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The United States population is aging and increasing in comorbidity, and patient care is accordingly growing increasingly complex. Complexity impacts patterns of resource consumption, adverse event and medical error rates, health-related quality of life, physician burnout, and more. Tools capturing complexity can be of benefit in the modern value-based reimbursement landscape and have been well-studied in specialties other than dermatology. In this paper, we describe the validation of a tool specific to outpatient dermatologic care that captures the complexity of clinical visit medical decision-making. We performed a cross-sectional retrospective study to determine the inter-rater reliability and face validity of the tool. By objectively grading a clinical encounter based on clinical complexity, there is increased awareness of opportunities to improve clinical care and the allocation of healthcare costs and resources within the dermatologic community can be better assessed.

PURPOSE: Skin cancer is prevalent in sexual minority men but little is known about risk factors and screening specifically among couples in same-sex relationships (SSR). We aimed to compare sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) between people in SSR with those in opposite-sex relationships (OSR). METHODS: We conducted a pooled cross-sectional analysis of 2000–2015 data from the National Health Interview Survey, a nationally representative survey of the United States civilian population. RESULTS: Of 102,365 adults with a spouse or married partner, 448 (0.4%) were men in SSR, 48,312 (48.1%) men in OSR, 497 (0.5%) women in SSR, and 53,108 women in OSR (51.9%). Men in SSR were more likely than men in OSR to seek shade (adjusted odds ratio [aOR] = 1.41; 95% confidence interval [CI] = 1.07–1.85), tan indoors (aOR = 3.71; 95% CI = 2.38–5.78), and receive any TBSE (aOR = 2.45; 95% CI = 1.69–3.54) after adjusting for sociodemographic factors, health insurance status, and health behaviors. Men in SSR were less likely than men in OSR to wear long pants (aOR = 0.63; 95% CI = 0.46–0.85) and caps or visors (aOR = 0.50; 95% CI = 0.36–0.69). No differences in sunburns, sun-protective behaviors, indoor tanning, and TBSE between women in SSR and OSR were observed after multivariable adjustment. CONCLUSION: Patterns of sun-protective behaviors and indoor tanning among men in SSR, compared with men in OSR, demonstrate modifiable behaviors that may mitigate skin cancer risk. Dyadic counseling and public health interventions geared toward men in SSR may promote sun-protective behaviors and reduce indoor tanning.

Background Pain is rated by patients with hidradenitis suppurativa (HS) as the disease’s most impactful symptom. HS therapies are often insufficient to control inflammatory disease activity and pain. A better understanding of patient experiences with pain may improve patient–provider relationships and help identify strategies for addressing HS pain. Objectives This qualitative study sought to characterize lived pain experiences of those with HS. Methods English-speaking patients ≥ 18 years old with a dermatologist-confirmed diagnosis of HS and an average numerical rating scale pain score of ≥ 1 over the preceding week were recruited from a single academic medical centre in Atlanta, Georgia, USA. Semistructured interviews were conducted from November 2019 to March 2020 to explore participants’ HS pain experiences and the subsequent impact on their lives. Thematic saturation was reached after interviewing 21 participants. Interviews were audio recorded, transcribed, and analysed using thematic analysis. Results Among 21 study participants, the median 7-day average pain score was 6 (interquartile range 3–7; scale ranges from 0 to 10, with 10 being most pain). Participants’ descriptions of pain were consistent with nociceptive pain, neuropathic pain and itch. Pain impacted multiple life domains, including physical limitations (decreased mobility and impaired sleep), decreased psychological wellbeing (irritability, depression, loss of control, and difficulty communicating pain experiences) and impaired social relationships (social isolation, intimacy problems and difficulty fulfilling social responsibilities). Although participants reported chronic discomfort, acutely painful and unpredictable HS disease flares caused more distress and quality-of-life (QoL) burden. Participants frequently treated their pain without input from the medical team, sometimes with unsafe medication doses or combinations. Factors contributing to self-management of pain included difficulty accessing timely outpatient care during disease flares and fear of stigma from healthcare providers. Conclusions When present, HS-related pain may impact not only physical wellbeing but also mental health and relationships. In addition to therapies that target the inflammatory disease burden, treating the symptom of pain may improve patients’ QoL and wellbeing. Because patients with HS have difficulty explaining their pain, proactively asking them about pain may identify unmet needs, facilitate better pain control and improve QoL. Further, the influence of HS-related pain on numerous aspects of QoL suggests the need for multidisciplinary, patient-centred approaches to HS pain management.

Background Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices. Methods We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). Results At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. Conclusions Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.

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 Teledermatology can increase patient access; however, its optimal implementation remains unknown. OBJECTIVE This study aimed to describe and evaluate the implementation of a pilot virtual clinic teledermatology service at Duke University. METHODS Leaders at Duke Dermatology and Duke Primary Care identified a teledermatology virtual clinic to meet patients’ access needs. Implementation was planned over the exploration, preparation, implementation, and sustainment phases. We evaluated the implementation success of teledermatology using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework and prioritized outcome collection through a stakeholder survey. We used the electronic health record and patient surveys to capture implementation outcomes. RESULTS Our process consisted of primary care providers (PCPs) who sent clinical and dermatoscopic images of patient lesions or rashes via e-communication to a teledermatology virtual clinic, with a subsequent virtual clinic scheduling of a video visit with the virtual clinic providers (residents or advanced practice providers, supervised by Duke Dermatology attending physicians) within 2-5 days. The teledermatology team reviews the patient images on the day of the video visit and gives their diagnosis and management plan with either no follow-up, teledermatology nurse follow-up, or in-person follow-up evaluation. Implementation at 4 pilot clinics, involving 19 referring PCPs and 5 attending dermatologists, began on September 9, 2021. As of October 31, 2021, a total of 68 e-communications were placed (50 lesions and 18 rashes) and 64 virtual clinic video visits were completed. There were 3 patient refusals and 1 conversion to a telephonic visit. Participating primary care clinics differed in the number of patients referred with completed visits (range 2-32) and the percentage of providers using e-communications (range 13%-53%). Patients were seen soon after e-communication placement; compared to in-person wait times of >3 months, the teledermatology virtual clinic video visits occurred on average 2.75 days after e-communication. In total, 20% of virtual clinic video visits were seen as in-person visit follow-up, which suggests that the majority of patients were deemed treatable at the virtual clinic. All patients who returned the patient survey (N=10, 100%) agreed that their clinical goals were met during the virtual clinic video visits. CONCLUSIONS Our virtual clinic model for teledermatology implementation resulted in timely access for patients, while minimizing loss to follow-up, and has promising patient satisfaction outcomes. However, participating primary care clinics differ in their volume of referrals to the virtual clinic. As the teledermatology virtual clinics scale to other clinic sites, a systematic assessment of barriers and facilitators to its implementation may explain these interclinic differences.

Patients with single primary melanomas have an increased risk of developing subsequent melanomas. Secondary tumors diagnosed within and after three months are termed "synchronous" and "asynchronous," respectively.Compare the tumor distributions and survival characteristics of patients with second primary melanoma subtypes to patients with single primary melanomas.Retrospective cohort study. Data were collected from an institutional database from 14,029 patients with a diagnosis of a primary melanoma seen between 1970 and 2004.The synchronous and asynchronous cohorts demonstrated significantly improved survival probabilities compared to the single primary cohort (p=.04 and .002, respectively). Single primaries (2.2mm, SD=2.3) were significantly thicker than the first identified synchronous (2.0mm, SD=1.7) and the first identified asynchronous lesions (1.7mm, SD= 1.3). Synchronous lesions were more likely to be anatomically concordant compared to asynchronous lesions (55.7% vs 38.2%, p.001).Our limitations include the single center study design as well as incomplete records for second primary melanoma Breslow depth and histopathology.Patients with second primary melanomas demonstrated a significant survival advantage and thinner lesions compared to single primary melanomas. Our reported tumor distributions support the role of FBSE's, with attention to the region of initial diagnosis.

Neither patient experienced myelosuppression. Acitretin was briefly withheld when the latter patient had hypercholesterolemia until pravastatin was started and cholesterol normalized. Both patients tapered down to acitretin, 10 mg/d after 4 months. After 3 additional months, they tapered to 10 mg every other day for prevention for up to 10 months. At 1-year follow-up, both patients remained without clinical recurrence (Figs 1, D and ​and2,2, D)

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.

Background Ultrasound was first introduced in clinical dermatology in 1979. Since that time, ultrasound technology has continued to develop along with its popularity and utility. Main text summary Today, high-frequency ultrasound (HFUS), or ultrasound using a frequency of at least 10 megahertz (MHz), allows for high-resolution imaging of the skin from the stratum corneum to the deep fascia. This non-invasive and easy-to-interpret tool allows physicians to assess skin findings in real-time, enabling enhanced diagnostic, management, and surgical capabilities. In this review, we discuss how HFUS fits into the landscape of skin imaging. We provide a brief history of its introduction to dermatology, explain key principles of ultrasonography, and review its use in characterizing normal skin, common neoplasms of the skin, dermatologic diseases and cosmetic dermatology. Conclusion As frequency advancements in ultrasonography continue, the broad applications of this imaging modality will continue to grow. HFUS is a fast, safe and readily available tool that can aid in diagnosing, monitoring and treating dermatologic conditions by providing more objective assessment measures.

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.

Recent progress in the treatment of advanced melanoma has led to unprecedented improvements in overall survival and, as these new melanoma treatments have been developed and deployed in the clinic, much has been learned about the natural history of the disease. Now is the time to apply that knowledge toward the design and clinical evaluation of new chemoprevention agents. Melanoma chemoprevention has the potential to reduce dramatically both the morbidity and the high costs associated with treating patients who have metastatic disease. In this work, scientific and clinical melanoma experts from the national Melanoma Prevention Working Group, composed of National Cancer Trials Network investigators, discuss research aimed at discovering and developing (or repurposing) drugs and natural products for the prevention of melanoma and propose an updated pipeline for translating the most promising agents into the clinic. The mechanism of action, preclinical data, epidemiological evidence, and results from available clinical trials are discussed for each class of compounds. Selected keratinocyte carcinoma chemoprevention studies also are considered, and a rationale for their inclusion is presented. These data are summarized in a table that lists the type and level of evidence available for each class of agents. Also included in the discussion is an assessment of additional research necessary and the likelihood that a given compound may be a suitable candidate for a phase 3 clinical trial within the next 5 years.

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 Teledermatology can increase patient access; however, its optimal implementation remains unknown. Objective This study aimed to describe and evaluate the implementation of a pilot virtual clinic teledermatology service at Duke University. Methods Leaders at Duke Dermatology and Duke Primary Care identified a teledermatology virtual clinic to meet patients’ access needs. Implementation was planned over the exploration, preparation, implementation, and sustainment phases. We evaluated the implementation success of teledermatology using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework and prioritized outcome collection through a stakeholder survey. We used the electronic health record and patient surveys to capture implementation outcomes. Results Our process consisted of primary care providers (PCPs) who sent clinical and dermatoscopic images of patient lesions or rashes via e-communication to a teledermatology virtual clinic, with a subsequent virtual clinic scheduling of a video visit with the virtual clinic providers (residents or advanced practice providers, supervised by Duke Dermatology attending physicians) within 2-5 days. The teledermatology team reviews the patient images on the day of the video visit and gives their diagnosis and management plan with either no follow-up, teledermatology nurse follow-up, or in-person follow-up evaluation. Implementation at 4 pilot clinics, involving 19 referring PCPs and 5 attending dermatologists, began on September 9, 2021. As of October 31, 2021, a total of 68 e-communications were placed (50 lesions and 18 rashes) and 64 virtual clinic video visits were completed. There were 3 patient refusals and 1 conversion to a telephonic visit. Participating primary care clinics differed in the number of patients referred with completed visits (range 2-32) and the percentage of providers using e-communications (range 13%-53%). Patients were seen soon after e-communication placement; compared to in-person wait times of >3 months, the teledermatology virtual clinic video visits occurred on average 2.75 days after e-communication. In total, 20% of virtual clinic video visits were seen as in-person visit follow-up, which suggests that the majority of patients were deemed treatable at the virtual clinic. All patients who returned the patient survey (N=10, 100%) agreed that their clinical goals were met during the virtual clinic video visits. Conclusions Our virtual clinic model for teledermatology implementation resulted in timely access for patients, while minimizing loss to follow-up, and has promising patient satisfaction outcomes. However, participating primary care clinics differ in their volume of referrals to the virtual clinic. As the teledermatology virtual clinics scale to other clinic sites, a systematic assessment of barriers and facilitators to its implementation may explain these interclinic differences. Acknowledgments We are grateful to the Private Diagnostic Clinic and Duke Institute for Health Innovation for their support. Conflicts of Interest None declared.

Complementary and alternative medicine (CAM) is widely used by patients who suffer from chronic pruritus, but there is little data on the efficacy or antipruritic mechanism of these interventions. This review assesses the current understanding of the clinical efficacy and purported mechanisms of CAM therapy for pruritic skin disease, and serves as a basis for further investigation into the pharmacological basis of plant-based CAM for pruritus and patient motivations in the adoption of these types of therapies. To assess the current state of the literature, we queried multiple databases for reports of botanical CAM therapies for pruritic skin conditions. Numerous in vitro and animal studies show positive results, but antipruritic effects in human trials are varied. Many of these topical and systemic therapies have demonstrated measurable impact on inflammatory pathways, including some that are known to be crucial in transmission of itch signaling. CAM is a frequently utilized but somewhat poorly understood intervention for chronic pruritus, though our understanding of the impact of these therapies on pruritus has improved in recent years. Further studies into the mechanism and efficacy of CAM-based therapies for chronic pruritus, and patient attitudes towards these practices, are warranted.

Melanoma is usually apparent on the skin and readily detected by trained medical providers using a routine total body skin examination, yet this malignancy is responsible for the majority of skin cancer-related deaths. Currently, there is no national consensus on skin cancer screening in the USA, but dermatologists and primary care providers are routinely confronted with making the decision about when to recommend total body skin examinations and at what interval. The objectives of this paper are: to propose rational, risk-based, data-driven guidelines commensurate with the US Preventive Services Task Force screening guidelines for other disorders; to compare our proposed guidelines to recommendations made by other national and international organizations; and to review the US Preventive Services Task Force's 2016 Draft Recommendation Statement on skin cancer screening.