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As of January 2021, there are more than 3.8 million women in the United States with a history of breast cancer. The current standard of care for breast cancer involves surgical resection, radiation therapy, adjuvant endocrine therapy, and/or adjuvant chemotherapy. Aromatase inhibitors (AIs) are the gold standard for endocrine therapy in postmenopausal women. Dermatologic adverse events (dAEs) associated with AIs are rare but have been reported in the literature. Commonly reported dAEs include unspecified rash, pruritus, alopecia, vulvovaginal atrophy, vasculitis, and autoimmune/connective tissue disorders. Appropriate preventative strategies and careful management considerations have the potential to optimize the comprehensive care of patients with cancer and improve quality of life. Furthermore, prevention of dAEs can lead to a reduction in cancer treatment interruptions and discontinuations. Herein, we characterize dAEs of AIs and discuss preventative management to reduce the incidence of AI therapy interruption.

Approximately fifty percent of sunlight reaching the Earth’s surface is visible light (400–700 nm). Other sources of visible light include lasers, light-emitting diodes (LEDs), and flash lamps. Photons from visible light are absorbed by photoreceptive chromophores (e.g., melanin, heme, and opsins), altering skin function by activating and imparting energy to chromophores. Additionally, visible light can penetrate the full thickness of the skin and induce pigmentation and erythema. Clinically, lasers and light devices are used to treat skin conditions by utilizing specific wavelengths and treatment parameters. Red and blue light from LEDs and intense pulsed light (IPL) have been studied as anti-microbial and anti-inflammatory treatments for acne. Pulsed dye lasers are used to treat vascular lesions in adults and infants. Further research is necessary to determine the functional significance of visible light on skin health and wellness without confounding the influence of ultraviolet and infrared wavelengths.

Targeted marketing and media may serve as potential sources of health information for consumers, influencing knowledge, practices, perception, and utilization of health care services. In addition to this vulnerable consumerism, there are barriers to healthy consumerism including exposure to different sources or lack thereof, lack of knowledge, inadequate transportation, or proximity to stores, cost, and marketing of products that are not suitable for all skin types. We conducted a multi-centerldquo;Skin of Color Skin Care Needsrdquo; survey to characterize the skin care practices, concerns, and habits of both persons of color and non-Hispanic whites to evaluate barriers and influences on product choice and behaviors in these populations. One hundred and twenty-one respondents (74%) self-identified as a nonwhite racial group, while 31 respondents (19%) self-identified as non-Hispanic white. The top skincare concerns in the skin of color population were acne and blemishes (40%), dry skin (32%), and pigmentation/dark spots (26%). In the non-Hispanic white population, the top concerns were fine lines and wrinkles (42%), followed by acne and blemishes (39%), and dry skin (26%). When questioned about barriers respondents faced in discovering and using dermatologic products, SOC respondents were more likely to cite lack of available products for their skin type (11%), as compared to white respondents (0%). Skin of color respondents identified internet (42%) and social media (29%) as major sources of information regarding dermatologic products as compared to white respondents (26% and 13%, respectively). Health care disparities can be heightened by targeted marketing and the media, which have a major impact on patient health literacy and consumer choices. Dermatologists should be aware of this impact in order to address the knowledge gaps, minimize bias, and increase inclusivity for all skin types. J Drugs Dermatol. 2022;21(7):709-711. doi:10.36849/JDD.6557.

Venous leg ulceration (VLU) is a medically, financially, and psychologically debilitating disease for patients and a financial burden for the health care system. Of all dermatologic diseases, VLU generates the highest cost. The purpose of this manuscript is to review the current guidelines on the diagnosis and management of VLU with an emphasis on novel approaches. Two novel approaches to VLU diagnosis have been proposed in 2019 including voltammetric analysis to determine leg ulcer etiology, identify infection, and predict clinical course, and the use of dynamic optical coherence tomography to image blood capillaries of the peri-wound skin. Novel approaches to management include the use of trichloroacetic acid and low-frequency ultrasound debridement, growth factors harvested from human amniotic membrane or platelet-rich plasma, low-level laser therapy, and low-energy light therapy. With shifting demographics toward an aging population, sedentary lifestyles, an increased prevalence of obesity, and the emergence of chronic diseases, VLU will likely continue to be a significant burden to patients and the health care system. Treatment should not purely be focused on healing, but should take a holistic approach, incorporating nutrition and well-being. The gold standard for the prevention and treatment of VLU is compression therapy and should be utilized with the TIME strategy which contributes to the stimulation of natural healing mechanisms and includes the following: Tissue debridement, Infection and inflammation control, Moisture balance, and Epidermization stimulation.

Immune checkpoint inhibitors have emerged as a pillar in the management of advanced malignancies. However, nonspecific immune activation may lead to immune-related adverse events, wherein the skin and its appendages are the most frequent targets. Cutaneous immune-related adverse events include a diverse group of inflammatory reactions, with maculopapular rash, pruritus, psoriasiform and lichenoid eruptions being the most prevalent subtypes. Cutaneous immune-related adverse events occur early, with maculopapular rash presenting within the first 6 weeks after the initial immune checkpoint inhibitor dose. Management involves the use of topical corticosteroids for mild to moderate (grades 1-2) rash, addition of systemic corticosteroids for severe (grade 3) rash, and discontinuation of immunotherapy with grade 4 rash. Bullous pemphigoid eruptions, vitiligo-like skin hypopigmentation/depigmentation, and psoriasiform rash are more often attributed to programmed cell death-1/programmed cell death ligand-1 inhibitors. The treatment of bullous pemphigoid eruptions is similar to the treatment of maculopapular rash and lichenoid eruptions, with the addition of rituximab in grade 3-4 rash. Skin hypopigmentation/depigmentation does not require specific dermatologic treatment aside from photoprotective measures. In addition to topical corticosteroids, psoriasiform rash may be managed with vitamin D3 analogues, narrowband ultraviolet B light phototherapy, retinoids, or immunomodulatory biologic agents. Stevens–Johnson syndrome and other severe cutaneous immune-related adverse events, although rare, have also been associated with checkpoint blockade and require inpatient care as well as urgent dermatology consultation.

Background Physician burnout is a common problem that can have negative ramifications for both physicians and patients. Lack of effective coping mechanisms decreases resilience, which can lead to burnout, and women may be particularly vulnerable. Objective We aimed to evaluate resilience by generation among professionals in dermatology. We hope to gain a better understanding of the plasticity of resilience traits to identify modifiable resilience components. Methods Attendees of the 2020 Women’s Dermatological Society Forum were asked to complete an 80-item questionnaire evaluating eight characteristics of resilience. Each participant received scores electronically, and attendees were invited to anonymously submit scores, job category (physician or industry), and birth year and/or generation category. Participants who provided scores and were part of the millennial generation (born 1980–1994; ages 26–40 years at the time of survey completion), Generation X (born 1965–1979; ages 41–55 years), or baby boomer generation (born 1944–1964; ages 56–76 years) were included. Results Of the 67 participants meeting the inclusion criteria, 96.7% were women and 3.3% were men, 69.4% were physicians and 30.6% were industry representatives. Millennials accounted for 43.3%, Generation X for 35.8%, and baby boomers for 20.9% of the study participants. There was a significant difference among the three generations for mean scores on rumination (p = .0071) and flexibility (p = .0005), with scores becoming more ideal for older generations. There was no significant difference among generations for other resilience or burnout indicators, including emotional inhibition, toxic achieving, avoidance coping, perfect control, detached coping, and sensitivity. Conclusion Resilience traits such as rumination and flexibility differed by generation, with the most favorable scores occurring in the oldest cohort, suggesting that some resilience traits may be malleable and improve with age or be inherently affected by environment during development. Health care professionals may benefit from engaging in activities that enhance malleable resilience traits and improve the ability to manage work-related stressors.

BACKGROUND: Scarring has significant aesthetic and functional consequences for patients. A need exists for anti-scarring therapeutics. Light emitting diode-red light (LED-RL) has been shown to modulate skin fibrosis. OBJECTIVE: Evaluate the safety and efficacy of LED-RL to reduce post-operative scarring. METHODS: CURES (Cutaneous Understanding of Red-light Efficacy on Scarring) was a randomized, mock-controlled, single-blind, dose-ranging, split-face phase II clinical trial. Starting one week post-surgery, patients received LED-RL irradiation and temperature-controlled mock therapy to incision sites at fluences of 160 J/cm(2), 320 J/cm(2), or 480 J/cm(2), triweekly for three weeks. Efficacy was assessed at 1, 3, and 6-12 months. The primary endpoint was difference in scar pliability between LED-RL-treated and control sites. Secondary outcomes included Patient and Observer Scar Assessment Scale, collagen and water concentration, and adverse events. RESULTS: There were no significant differences in scar pliability between treated and control scars. At certain fluences, treated scars showed greater improvements in observer rating and scar pliability, reflected by greater reductions in induration, from baseline to 6 months compared to control scars. Treatment-site adverse events included blistering (n=2) and swelling (n=1), which were mild and resolved without sequelae. CONCLUSIONS: LED-RL phototherapy is safe in the early postoperative period and may reduce scarring. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03795116. Registered 20 December 2018, https://clinicaltrials.gov/ct2/show/NCT03795116

Cutaneous photobiology studies have focused primarily on the ultraviolet portion of the solar spectrum. Visible light (VL), which comprises 50% of the electromagnetic radiation that reaches the Earth's surface and, as discussed in Part I of this CME, has cutaneous biologic effects, such as pigment darkening and erythema. Photoprotection against VL includes avoiding the sun, seeking shade, and using photoprotective clothing. The organic and inorganic ultraviolet filters used in sunscreens do not protect against VL, only tinted sunscreens do. In the United States, these filters are regulated by the Food and Drug Administration as an over-the-counter drug and are subject to more stringent regulations than in Europe, Asia, and Australia. There are no established guidelines regarding VL photoprotection. Alternative measures to confer VL photoprotection are being explored. These novel methods include topical, oral, and subcutaneous agents. Further development should focus on better protection in the ultraviolet A1 (340-400 nm) and VL ranges while enhancing the cosmesis of the final products.

Lichen myxedematosus (LM) is an idiopathic cutaneous mucinosis, commonly described as localized scleromyxedema. In contrast to scleromyxedema, there is typically no systemic involvement. Treatment options are limited and spontaneous resolution has been reported. We present the case of a 66-year-old Hispanic male referred by his primary care physician for evaluation of asymptomatic dark spots on his trunk and extremities present for about one-year. Physical exam revealed smooth, brown hyperpigmented papules coalescing into plaques on the trunk. Multiple well-demarcated oval dark brown plaques measuring 3 cm in size were located on the upper back, peri-umbilical area, bilateral lower extremities, and buttocks. A diagnosis of lichen myxedematosus was made based on histologic features observed in the dermis. There are 5 subtypes of LM: a discrete papular form, acral persistent papular mucinosis, self-healing papular mucinosis, papular mucinosis of infancy, and a pure nodular form. Occasional patients with LM have atypical features or features intermediate between scleromyxedema and localized LM. We present a case of atypical LM with mixed features of the different subtypes. Herein we will review the varied clinical presentations of LM and highlight the distinguishing features of scleromyxedema. J Drugs Dermatol. 2020;19(3): 320-322 doi:10.36849/JDD.2020.4864.

2632 Background: Immune-related cutaneous adverse events (irCAEs) are the most common and often the first toxicity of immune checkpoint inhibitors (CPIs). In the general population, irCAEs occur on average within 3.6 weeks of treatment initiation and most commonly manifest as maculopapular rash, lichenoid rash, and pruritus. Less is known about these irCAEs in racial and ethnic minority patients. The purpose of this study is to compare the irCAEs of cohorts of Caucasian and racial and ethnic minority patients at Memorial Sloan Kettering Cancer Center. Methods: Herein, we conducted a retrospective chart review of racial and ethnic minority patients treated with CPIs between 2012-2019 at Memorial Sloan Kettering Cancer Center. irCAEs were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. These were compared to a Caucasian cohort matched by demographics and cancer therapy regimen. Results: One hundred ten racial and ethnic minority patients presented to dermatology for irCAEs. Our population consisted of 59 (53.6%) females and 51 (46.4%) males with a mean age of 59 (range 20-85). Of the patients who were seen by dermatology, 63/110 were Asian (57.3%) followed by 34/110 African American (30.9%), and 1 Native American. Twelve patients were of Hispanic ethnicity (10.9%), which included those of both African American and Caucasian race. The 110 patients that were evaluated by dermatology had 221 cutaneous adverse events. Rash (96, 43.4%), pruritus (40, 18.1%), and xerosis (23, 10.4%) were most frequently diagnosed (average time from treatment start to presentation was 125 days). Dermatology identified 87 (39.3%) grade 1, 103 (46.6%) grade 2, 30 (13.5%) grade 3, and 1 (0.4%) grade 4 events. There were 17 (15.5%) treatment interruptions, including 7 patients who required permanent discontinuation. In the Caucasian cohort, mean time to onset was 228 days (range 1-1500). Dermatology identified 48 (43.6%) grade 1, 44 (40.0%) grade 2, 18 (16.4%) grade 3, and 0 (0.0%) grade 4 events, with maculopapular rash (55, 50.0%) and pruritus (25, 22.7%) most frequently diagnosed. Conclusions: Our findings suggest that irCAEs occur frequently in cancer patients from racial and ethnic minority groups, with similar grade and morphology as Caucasian patients. When irCAEs develop in this population, the diagnosis occurred later than what has previously been reported, possibly due to these patients seeing MSK oncologists with an established dermatology consultation system and insight into how to manage these patients on their own. Prospective evaluation of underrepresented minorities receiving CPI therapy is warranted in order to identify risk factors and therapeutic strategies for these untoward events, so that optimal cancer care may be delivered.

3076 Background: The advent of immune checkpoint inhibitors (CPIs) for the management of advanced malignancies has led to unintended consequences of nonspecific immune activation. Cutaneous immune related adverse events (irCAEs) are the most common and first to manifest, on average within 3.6 weeks of treatment initiation. irCAEs may require CPI treatment dose reduction or discontinuation and negatively impact patient quality of life. There is substantial variability in the reporting of these toxicities and inadequate reporting in skin of color patients (SOC), who are often underrepresented in oncology clinical trials. The purpose of this study is to characterize irCAEs in SOC cancer patients. Methods: A single center retrospective analysis of electronic medical records from 2009-2020 was conducted. SOC was defined as African American, Hispanic, Native American/Pacific Islander, or Asian. irCAEs were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Results: Of 1459 SOC patients that presented to our institution and received CPIs during the study period, 175 (12%) presented to dermatology for irCAEs [African American (56, 32%); Asian (98, 56%); Hispanic (20,11%); Native American (1, 0.5%)]. Patients’ toxicities were stratified by CPI mechanism: anti-PD-1/L1 (139, 79%), combination of anti-PD-1/L1 plus anti-CTLA-4 (29, 17%), and anti-CTLA-4 therapy (7, 4%). Of 376 irCAEs, pruritus (62, 16%), xerosis (42, 11%), maculopapular rash (40, 11%), and cutaneous hyperpigmentation (36, 10%) were most frequently diagnosed. There were 86 (23%) grade 1, 93 (25%) grade 2, and 18 (5%) grade 3 events. Average time from CPI-treatment initiation to irCAE onset was 6.5 months (SD 7.9). Fifteen (9%) patients required CPI dose reduction or discontinuation due to skin toxicity. Topical corticosteroids (133, 76%) were the most frequently used treatment for all irCAEs. Conclusions: Our findings suggest that irCAEs occur frequently in SOC cancer patients. Furthermore, a 6.5-month delay in time to diagnosis highlights a need for increased surveillance of these cutaneous toxicities in darkly pigmented skin. Generally, SOC patients present unique diagnostic and management challenges due to differences in skin biology and propensity toward hyperpigmentation; however, in SOC cancer patients, the mechanisms of oncologic immunotherapy must be considered in developing successful treatment strategies and management of dermatologic health in this population.

Female genital cutting (FGC), also called female genital mutilation, is defined as "all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious, or other nontherapeutic reasons." FGC can have significant health consequences, including multiple physical and psychological complications, throughout the life course. Despite violating numerous human rights and existing legal prohibitions, the practice continues. In the United States, FGC is becoming increasingly prevalent, however, physicians are not routinely trained to care for these patients. Despite the evidence of the need, there is a woeful lack of training regarding FGC in undergraduate, graduate, and continuing medical education programs. Furthermore, many health care providers (HCPs) are unaware of their mandatory reporting obligations regarding FGC under current state laws. There are no established educational competencies or training guidelines for incorporating FGC into all levels of medical education. This article establishes the need to develop competencies and underscores that models exist for undertaking this work. It also aims to engender dialog about FGC education and calls for launching an initiative to develop educational competencies to train HCPs about FGC. By integrating comprehensive, evidence-based education and training at all levels of medical education, HCPs will be able to provide high-quality, team-based, culturally sensitive care to the hundreds of thousands of affected women and girls in the United States, and work to prevent the practice from being carried out on girls who are at risk but have not yet been cut.