Search

Introduction. Telemedicine has been of heightened focus due to spikes in usage during the COVID-19 pandemic. Disparities in health care may affect patient satisfaction with this resource depending on factors such as patient race, age, or socioeconomic background. The purpose of this study was to analyze patient satisfaction with teledermatology to identify any differences in satisfaction based on race, age, and income during the COVID-19 pandemic period. Methods. A 21-question, IRB-approved survey was administered to patients at two academic dermatology clinics in Kansas City. Patient satisfaction was measured using a five-point Likert scale. Results. A total of 64 completed surveys were analyzed (17.8% response rate). Most of the participants were female (n = 48, 75%), age 45 to 60 (n = 17, 26.6%), and reported White for race (n = 55, 85.9%). Overall, 73.4% (n = 47) of patients reported being satisfied with their visit. However, only 38.7% (n = 24) of participants were likely to choose a video over an in-person visit. Reasons for low patient satisfaction included concerns regarding ability to perform an accurate physical exam with a video visit (n = 9, 14.1%), receiving inadequate care (n = 4, 6.3%), protected privacy (n = 3, 4.7%), and provider understanding the patient (n = 2, 3.1%). Conclusions. Our findings were similar to prior studies stating no difference in patient satisfaction with regards to age, income, or race and patients reporting high satisfaction with teledermatology appointments despite a preference for in-person dermatology visits. Future studies with a larger diverse cohort of participants are needed to elucidate and address possible disparities associated with teledermatology use.

Adnexal carcinomas and sebaceous neoplasms are rare malignant neoplasms that are derived from eccrine and apocrine sweat glands or the pilosebaceous unit. Distinction of these neoplasms is essential, as treatment, workup, and prognosis varies widely among subtypes. For this comprehensive review, apocrine, eccrine, follicular, and sebaceous neoplasms are discussed. For each neoplasm, a review of clinical presentation, classic histologic findings, and management recommendations is provided.

BACKGROUND Patients who understand their diagnosis and treatment are more likely to be satisfied with their care and more compliant with treatment. Dermatologic surgery is a specialized field with associated jargon that many patients may not understand. OBJECTIVE The aim of the study was to assess patient understanding of dermatology medical terminology. METHODS This was a single-blinded study conducted with patients 18 years and older from an academic dermatology clinic surveying patients on 12 terms that are frequently used in dermatologic surgery. Participants rated their level of confidence in their understanding of each term using a 5-point Likert scale, followed by explaining the definition of the term. 3 blinded physicians graded each participant’s definition using a 5-point scale of accuracy of understanding, designed to mimic the Likert scale. RESULTS A total of 200 respondents completed the survey (96% response rate). The average term perceived understanding was 3.90 ±0.66, the average term accuracy was 3.26±0.93. Patients overestimated their understanding 44% of the time, and underestimated their knowledge 17% of the time. The terms with the lowest respondent confidence were the terms secondary intention, Mohs, and flaps. The terms with the lowest respondent accuracy was secondary intention, defect, and Mohs surgery. CONCLUSION There is a gap in knowledge in commonly used dermatologic surgery terms among patients. Certain demographics appear to be more at risk for not understanding medical jargon or overestimating their understanding of terms. Obtaining these patient demographics may help to identify patients needing additional education regarding dermatologic surgery. J Drugs Dermatol. 2021;20(11):1252-1254. doi:10.36849/JDD.6174.

Suture removal after surgery is low risk; however, it is often performed by a medical provider. The current SARS-CoV-2 pandemic has forced providers to assess means of reducing in-person contact.To determine whether patients undergoing Mohs surgery are willing and successful with home suture removal.A prospective study was performed with patients undergoing Mohs surgery. Before their surgery, patients were assessed for their willingness to remove sutures before and after viewing educational material. Patients who were willing to attempt removal were contacted after expected suture removal date to verify success and assess their experience.One hundred fifty patients were enrolled in the study. 90.1% were willing to attempt home suture removal. Patients were more willing ( p = .003), more confident ( p = .024), and had lower anxiety ( p = .049) with removal after viewing educational resources. Patients with a history of suture removal were more likely to attempt removal after their procedure ( p = .036). Ninety-seven percent of patients who were willing to attempt suture removal were successful. There were no major complications with removal.Patients were overwhelmingly successful with suture removal after an educational intervention. Providers should consider providing this option after surgical procedures when clinically appropriate.

Background The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines. Objective The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma. Materials and methods A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery. Results A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS. Conclusion Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

Purpose: Mycosis fungoides is the most common subtype of cutaneous T-cell lymphoma. Skin-directed treatments often improve but do not cure mycosis fungoides skin lesions. The purpose of this study was to (i) assess whether remission was associated with malignant T-cell clone depletion at treated sites using either low-dose radiotherapy (LDRT, 8 Gy) or topical steroids and (ii) assess whether a clone-ablative therapy, like LDRT, is associated with overall survival in patients with high-risk early-stage CTCL. Experimental Design: Pre- and posttreatment biopsies from 20 lesional skin samples of 18 patients with mycosis fungoides who received either 8 Gy LDRT (n = 16) or topical steroids (n = 4) underwent high-throughput T-cell receptor sequencing of the TCRB gene to quantify the malignant T-cell clone. For the retrospective chart review, overall survival of 47 high-risk early-stage patients was compared between patients who did or did not receive radiation. Results: LDRT eradicated the clone in 5 of 16 lesions and reduced it >90% in 11 of 16; there were no recurrences in these lesions. Patients treated with topical steroids appeared to clinically improve, but the malignant clone persisted. We found that the number of residual malignant T cells predicted lesion recurrence. A retrospective review showed that early-stage high-risk patients who received radiation as part of their treatment regimen had prolonged overall survival compared with patients who did not. Conclusions: These findings demonstrate that LDRT can eradicate malignant T cells in mycosis fungoides, provides robust disease control, and is associated with improved survival in high-risk early-stage patients.

Biologic medications have revolutionized treatment of psoriasis; however, there remains uncertainty in which medications should be used to maximize efficacy based on race/ethnicity. The purpose was to determine if efficacy of biological medications differs based on race/ethnicity. A systematic review identified all clinical trials focused on biologic treatment outcomes from inception of database until March 5th, 2021. Included studies provided data on racial/ethnic differences in biologic skin clearance efficacy using the Psoriasis Area and Severity Index (PASI) and "clear/almost clear" scores. There were 1220 studies identified, and 24 included in the review. The races/ethnicities included were Asian (n = 2740), White (n = 9745), Black (n = 138), and Latino (n = 728). Ixekizumab provided the highest "clear/almost clear" score (90.7%, 89.4%) and PASI 75 (98.8%, 96.6%) for Asian and Latino patients, respectively. Guselkumab had the highest "clear/almost clear" score for White (86.8%) patients, while Black patients had highest "clear/almost clear" (75.0%) and PASI 75 (91.7%) scores to brodalumab. Limitations included lack of studies reporting outcome data based on race/ethnicity and lack of patients of color within psoriasis clinical trials. For treatment of plaque psoriasis, there is evidence of differences in efficacy of biologics improving clinical disease severity between different races or ethnicities.

Background: Perception of medication risk is often disproportionately greater than actual risk. As a result, patients with psoriasis who would benefit from biologic therapies may be reluctant to start therapy, despite these medications’ favorable safety profile. The purpose of this study is to determine whether perceptions of biologic medications change when reviewing a handout designed to portray risk use alongside common risks unrelated to medication use. Methods: A handout designed to put biologic medication risk into perspective was compared to 2 standard of care handouts on systemic and biologic medication for psoriasis. Twenty adult patients and 17 parents who have a child with moderate to severe psoriasis were randomized to receive each handout and complete a questionnaire related to perceived risk and willingness to use. The questionnaire assessed patient’s likeliness of use, and comfort with use, and perceived risks associated with biologic medications. Statistical analysis was performed using t tests and Fisher exact test. Results: Patients reported a lower perceived risk with biologic medication use when using the newly designed handout (average score of 4.1 of 10 compared to 4.7 and 5.1 with current standard of care). Comfort with taking biologic medications was also higher with this handout compared to a 15-page standard of care handout ( P = .029). Limitations: This study was observational and contained a small sample size. Conclusions: Handouts specifically designed to portray risk of biologic medications for the treatment of psoriasis can reduce perceived risk and increase comfort with use as compared to the current standard of care.

Scaphoid fractures in the pediatric population represent ∼3% of all hand and carpal fractures. Cast immobilization has been shown to yield excellent results in the acute phase, however some patients develop nonunions. Currently, there is no consensus regarding the best surgical treatment after development of a pediatric/adolescent scaphoid nonunion.A comprehensive literature review was performed utilizing Medline, Ovid, and Embase databases to compare surgical techniques for adolescent scaphoid nonunions on the basis of union rates, functional outcomes, and operative complications. Our initial search returned 2110 publications. Inclusion criteria consisted of a scaphoid fracture with3 months of no clinical or radiographic improvement after cast immobilization and age less than 18 years. Ultimately, 11 studies met our criteria and were included in the final analysis.A total of 176 surgically treated pediatric/adolescent scaphoid nonunions were identified from the 11 studies, including 157 nonvascularized bone graft procedures and 19 nongrafted rigid fixation procedures. Patients treated with a nongrafted method achieved union with a total random effects model revealing a union rate of 94.6%, whereas the grafted cohort had a union rate of 94.8%. Functional outcomes including range of motion and grip strength were significantly improved in both cohorts. Patients managed operatively with bone graft had 4 complications, in contrast those without bone grafting did not report complications (P=0.9).Surgical treatment of pediatric/adolescent scaphoid fracture nonunions produce excellent union rates and functional outcomes after surgical intervention, using both grafted and nongrafted techniques. Future prospective studies are needed to assess if the outcomes of a specific technique are more favorable, as well as to determine if differences exist based on fracture location.Level III. This study is a meta-analysis of studies containing level of evidence of III or greater.

Healthcare providers interact with individuals from a wide range of social, ethnic, and geographic backgrounds. We must be competent in treating disease, but also in understanding and providing compassionate care for each patient. Our success in the latter depends in part on recognizing that inherent differences exist between how patients from different cultures access and receive care. Barriers such as cost of service and proximity to facilities may limit access to physicians. When care is delivered, a provider’s lack of familiarity with different cultural norms and beliefs can result in less effective care. These same concepts can be applied to many vulnerable populations such as the disabled, the elderly, and the incarcerated. Interventions can be utilized to reduce these disparities. Cultural education and training for providers alongside individual and community-based health outreach programs have the potential for universally improving care for all patients.

Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.

The original article was published on March 15, 2020 and corrected on June 15, 2020. The revised version of the article corrects an Author's name. The changes appear in the revised online PDF copy of this article.

Research shows that individuals consume more calories when provided with a larger portion size. It is unclear if similar behavior translates to topical medication use. The impact of container size and provider instructions on patient usage of topical medications has yet to be assessed.Data was collected from 128 participants in an IRB randomized, controlled trial. To a marked 3cmx8cm rectangle on the forearm, patients applied petroleum jelly from either a large container or a small tube. Pre and post application container weights were measured.Patients applied more topical medication from the large container compared to the small tube.Topical medication usage is influenced by the size of the container provided. It is beneficial to consider container size when prescribing topical medications and greater application is desired.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

INTRODUCTION: Research shows that individuals consume more calories when provided with a larger portion size. It is unclear if similar behavior translates to topical medication use. The impact of container size and provider instructions on patient usage of topical medications has yet to be assessed. METHODS: Data was collected from 128 participants in an IRB randomized, controlled trial. To a marked 3cmx8cm rectangle on the forearm, patients applied petroleum jelly from either a large container or a small tube. Pre and post application container weights were measured. RESULTS: Patients applied more topical medication from the large container compared to the small tube. CONCLUSION: Topical medication usage is influenced by the size of the container provided. It is beneficial to consider container size when prescribing topical medications and greater application is desired.

The original article was published on March 15, 2020 and corrected on June 15, 2020. The revised version of the article corrects an Author's name. The changes appear in the revised online PDF copy of this article.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Keratoacanthomas are rapidly growing neoplasms of squamous epithelium. Despite their benign nature, they are often difficult to distinguish from squamous cell carcinoma and require excision. In cases in which excision is not successful or not desired, intralesional treatments may be considered. However, limited research exists on individual therapeutic efficacy. We present a 68-year-old man who developed multiple eruptive keratoacanthomas around the wound edge of a previous keratoacanthoma excision. Considering previous excisional failure, intralesional 5-fluorouracil was used as a treatment modality. Injections every 3-4 weeks over a course of 12 weeks induced clinical keratoacanthoma clearance with excellent cosmetic results. This case showcases that weekly intralesional 5-fluorouracil injections, as was the standard mode of treatment in previous case reports, may not be necessary. This less frequent injection strategy is more convenient for the patient and may lead to fewer treatments and less medication necessary. Although a case-by-case basis is needed for any alternative approach to keratoacanthoma treatment, this report is useful for the practicing clinician in showing that 5-fluorouracil may be efficacious in these difficult-to-treat patients.

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) represent a spectrum of the same condition defined by its widespread skin and mucosal loss.1 SJS/TEN represents a true dermatologic emergency, as the disease quickly evolves and is often fatal without early identification and treatment. It is essential for all clinicians to be familiar with common signs associated with SJS/TEN, as patients are more likely to present initially to primary care providers and emergency physicians than they are to a dermatologist. Certain characteristics of SJS/TEN allow it to be distinguished from common mimickers such as Drug Rash with Eosinophilia and Systemic Symptoms (DRESS), Erythema Multiforme (EM), and morbilliform drug reactions.1 We present the “SJS/TENN” mnemonic of clinical char acteristics to aid in the early diagnosis for suspected cases (Table 1). Table 1 Prevalence of clinical findings included in SJS/TENN mnemonic.

BackgroundKeratoacanthomas (KAs) are neoplasms of squamous epithelium which exhibit rapid growth and are often difficult to distinguish clinically from squamous cell carcinoma. Excision is the most common treatment, but in refractory cases or for KAs in cosmetically sensitive areas, nonoperative modalities may be better suited.ObjectiveTo compare efficacies of topical and intralesional therapies for the treatment of KAs.MethodsA systematic literature review was performed using Medline, Ovid, and Embase. Studies looking at the efficacy of topical or intralesional treatments for KAs were included. To compare efficacy, 2-tailed t-tests were performed, with P < .05 considered statistically significant.ResultsForty-one studies were identified across 5 modalities. Both topical and intralesional treatments had high KA eradication rates (92%-100%). Intralesional 5-fluorouracil led to faster KA healing times when compared to intralesional methotrexate (3.7 vs 4.6 weeks, P = .017). Similarly, topical 5-fluorouracil led to faster time to heal than topical imiquimod (3.8 vs 7.6 weeks with imiquimod, P < .0001).ConclusionFor nonoperative treatment of KAs, strong evidence currently exists for both topical and intralesional therapies. Decisions on which modality to use should be made on a case-by-case basis.

An itch during surgery can be distracting. Sterile cotton tipped applicators are inexpensive and multipurpose tools that may be used for a variety of simple surgical tasks such as scratching an itch on the surgeon or patient's face. They may also be used to adjust glasses and turn on surgical lights or the electrocautery machine.

Psoralen plus UVA (PUVA) is an effective therapy for mycosis fungoides (MF), the skin-limited variant of cutaneous T cell lymphoma (CTCL). In low-burden patients, PUVA reduced or eradicated malignant T cells and induced clonal expansion of CD8(+) T cells associated with malignant T cell depletion. High-burden patients appeared to clinically improve but large numbers of malignant T cells persisted in skin. Clinical improvement was linked to turnover of benign T cell clones but not to malignant T cell reduction. Benign T cells were associated with the Th2-recruiting chemokine CCL18 before therapy and with the Th1-recruiting chemokines CXCL9, CXCL10, and CXCL11 after therapy, suggesting a switch from Th2 to Th1. Inflammation was correlated with OX40L and CD40L gene expression; immunostaining localized these receptors to CCL18-expressing c-Kit(+) dendritic cells that clustered together with CD40(+)OX40(+) benign and CD40(+)CD40L(+) malignant T cells, creating a proinflammatory synapse in skin. Our data suggest that visible inflammation in CTCL results from the recruitment and activation of benign T cells by c-Kit(+)OX40L(+)CD40L(+) dendritic cells and that this activation may provide tumorigenic signals. Targeting c-Kit, OX40, and CD40 signaling may be novel therapeutic avenues for the treatment of MF.

An itch during surgery can be distracting. Sterile cotton tipped applicators are inexpensive and multipurpose tools that may be used for a variety of simple surgical tasks such as scratching an itch on the surgeon or patient’s face. They may also be used to adjust glasses and turn on surgical lights or the electrocautery machine.

Background: Scaphoid fractures progress to nonunion rates of up to 15% when non-displaced, and are even more frequent when the fracture is displaced. Standard treatment in these cases is surgery; however, individuals unable to undergo this operation, or for those who wish to try more conservative measures, there may be benefit from nonoperative options. Of these, low-intensity pulsed ultrasound (LIPUS) has been shown to improve fracture nonunion healing. The purpose of this study was to perform a comprehensive meta-analysis of relevant literature to determine success of the use of LIPUS for treatment of scaphoid nonunion. Methods: Utilizing PubMed, Embase, and Ovid databases, we performed a literature search using key terms for scaphoid nonunions. A total of 686 studies met initial search criteria. Studies reporting fewer than 5 cases, those not published in English, those not related to LIPUS nonoperative scaphoid nonunion treatment, and those without sufficient data were excluded. Five studies met these criteria, and statistical analysis was performed to determine overall union rates. Results: The use of LIPUS on 166 nonunions reported a mean healing index of 78.6%. The average time to union following LIPUS treatment was 4.2 months. Conclusions: While surgical intervention is still the standard, our results show that LIPUS may serve as a nonoperative alternative to scaphoid nonunion in certain cases. The results are encouraging in which these challenging fracture a nonunions can heal without further surgical intervention in the majority of patients.

Background Systemic medications are often required for severe atopic dermatitis (AD) refractory to topical therapies. Biologic medications are a recent advancement in the field and a comparison with standard systemic approaches would be beneficial. Objective To compare efficacies of systemic therapies for the treatment of AD. Methods A systematic literature review was performed using Medline, Ovid, and Embase. Randomized controlled trials looking at the efficacy of systemic treatments for AD in adults and children were included. Results A total of 41 studies met criteria and were included in our final analysis. Consistent improvements in Eczema Area and Severity Index and Scoring Atopic Dermatitis were reported with dupilumab and cyclosporine. Phase 2 clinical trials for lebrikizumab and tralokinumab were effective and would benefit from phase 3 trials. No study reported efficacy of biologic medications in pediatric patients; however, cyclosporine improved clinical severity by the greatest amount in this group. Limitations A lack of well controlled comparison studies make direct comparisons between the treatments difficult. Conclusion For treatment of severe AD, the strongest evidence currently exists for dupilumab and cyclosporine at improving clinical disease severity. Further research is required to determine long-term safety and efficacy of biologic medications.