.4 for ItchyQuant. A 3-dimensional bifactor model was most appropriate (RMSEA = 0.048) on the confirmatory factor analyses. As a function of those reporting worsening, improvement, or no change at their final visit, TweenItchyQoL and ItchyQuant scores in those cohorts changed as expected. CONCLUSIONS This new set of validated and feasible instruments shows promise to quantify itch severity and QoL impact in older children.

Background/objectives Measures of pruritus severity and quality of life (QoL) are necessary for the development of therapeutics for children with chronic pruritus. In children, questionnaires need to be developed for specific age groups given the differences in cognitive levels. In this study, we aimed to develop tools to assess QoL and pruritus severity in children 6 to 7-years-old with chronic pruritus. Methods Based on open interviews with children, we developed a cartoon-annotated QoL instrument, KidsItchyQoL, and validated an existing pruritus severity instrument, ItchyQuant, that measures pruritus impact and severity for the preceding week. Both instruments were administered to 100 children aged 6-7 years with chronic pruritus. The data were analyzed for reliability, reproducibility, construct validity, and responsiveness. Results We found the 14-item KidsItchyQoL to be reliable (Cronbach's α = 0.846) and reproducible (intraclass correlation coefficient (ICC) = 0.66) as was the ItchyQuant (ICC = 0.47). With respect to construct validity, examination of eigenvalues of the inter-item polychoric correlation matrix suggested three dominant factors. A subsequent confirmatory factor analysis suggested that a 3-dimensional simple structure model with correlated factors provided a reasonable data representation. The responsiveness of KidsItchyQoL and ItchyQuant (P = .005, GLM procedure) were demonstrated with scores changing as expected with the self-reported change of itch severity. Conclusions These results demonstrate promise for a new set of reliable research tools to assess QoL and pruritus severity in children 6 to 7 years of age.

IMPORTANCE: Acne is a common dermatologic condition and significantly affects psychosocial health and quality of life. An international task force recommended routine use of quality-of-life measures for clinic visits associated with acne management, but this has yet to translate into clinical practice. OBJECTIVE: To assess mean Skindex-16 scores over time among patients with moderate to severe acne receiving isotretinoin treatment. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal, retrospective case series study of Skindex-16 data collected at monthly visits from 57 consecutive patients with acne receiving isotretinoin; data were collected and evaluated between November 23, 2016, and January 22, 2019. Continuous variables were compared using quantile regression. Multivariable linear mixed models evaluated mean (95% CI) score trajectory over time. MAIN OUTCOMES AND MEASURE: Skindex-16 scores, including normalized scores for the emotional, symptomatic, and functional aspects of having skin disease as well as an overall score. RESULTS: Fifty-seven patients (31 [54.4 %] males, with median [interquartile range] age of 17.2 [15.9-18.1] years) in this case series study completed the Skindex-16 at baseline and at least once during follow-up. Baseline Skindex-16 scores were similar by sex but worse with increasing age. Emotional impact was more bothersome to patients with acne requiring isotretinoin treatment than either symptoms or functioning. Improvements of greater than 50% in overall and Emotional domain scores were seen by month 2 of receiving isotretinoin treatment (eg, overall scores decreased from 39.4 to 17.5 by month 2; a decrease of 22.0; P

IMPORTANCE: Asian American individuals are the fastest growing racial group in the US but remain underrepresented in health disparities research, including research on skin cancer risk factors and screening. Improved understanding of preventable skin cancer risk factors and screening may demonstrate unmet needs among Asian American individuals. OBJECTIVE: To examine sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) for skin cancer screening among Asian American subgroups compared with non-Hispanic White individuals. DESIGN, SETTING, AND PARTICIPANTS: The National Health Interview Survey is a nationally representative cross-sectional survey in the US that assesses health behaviors. Self-identified Asian Indian, Chinese, Filipino, non-Hispanic White, and other Asian respondents from survey years 2000, 2005, 2010, and 2015 were included. Data were analyzed from July to November 2021. MAIN OUTCOMES AND MEASURES: Any sunburn within the last year; sun-protective behaviors included applying sunscreen, staying under shade, wearing long-sleeved shirts, wearing long clothing to the ankles, wearing hats, and wearing caps most of the time or always when out in the sun; any indoor tanning within the last year; any TBSE ever. RESULTS: Of 84 030 participants, 5694 were Asian American (6.8%) and 78 336 (93.2%) were Non-Hispanic White; of these individuals, 1073 (weighted prevalence, 21.0%) were Asian Indian, 1165 (19.4%) Chinese, 1312 (23.5%) Filipino, and 2144 (36.1%) Other Asian. All Asian American subgroups were more likely to seek shade, wear long clothing to the ankles, and wear long-sleeved shirts but less likely to sunburn, apply sunscreen, tan indoors, and receive TBSE than Non-Hispanic White individuals. Asian Indian individuals were less likely than Chinese participants to apply sunscreen (adjusted odds ratio [aOR], 0.55; 95% CI, 0.41-0.74) or wear a hat (aOR, 0.53; 95% CI, 0.37-0.76) and more likely to wear long-sleeved shirts (aOR, 1.89; 95% CI, 1.52-2.33) or long clothing to the ankles (aOR, 1.56; 95% CI, 1.28-1.90). CONCLUSIONS AND RELEVANCE: The results of this cross-sectional study found that disaggregated comparisons among Asian American individuals demonstrated differences in skin cancer risk factors that may be used to identify high-risk subgroups and inform culturally aware counseling when indicated. Future studies should further sample Asian American individuals to evaluate for potential masked health disparities through disaggregated analysis.

BACKGROUND/OBJECTIVES Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P

Infantile haemangiomas (IHs) with functional or cosmetic concerns necessitate systemic treatment for which propranolol is the preferred treatment. However, the mechanism of action is unknown. Mouse models suggest the angiopoietin-2 (Ang2)/Tie-2 system is implicated. Ang2 can promote endothelial growth or induce apoptosis depending on the presence of vascular endothelial growth factor. This pilot study investigates the saliva Ang2 levels in infants with IH treated with and without systemic propranolol. Patients with clinically confirmed IHs were recruited from an academic paediatric dermatology centre. Treatment was based on clinical evaluation. Saliva samples were collected over 6 months. An enzyme-linked immunosorbent assay determined Ang2 levels. Ang2 levels were detectable in 45% of samples. However, by the late time point, only 28% had detectable levels. There were no changes of Ang2 over time, and there were no differences in Ang2 levels between groups. However, Ang2 levels were correlated with baseline size and changes in size from baseline. Ang2 is detectable in saliva of affected infants, but does not decrease with propranolol treatment. However, Ang2 levels are positively correlated with size and changes in size. Thus, Ang2 is not the primary factor in the mechanism of propranolol resulting in IH reduction.

Atopic dermatitis is the most common chronic skin disease, and it primarily affects children. Although atopic dermatitis (AD) has the highest effect on burden of skin disease, no high-level studies have defined optimal therapy for severe disease. Corticosteroids have been used to treat AD since the 1950s and remain the only systemic medication with Food and Drug Administration approval for this indication in children, despite published guidelines of care that recommend against this option. Several clinical trials with level 1 evidence have supported the use of topical treatments for mild to moderate atopic dermatitis in adults and children, but these trials have had little consistency in protocol design. Consensus recommendations will help standardize clinical development and trial design for children. The Food and Drug Administration issues guidance documents for industry as a source for "the Agency's current thinking on a particular subject." Although they are nonbinding, industry considers these documents to be the standard for clinical development and trial design. Our consensus group is the first to specifically address clinical trial design in this population. We developed a draft guidance document for industry, Developing Drugs for Treatment of Atopic Dermatitis in Children (≥3 months to

Background Long-term safety of topical calcineurin inhibitors is not well understood. APPLES (A Prospective Pediatric Longitudinal Evaluation to Assess the Long-Term Safety of Tacrolimus Ointment for the Treatment of Atopic Dermatitis; NCT00475605 ) examined incidence of lymphoma and other cancers in a pediatric population with atopic dermatitis. Objective To quantify incident malignancies during 10 years in children with atopic dermatitis who used topical tacrolimus for ≥6 weeks. Methods Standardized incidence ratios for cancer events were analyzed relative to sex-, age-, and race-matched control data from national cancer registries. Results There were 7954 eligible patients enrolled at 314 sites in 9 countries. During 44,629 person-years, 6 confirmed incident cancers occurred (standardized incidence ratio, 1.01; 95% confidence interval, 0.37-2.20). No lymphomas occurred. Limitations Observational prospective cohort study. Conclusion The cancer incidence was as expected, given matched background data. This finding provides no support for the hypothesis that topical tacrolimus increases long-term cancer risk in children with atopic dermatitis.

Background Cutaneous T-cell lymphoma (CTCL) is a rare form of non-Hodgkin lymphoma arising in the skin. Geographic clustering of CTCL has recently been reported, but its association with environmental factors is unknown. Benzene and trichloroethylene (TCE) are environmental toxins with carcinogenic properties. The authors investigated associations between geographic clustering of CTCL incidence in the state of Georgia with benzene and TCE exposure. Methods The statewide county-level incidence of CTCL within Georgia was obtained from the Georgia Cancer Registry for the years 1999 to 2015. Standardized incidence ratios (SIRs) were calculated by dividing observed cases by expected cases using national incidence rates by age, sex, and race. Clustering of CTCL was analyzed using spatial analyses. County-level concentrations of benzene and TCE between 1996 and 2014 were collected from the Environmental Protection Agency's National Air Toxics Assessment database. Linear regression analyses on CTCL incidence were performed comparing SIRs with levels of benzene and TCE by county. Results There was significant geographic clustering of CTCL in Georgia, particularly around Atlanta, which was correlated with an increased concentration of benzene and TCE exposure. Among the 4 most populous counties in Georgia, CTCL incidence was between 1.2 and 1.9 times higher than the state average, and benzene and TCE levels were between 2.9 and 8.8 times higher. Conclusions The current results demonstrate nonrandom geographic clustering of CTCL incidence in Georgia. To the authors' knowledge, this is the first analysis to identify a correlation between geographic clustering of CTCL and environmental toxic exposures.

More than 10 million lesbian, gay, bisexual, and transgender (LGBT) persons live in the United States. Improving their health is a public health priority. LGBT persons have specific health concerns and face health care disparities. Awareness of those issues and disparities can enable dermatologists to provide medically appropriate and culturally competent care to LGBT patients. This review highlights terminology important in caring for LGBT persons, LGBT demographics in the United States, health care disparities faced by LGBT persons, and approaches to caring for LGBT patients.

Background Chronic pruritus (CP) is a frequently occurring symptom in inflammatory dermatoses, causing a high burden and limitations to health-related quality of life (HRQoL). Objective The ItchyQoL was developed to assess the impairment to HRQoL in patients with CP. However, it has only been validated in English and German. Here, we report the validation in several languages across Europe. Methods After professional translation, the versions of ItchyQoL were digitized for use as a tablet application. Validation was performed in clinics for dermatology in Austria, France, Germany, Italy, Poland, Russia, Spain, Switzerland and Turkey. Results Five hundred and thirty-five patients with either contact dermatitis, chronic prurigo - nodular type, psoriasis vulgaris, lichen planus or mycosis fungoides/Sezary syndrome and with CP >= 3 on the numerical rating scale were included. ItchyQoL showed a high level of consistency (Cronbach's-alpha, all: 0.95) and test-retest reliability (intraclass correlation: 0.91). It strongly correlated with the Dermatology Life Quality Index (r = 0.72, P < 0.001) and moderately correlated with itch intensity scales in the study population (visual analogue scale r = 0.46; numerical rating scale r = 0.51; verbal rating scale r = 0.51, for all: P < 0.001). Conclusion ItchyQoL is now also validated in French, Italian, Polish, Russian, Spanish and Turkish and can be used in clinical trials in countries speaking these languages.

Skin conditions can significantly impact QOL. Dermatology QOL instruments may measure general skin-specific, disease-specific, or condition-specific QOL. Key components in the development of QOL instruments include (i) instrument and conceptual framework development, (ii) items and conceptual framework refinement, (iii) psychometric property testing, and (iv) clinical meaning and interpretation. First, a theoretical framework based on existing literature and subject experts (i.e., patients living with these conditions) is developed. By administering the pilot instrument to patients, the theoretical framework undergoes testing and revision to improve the instrument. At initial testing, construct validity and internal consistency can be assessed. At 72-hour follow-up, test-retest reliability can be determined. Responsiveness is determined by a follow-up test at a time point reasonable to allow for a detectable change in condition. The clinical meaning of the results must then be determined to allow clinical and statistical interpretation.

Little evidence exists to guide the management of moderately dysplastic nevi excisionally biopsied without residual clinical pigmentation but with positive histologic margins (hereafter referred to as moderately dysplastic nevi with positive histologic margins).To determine outcomes and risk for the development of subsequent cutaneous melanoma (CM) from moderately dysplastic nevi with positive histologic margins observed for 3 years or more.A multicenter (9 US academic dermatology sites) retrospective cohort study was conducted of patients 18 years or older with moderately dysplastic nevi with positive histologic margins and 3 years or more of follow-up data collected consecutively from January 1, 1990, to August 31, 2014. Records were reviewed for patient demographics, biopsy type, pathologic findings, and development of subsequent CM at the biopsy site or elsewhere on the body. The χ2 test, the Fisher exact test, and analysis of variance were used to assess univariate association for risk of subsequent CMs, in addition to multivariable logistic regression models. To confirm histologic grading, each site submitted 5 random representative slide cases for central dermatopathologic review. Statistical analysis was performed from October 1, 2017, to June 22, 2018.Development of CM at a biopsy site or elsewhere on the body where there were moderately dysplastic nevi with positive histologic margins.A total of 467 moderately dysplastic nevi with positive histologic margins from 438 patients (193 women and 245 men; mean [SD] age, 46.7 [16.1] years) were evaluated. No cases developed into CM at biopsy sites, with a mean (SD) follow-up time of 6.9 (3.4) years. However, 100 patients (22.8%) developed a CM at a separate site. Results of multivariate analyses revealed that history of CM was significantly associated with the risk of development of subsequent CM at a separate site (odds ratio, 11.74; 95% CI, 5.71-24.15; P .001), as were prior biopsied dysplastic nevi (odds ratio, 2.55; 95% CI, 1.23-5.28; P = .01). The results of a central dermatopathologic review revealed agreement in 35 of 40 cases (87.5%). Three of 40 cases (7.5%) were upgraded in degree of atypia; of these, 1 was interpreted as melanoma in situ. That patient remains without recurrence or evidence of CM after 5 years of follow-up.This study suggests that close observation with routine skin surveillance is a reasonable management approach for moderately dysplastic nevi with positive histologic margins. However, having 2 or more biopsied dysplastic nevi (with 1 that is a moderately dysplastic nevus) appears to be associated with increased risk for subsequent CM at a separate site.

Importance Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population. Objective To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients. Design, Setting, and Participants A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries. Main Outcomes and Measures Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018. Results More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015. Conclusions and Relevance This study’s findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

In our evolving health care system, dermatologists are increasingly being asked to prove the value of care they provide to patients with severe skin diseases. Current quality measures for inflammatory dermatoses have limited validity and feasibility. Through collaboration and a modified Delphi process, International Dermatology Outcome Measures and the American Academy of Dermatology sought to reach consensus on a valid and feasible provider-assessed global disease severity metric to be incorporated into a quality measure for inflammatory dermatoses. To inform the modified Delphi process, a review of the literature was performed, and data were collected on current provider-assessed global disease severity metrics. After literature review, 36 members of International Dermatology Outcome Measures and the American Academy of Dermatology participated in the modified Delphi process to reach consensus on features of the metric. Psoriasis, atopic dermatitis, and acne achieved overwhelming consensus for inflammatory dermatoses that could be measured in a global disease severity metric. Consensus was also reached on the use of a 5-point ordinal scale with descriptors provided through referenced electronic platforms. Expert development of quality measures incorporating this metric and its inclusion in data collection platforms are critical to enabling dermatologists to prove the value of care provided to patients with severe inflammatory dermatoses.

Background Teledermatology may improve dermatologic care access in underserved areas and expand the clinical experience of dermatologists-in-training. The potential for teledermatology to supplement global health curricula in dermatology residency education has not been explored. Methods An international virtual grand rounds (VGR) curriculum was created based on teledermatology cases from Kabul, Afghanistan. The learning objectives included understanding the diagnosis and management of skin diseases in unfamiliar resource-limited settings and highlighting socioeconomic, cross-cultural, and ethical issues. A 17-item, Likert scale questionnaire was used to assess the effectiveness of the curriculum, including specific Accreditation Council for Graduate Medical Education (ACGME) competencies, as well as interest in global health and teledermatology. Results The survey was completed by 85 of 118 VGR attendees (72% response rate). Most respondents considered the curriculum valuable to their education (mean 4.5 on a 5-point Likert scale; standard deviation, 0.5), learned more about diagnosis and treatment of skin diseases in international settings (4.5; 0.6) and in the US (4.1; 0.8), and learned more about socioeconomic, cultural, and ethical issues in skin health (4.6; 0.5). The majority also reported being more interested in global dermatology (4.1; 0.8) and would recommend VGR to a colleague (4.5; 0.6). Conclusion This pilot curriculum provided an innovative platform to enhance undergraduate and graduate medical education in international dermatology. International teledermatology education may be used to address multiple ACGME core competencies and increase resident awareness of sociocultural determinants of skin health.

Importance Keratinocyte carcinoma (ie, cutaneous basal and squamous cell carcinoma) is the most common cancer in the United States. Objective To determine whether topical fluorouracil could prevent surgically treated keratinocyte carcinoma. Design, Setting, and Participants The Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial was a randomized, double-blind, placebo-controlled trial of topical fluorouracil for chemoprevention of keratinocyte carcinoma. Participants were recruited from May 2009 to September 2011 from 12 Veterans Affairs medical centers and followed until June 30, 2013. Participants were veterans (n = 932) with a history of at least 2 keratinocyte carcinomas in the past 5 years; almost all were white males and the median age was 70 years. Interventions Application of fluorouracil, 5%, (n = 468) or vehicle control cream (n = 464) to the face and ears twice daily for 2 to 4 weeks upon randomization. Main Outcomes and Measures Surgically treated keratinocyte, basal cell, and squamous cell carcinoma risk on the face and ears in the first year after enrollment; and time to first surgically treated keratinocyte, basal cell, and squamous cell carcinoma. The a priori hypothesis was that fluorouracil would be effective in preventing these cancers. Results Of 932 participants (916 men [98%]; 926 white [99%]; median age, 70 years), 299 developed a basal cell carcinoma end point (95 in year 1) and 108 developed a squamous cell carcinoma end point (25 in year 1) over 4 years (median follow-up, 2.8 years). Over the entire study, there was no difference between treatment groups in time to first keratinocyte, basal cell, or squamous cell carcinoma. During the first year, however, 5 participants (1%) in the fluorouracil group developed a squamous cell carcinoma vs 20 (4%) in the control group, a 75% (95% CI, 35%-91%) risk reduction (P = .002). The 11% reduction in basal cell carcinoma risk during year 1 (45 [10%] in the fluorouracil group vs 50 [11%] in the control group) was not statistically significant (95% CI, 39% reduction to 31% increase), nor was there a significant effect on keratinocyte carcinoma risk. However, a reduction in keratinocyte carcinomas treated with Mohs surgery was observed. Conclusions and Relevance A conventional course of fluorouracil to the face and ears substantially reduces surgery for squamous cell carcinoma for 1 year without significantly affecting the corresponding risk for basal cell carcinoma. Trial Registration clinicaltrials.gov Identifier:NCT00847912

Trends in the training, supply, availability, career decisions, and retirement of US dermatology physicians are not well delineated. The current study evaluates whether growth in the dermatology workforce will keep pace with population expansion in the United States. A dermatologist supply model was projected to 2030 drawing on data from the American Academy of Dermatology, American Medical Association, Bureau of Labor Statistics, American Association of Medical Colleges, and other associations. The clinically active dermatologist workforce in 2015 was 36 per capita (1,000,000); entry following postgraduate training was age 30 with career separation at age 65 on average. Added to the provider model are physician assistants and nurse practitioners in dermatology practices. A linear regression micro simulation model based on age cohorts produced a per capita supply of dermatology providers of 61 (±3) per 1,000,000 by 2030, up from 47 in 2016. The dermatology workforce is growing faster than population expansion. Workforce estimates could be affected by changing trends in retirement and training of dermatology providers. Investments in training of nurse practitioners and physician assistants, in addition to training more doctors, may be an effective strategy for increasing access to care in populations with low dermatologist density.

Video-based patient education about long-term systemic corticosteroid treatment has not been assessed.To compare video-based versus verbal education in patient knowledge gained and satisfaction.English-speaking adults (≥18 years) were recruited from March-August 2013 from medical dermatology clinics. Study provider clinics were the unit of randomization. Verbal subjects heard a script based on the standard discussions of two top systemic corticosteroid prescribers at Emory. Video subjects viewed a video developed by the investigators. A 12-item survey created by the the investigators assessed baseline and post-education knowledge (immediate, one-, three-, and six-month).Baseline knowledge scores averaged 7.2±2.2 correct answers with no between-group differences. Post-education, the video group's (N=39) mean paired score difference was 0.9±2.0 higher than the verbal group's (plt;0.04). After 1 month, most scores maintained gains with no between-group differences. 97% of patients in each group were satisfied (none were unsatisfied) with their education.Our cohort was more literate than the general public, and a minority of subjects completed long-term follow up assessments.Video education enhanced near-term patient knowledge more than verbal education and maintained patient satisfaction.

A skin care regimen which significantly improved atopic dermatitis and pruritus was evaluated for its efficacy and acceptability in senior subjects diagnosed with xerosis who also suffer from pruritus. This was an open-label, single-center study, designed to evaluate the daily use of a skin care regimen for 15 days. Assessments were made at baseline, day 8 and day 15 for visual skin dryness, transepidermal water loss (TEWL), hydration, desquamation, subject-perceived itch and quality of life (QoL). Twenty-five subjects, ages 60-73 years, had significantly improved skin visual dryness, hydration, desquamation, itch and QoL at days 8 and 15, relative to baseline (P < .05). TEWL was improved, though not significantly. Subjects expressed a high degree of satisfaction with the results. This regimen provides geriatric patients with an easily incorporated skin routine to help improve a common symptom of aging skin which negatively affects QoL.

Objective Utilities are values of health-related quality of life (HRQoL) based on patient preference for a health status. The purpose of this study was to compare indirect measures to a directly elicited utility. Design Cross-sectional study. Setting and Patients Emory Spine Center and the Emory Center for Chronic Pain at Crawford Long Hospital. Patients at least 18 years of age with chronic pain, defined as pain that persists beyond the normal time of healing, usually beyond 6 months. Measures Chronic pain subjects completed a paper-based, self-administered time trade-off (TTO) survey, EQ-5D survey, and a face-to-face (FTF) TTO interview. Current pain severity was graded using the Numeric Rating Scale-11, subsequently stratified into no (0), mild (1–3), moderate (4–6), and severe (7–10) pain. Results Paired t test comparing FTF TTO and proxy utility measures stratified by severity revealed FTF TTO utility values significantly higher than EQ-5D utility values for all pain severities (overall mean difference 0.18, standard deviation [SD] 0.30, P

Summary Background Enumerating actinic keratoses (AKs) is highly variable but important to standardize as new therapies are emerging. Objectives To assess the reliability of four different methods used to quantify AKs and to investigate whether a consensus meeting affects the reliability. Methods This was a single-blinded study of 12 experienced dermatologist raters counting AKs on the face and ears of nine subjects before and after a consensus meeting. Raters were recruited from investigators of a multicentre Veterans Affairs cooperative study. The intraclass correlation coefficient (ICC) among raters for pre- and post-consensus evaluations was the primary outcome measure. Results Of the four assessment methods, the ‘total count’ method had the greatest ICC for both pre- (0·18, P = 0·04) and post-consensus (0·66, P =

Background Chronic pruritus has a lifetime prevalence of up to 26% in the worldwide population. Research has shown that the incidence and quality of life (QoL) impact of chronic pruritus varies by race. Objective We sought to explore the effects of race on specific pruritus-related QoL factors and resource utilization. Methods We performed a cross-sectional, national telephone survey of 6000 US veterans randomly sampled from the Veterans Hospital Patient Database. We administered surveys to assess QoL impact and resource utilization of chronic pruritus. Results Nonwhites overall reported higher levels of burning and scarring with their pruritus. African Americans had a significantly greater emotional impact and use of special soaps, lotions, and clothes. African Americans were also more likely to visit their primary care provider for pruritus (P = .03), yet had similar numbers of specialty care visits. Limitations Because our sample was drawn from a veteran population, generalizability may be limited. Conclusion The data indicate a racial disparity in specific QoL impact and resource utilization from pruritus. These findings merit further exploration into explanations, such as access, communication, trust of the medical system, and biologic differences.