Pilot randomized-control trial to assess the effect product sampling has on adherence using adapalene/benzoyl peroxide gel in acne patients.

BACKGROUND: The treatment of acne can be difficult, with suboptimal adherence resulting in poor treatment outcomes. PURPOSE: To determine whether demonstrating to patients how to properly apply a topical acne medication through the use of a sample product will improve adherence. METHODS: Subjects with mild to moderate acne were instructed to use adapalene/benzoyl peroxide gel once daily for six weeks. Subjects were randomized into sample or no sample group. Sample group received a demonstration on how to apply the medication using a product sample. The primary outcome was median adherence, recorded using electronic monitoring, and secondary outcomes were efficacy measures including the Acne Global Assessment (AGA) and lesion counts and the Perceived Medical Condition Self-Management Scale (PMCSMS). RESULTS: Data from 17 patients was collected and analyzed. Median adherence rates were 50% in the sample group and 35% in the no sample group (p=0.67). The median percent improvement in non-inflammatory lesions were 46% for the sample group and 33% for the no-sample group (p=0.10). LIMITATIONS: The small size of this pilot study limited the extent of subgroup analyses. CONCLUSIONS: Objective electronic monitoring expanded our previous observations of poor adherence in the treatment of acne. There is a considerable potential effect size on adherence for the use of samples, supporting the need for future, well powered studies to assess the value of using samples in the treatment of acne and other dermatologic skin diseases.

Trends in sunscreen recommendation among US physicians.

IMPORTANCE: Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate. OBJECTIVE: To evaluate trends in sunscreen recommendation among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis. DESIGN, SETTING, AND PARTICIPANTS: The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989-December 26, 2010) during which sunscreen was recommended. MAIN OUTCOMES AND MEASURES: Frequency of sunscreen recommendation. RESULTS: According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation. CONCLUSIONS AND RELEVANCE: Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.

Reconstructing complex central facial defects involving multiple cosmetic subunits.

Defects of the central face can pose significant reconstructive challenges and are some of the most frequently encountered defects in facial reconstructive surgery. Familiarity with the repair of such defects is essential. At our institution, we have found that a systematic approach to central facial defects allows for superior results. We present that approach here using several cases to demonstrate the intraoperative planning involved. The cosmetic units and subunits within the defect must be identified. The defect must then be assessed for structural defects and deep soft tissue defects, which can be repaired utilizing cartilage grafts and hinge flaps respectively. Superficial defects of the cheek, lip, and nasal sidewall can then be assessed and repaired, taking advantage of the available tissue reservoirs using adjacent sliding flaps. The remaining distal nasal defect can then be repaired, depending on size, with a full-thickness skin graft, a cheek interpolation flap, or if necessary, a paramedian forehead flap. This systematic approach to reconstructing central facial defects simplifies seemingly complex reconstructive challenges and optimizes results.

Iododerma following serial computed tomography scans in a lung cancer patient.

Iododerma is a rare cutaneous eruption occurring after iodine administration. Nine cases of iododerma following intravenous contrast have been reported in the English-language literature, typically in patients with renal insufficiency. We report a case of iododerma in a patient with relatively unimpaired renal function who underwent serial computer tomography (CT) scans with intravenous contrast. An 81-year-old woman with stage IV lung cancer developed fever and rash following serial CT scans with iodixanol contrast media. On examination, we noted conjunctival injection, enlarged glands, oral ulcers, and erythematous papules and plaques on her forehead, arms, and legs. Random urine iodine was elevated to 106,767 µg/L (normal range, 26-705 µg/L). Skin biopsy revealed diffuse predominantly neutrophilic dermal infiltrate. The patient's clinical presentation, laboratory findings, and biopsy results were consistent with iododerma. Iododerma can occur in patients with adequate kidney function, and its presentation can include ocular and glandular symptoms, as in this case. Withdrawal of the source of iodine typically leads to resolution of symptoms.

Timing of office visits can be a powerful tool to improve adherence in the treatment of dermatologic conditions.

BACKGROUND: Poor adherence to treatment is a significant problem throughout medicine and particularly in the treatment of dermatologic conditions with topical medications, which present unique barriers to adherence. PURPOSE: We reviewed the literature to assess whether timing of office visits can be used to improve adherence. METHODS: Studies examining adherence and office visits were identified using two search engines. PubMed was searched using the terms "medication adherence" OR "medication compliance" AND "visits." A Web of Science cited reference search was performed to identify articles referencing the paper "On white-coat effects and the electronic monitoring of compliance" by Alvan R. Feinstein, MD. RESULTS: Fifteen studies were identified, three of which were on dermatologic conditions. Thirteen studies found a positive correlation between adherence and office visits. Three of these studies demonstrated increased adherence with increased visit frequency. One study reported adherence was unaffected by office visits. LIMITATIONS: Our review was limited in that none of the studies identified looked at the effect timing of office visits had on adherence in the long term. CONCLUSIONS: Strategic scheduling of office visits can be a valuable tool to improve adherence, particularly in the management of dermatologic conditions, and may help spare patients unnecessary exposure to more toxic systemic therapies.

Nonmelanoma skin cancer treatment training varies across different medical specialists.

BACKGROUND: Physicians from various specialties treat patients with nonmelanoma skin cancer (NMSC). The isolation of specialties from each other may result in different approaches to skin cancer training. PURPOSE: Our purpose was to determine the type and amount of NMSC surgical training that is received during dermatology, general surgery, internal medicine, otolaryngology, and plastic surgery residencies. METHODS: E-mail contact information for residency program directors of all accredited programs in each specialty was compiled through the American Medical Association's online residency database. A total of 920 residency program directors were emailed surveys concerning the training of residents in the treatment of NMSC. RESULTS: Forty-two of 920 surveys were returned. All surveyed specialty groups, except internal medicine, had training in NMSC treatment including simple excision, split thickness skin grafts, and tissue rearrangement. A majority of the dermatology and plastic surgery programs instruct their residents in Mohs micrographic surgery and full thickness skin grafts. Electrodessication and curettage was most often instructed in dermatology, general surgery, and plastic surgery programs. CONCLUSION: Greater consistency in NMSC treatment training may be beneficial. Because different approaches may be best suited to particular clinical situations, NMSC treatment training should include adequate exposure to all NMSC treatment techniques.

Incidence, risk factors, and preventative management of skin cancers in organ transplant recipients: a review of single- and multicenter retrospective studies from 2006 to 2010.

BACKGROUND: Organ transplant recipients (OTRs) taking immunosuppressants are at high risk of skin cancer, which is the most common malignant condition in OTRs, so dermatologic surveillance is important for OTRs. OBJECTIVES: To characterize the most common skin cancers arising from chronic immunosuppression in OTRs. METHODS: A PubMed search for retrospective single- and multicenter studies reporting skin cancer incidence from 2006 to 2010 was undertaken. Data regarding each study's immunosuppressive regimen, affected skin cancer cohort, and associated risk factors were extracted. RESULTS: Thirty-six articles that met our inclusion criteria reported incidences of nonmelanoma skin cancer (NMSC), Kaposi's sarcoma, melanoma, and Merkel cell carcinoma. NMSC was the most commonly reported cancer of all skin cancers after transplantation. Common risk factors were sex, age, sunlight exposure, and immunosuppressive agent-related (duration, type). CONCLUSION: Sun education programs and frequent screenings in organ transplant clinics have provided the best preventative strategies after transplantation, although the characteristics of the immunosuppressive regimen also play an important role. Thus, the adjuvant strategy of modifying immunosuppression may be effective when confronting severe transplant-associated skin cancer. Although the decision-making process for curbing levels of immunosuppression is difficult, further long-term, randomized controlled studies should assess the effect of using less immunosuppressant medication while preserving graft function.

Practice trends in the treatment of actinic keratosis in the United States: 0.5% fluorouracil and combination cryotherapy plus fluorouracil are underused despite evidence of benefit.

BACKGROUND: Topical fluorouracil and cryotherapy are among the most commonly used treatments for actinic keratosis. Evidence shows that 0.5% fluorouracil has similar efficacy and is better tolerated than 5% fluorouracil. Evidence also shows that combination therapy with cryosurgery and fluorouracil is beneficial. OBJECTIVE: To examine fluorouracil and cryotherapy use in the treatment of actinic keratosis. METHODS: The National Ambulatory Medical Care Survey database was queried for visits for actinic keratosis. Visits were analyzed for patient demographics, provider specialty, and treatment regimens. Fluorouracil and cryotherapy use was analyzed over time. RESULTS: Cryotherapy was the most commonly used treatment for actinic keratosis. Fluorouracil products were prescribed to 1.1 million patients (6.6%) between 2001 and 2008; of these, dermatologists prescribed 0.5% fluorouracil in 51.8% of cases and 5% fluorouracil in 38.9% of cases. Combination fluorouracil and cryotherapy was used for only 1.1% of actinic keratosis visits between 1993 and 2008 and was never used by nondermatologists. CONCLUSIONS: Despite evidence suggesting comparable efficacy, greater tolerability, and lower cost of 0.5% fluorouracil relative to 5% fluorouracil, 5% fluorouracil is used by dermatologists almost as often as 0.5% fluorouracil. Among nondermatologists, 5% fluorouracil is used exclusively. Combination therapy of fluorouracil and cryotherapy is underused despite evidence of its benefit.

Isotretinoin and oral contraceptive use in female acne patients varies by physician specialty: analysis of data from the National Ambulatory Medical Care Survey.

OBJECTIVE: To determine whether oral contraceptives (OCPs) are underutilized in the treatment of acne in women of reproductive age, how use of OCPs compares with use of isotretinoin and whether adequate use and documentation of OCPs is occurring with isotretinoin. MATERIAL AND METHODS: The National Ambulatory Medical Care Survey (NAMCS) was analyzed over the years 1993-2008 for isotretinoin and OCP use in females aged 12-55 with acne. RESULTS: Isotretinoin was prescribed more often than OCPs at both first visits (4.7% vs. 3.3%) and overall visits (13% vs. 2.6%) for acne. Documentation of OCP or other contraceptive use occurred only 4.1% of the time overall in patients treated with isotretinoin. Specialties varied in both OCP use for acne and contraceptive use with isotretinoin, with ob/gyn specialists most likely to prescribe OCPs and isotretinoin and to report contraceptive use in patients using isotretinoin, and dermatologists least likely to prescribe OCPs. CONCLUSIONS: The findings of the current study indicate that OCPs may be underutilized in women with acne. Underreporting of contraceptive use with isotretinoin and variations between specialties in OCP and isotretinoin use indicate a potential for education about the viability of OCPs in acne treatment and the importance of reporting contraceptive use with isotretinoin.

Trends in the use of topical over the counter products in the management of dermatologic disease in the United States.

BACKGROUND: Over the counter (OTC) products play an important role in treating and preventing disease in the U.S. Topical OTCs are widely used but use in dermatology is not well defined. OBJECTIVE: To characterize topical OTC use in the U.S. METHODS: The National Ambulatory Medical Care Survey was queried for physician visits in which topical OTCs were recorded. Physician specialty, patient demographics, and diagnoses were examined and linear regressions were performed to determine trends over time. RESULTS: From 1989 to 2008, there were an estimated 320 million visits documenting topical OTC recommendations; the majority of which were visits to a dermatologist (33.5%). Dermatologists most commonly recommended hydrocortisone (16.9%), benzoyl peroxide (13.3%), and sunscreen (7.4%). Dermatologists were more likely than other providers to use moisturizers in the treatment of dermatologic disease. Overall, topical OTC recommendations by all physicians has decreased over time (p < 0.0001). However, dermatologists' recommendations for moisturizers and sunscreens has increased significantly. CONCLUSION: Topical OTC products have an important role in the prevention and treatment of dermatologic disease. Topical OTC recommendations are decreasing over time whereas their use as complementary components (sunscreen/moisturizers) appears to be increasing. Increased awareness of the utility of these agents may help to improve patient outcomes.

Quality of life measures for acne patients.

Acne vulgaris affects most adolescents and two-thirds of adults and is associated with substantial psychosocial burden. Health-related quality of life (HRQOL) for patients with acne is an important factor of patient care, and several dermatologic and acne-specific measures have been created to assist in acne research, management, and care. This review describes several skin disease and acne-specific HRQOL measures and their applications in clinical care or research. The ideal HRQOL measure for the management of patients with acne is a concise questionnaire that places minimal burden on respondents and allows physicians to track improvement in HRQOL with successful treatment.

Use of topical antibiotics as prophylaxis in clean dermatologic procedures.

BACKGROUND: Topical antibiotics are not indicated for routine postoperative care in clean dermatologic procedures, but may be widely used. OBJECTIVE: We sought to describe topical antibiotic use in clean dermatologic surgical procedures in the United States. METHODS: The 1993 to 2007 National Ambulatory Medical Care Survey database was queried for visits in which clean dermatologic surgery was performed. We analyzed provider specialty, use of topical antibiotics, and associated diagnoses. Use of topical antibiotic over time was analyzed by linear regression. RESULTS: An estimated 212 million clean dermatologic procedures were performed between 1993 and 2007; topical antibiotics were reported in approximately 10.6 million (5.0%) procedures. Dermatologists were responsible for 63.3% of dermatologic surgery procedures and reported use of topical antibiotic prophylaxis in 8.0 million (6.0%). Dermatologists were more likely to use topical antibiotic prophylaxis than nondermatologists (6.0% vs 3.5%). Use of topical antibiotic prophylaxis decreased over time. LIMITATIONS: Data were limited to outpatient procedures. The assumption was made that when topical antibiotics were documented at procedure visits they were being used as prophylaxis. CONCLUSIONS: Topical antibiotics continue to be used as prophylaxis in clean dermatologic procedures, despite being ineffective for this purpose and posing a risk to patients. Although topical antibiotic use is decreasing, prophylactic use should be eliminated.

Topical antibiotic trends from 1993 to 2007: use of topical antibiotics for non-evidence-based indications.

BACKGROUND: Systemic antibiotic use has become more conservative with the emergence of drug resistance. Topical antibiotics are employed for a variety of indications, although there are only a few evidence-based indications. OBJECTIVE: To examine topical antibiotics use in the outpatient setting. METHODS: Topical antibiotic use was characterized using data from the 1993 to 2007 National Ambulatory Medical Care Survey. Visits were identified at which a topical antibiotic was used and analyzed according to patient demographics, diagnoses, procedures, concomitant medications, and provider specialty. Topical antibiotic use over time was analyzed using linear regression. RESULTS: The most frequent diagnoses associated with topical antibiotic use were benign or malignant neoplasm of skin, impetigo, insect bite, and cellulitis. Data revealed a significant downward trend in topical antibiotics associated with dermatologic surgery (p<.001) and a nonsignificant downward trend in use in conjunction with skin biopsies (p=.09). Topical antibiotic use by dermatologists was noted to be decreasing over time, whereas among non dermatologists, it was noted to be increasing, although neither of these trends was statistically significant. CONCLUSION: Topical antibiotics continue to be used for non-evidence-based indications, despite data that suggest that such use may be detrimental for patients and represents significant costs to the health care system. The authors have indicated no significant interest with commercial supporters.

Commentary: psoriasis patients with a history of malignancy represent an important but overlooked study population.

The treatment of moderate to severe psoriasis often requires the administration of systemic agents. However, information is limited on the safety of systemic agents in patients with pre-existing cancers. We attempt to summarize the small body of data and urge organized study of this patient population.

Eyeglass allergic contact dermatitis.

Allergic contact dermatitis is a common problem. The distribution of the eruption with which a patient presents is the key to identifying the offending agent. The ability to quickly recognize characteristic presentations of common allergens is valuable. We present a case of red plaques on the face. The distribution of these plaques pointed clearly to eyeglasses as the cause. Eyeglass frames are manufactured from various materials that have the potential to act as allergens.