Hidradenitis suppurativa: a new, principle-centered paradigm for managing a dynamic disease.

Hidradenitis suppurativa (HS) is a chronic, debilitating skin condition that disproportionately affects socioeconomically underserved patients. Currently, treatment outcomes for patients with HS remain poor, largely because of a deficiency in current guidelines on exactly how and when to employ the myriad treatment tools, resulting in heterogeneous care models and confusion. Aggressive medical therapy is often started too late, pursued for too long whilst delaying procedural intervention, or skipped over altogether for procedures. Here, we propose a new, principle-centered management paradigm for HS that emphasizes the need for prompt intervention to minimize suffering and an understanding of how sinus tract development dictates the timing of medical and procedural interventions.

Characterizing differences in outpatient dermatologic care utilization among disaggregated Asian American subgroups.

Despite having significantly higher rates of atopic dermatitis, psoriasis, and pigmentary disorders compared to White patients, studies suggest that Asian Americans are underrepresented in outpatient dermatology clinics. In this study, we utilize the National Health Interview Survey (NHIS) and prioritize disaggregated analyses to evaluate differences between the most populous Asian American subgroups (Chinese, Filipino, Indian, and "Other") in utilization of outpatient dermatologic care. We utilized multivariable logistic regression to compare outpatient dermatologic care use between each Asian American subgroup and Non-Hispanic Whites. Out of 96,559 adults, our study included 5264 self-identified Asian American and 91,295 non-Hispanic White adults. Most Asian participants were female, had health insurance, and had incomes > 2 times above the federal poverty line. We found that, compared to 21.4% for NH whites, lifetime prevalence of total body skin exam was highest among Filipino Americans (12.3%) and lowest among Indian Americans (7%). Additionally, all Asian American subgroups had a significantly lower odd than NH Whites of ever having a total body skin exam, with Indian Americans having the lowest odds. While the benefit of TBSEs in Indian Americans is unclear, it is possible that differing cultural perceptions about dermatologic needs, barriers to care, or immigration status may be contributing to the observed difference. Furthermore, the Indian diaspora encapsulates a range of skin tones, risk factors, and behaviors that may differentially influence dermatologic disease risk, similar to trends identified among Hispanic patients (Trepanowski et al. in J Am Acad Dermatol 88:1206-1209, 2023). Additional research utilizing the seven national databases that have been identified as providing disaggregated Asian racial information (Kamal et al. in J Am Acad Dermatol, 2023) may be useful to further illuminate avenues for intervention.

Superficial and Bullous Neutrophilic Dermatoses: Sneddon-Wilkinson, IgA Pemphigus, and Bullous Lupus.

Sneddon-Wilkinson disease (SWD), IgA pemphigus, and bullous systemic lupus erythematosus (BSLE) are superficial and bullous neutrophilic dermatoses. They are all characterized by sterile neutrophilic infiltrate but differ in the level of skin affected and presence of autoantibodies. Both SWD and IgA pemphigus present with grouped flaccid pustules and have epidermal involvement; it is unclear whether they are distinct or exist on a spectrum of the same disease. IgA pemphigus is distinguished from SWD by positive direct immunofluorescence showing intercellular IgA deposition. BSLE presents with tense bullae, dermal neutrophilic infiltrate, and direct immunofluorescence showing linear IgG deposition along the dermal-epidermal junction.

Evaluation of Stigma Toward Individuals With Acne.

Importance: Little is known about the prevalence and magnitude of stigmatizing attitudes of the general public toward individuals with acne. Objective: To explore the degree of stigma toward individuals with acne and whether these attitudes vary based on characteristics of the individuals with acne or of the survey participants. Design, Setting, and Participants: In this cross-sectional internet survey study, 4 stock portraits of adults that varied in sex (male/female) and skin tone (light/dark) were digitally enhanced to have acne (mild/severe). One of these 12 images was randomly presented to survey participants, who subsequently answered questions regarding stigmatizing attitudes with respect to the pictured individual, such as desire for social distance and stereotype endorsement. The survey was administered to a convenience sample of adult respondents in the US who were volunteers on the ResearchMatch platform. Main Outcomes and Measures: Prevalence and magnitude of stigma toward individuals with acne. Results: The survey was completed by 1357 respondents (65.7% completion rate) (mean [SD] age, 42.4 [14.3] years; 918 [67.7%] female, 439 [32.4%] male). Compared to those with no acne, for those with severe acne, participants reported less comfort being friends (adjusted coefficient [95% CI], -0.28 [-0.47 to -0.10]; P = .003), hiring (-0.33 [-0.51 to -0.15]; P < .001), having physical contact (-0.26 [-0.45 to -0.08]; P = .006), dating (-0.44 [-0.74 to -0.14]; P = .004), and posting a photograph together on social media (-0.50 [-0.70 to -0.30]; P < .001). Compared to those with no acne, participants were more likely to rate individuals with severe acne as having poor hygiene (adjusted coefficient [95% CI], -1.04 [-1.46 to -0.82]; P < .001) and being unattractive (-0.89 [-1.12 to -0.67]; P < .001), unintelligent (-0.42 [-0.63 to -0.22]; P < .001), unlikable (-0.36 [-0.56 to -0.15]; P < .001), immature (-0.52 [-0.74 to -0.30]; P < .001), and untrustworthy (-0.40 [-0.61 to -0.18]; P < .001). There was evidence that the effect size of the association of acne with desire to social distance was greater for individuals with dark skin. Conclusions and Relevance: This survey study demonstrates that stigmatizing attitudes toward patients with acne existed across a variety of social and professional scenarios, with severe acne and acne in darker skin tone being associated with a greater degree of stigma. These findings highlight the need to identify approaches to reduce stigmatizing attitudes in the community and for adequate access to care, which might prevent negative downstream effects related to these stigmatizing attitudes.

Janus Kinase Inhibitors and Adverse Events of Acne: A Systematic Review and Meta-Analysis.

Importance: Janus kinase (JAK) inhibitors are increasingly used across a range of dermatologic conditions. Adverse events of acne have been noted in some studies in clinical practice, but the scope of this outcome across JAK inhibitors has not been established. Objective: To systematically analyze all published phase 2 and 3 placebo-controlled randomized clinical trials (RCTs) of JAK inhibitors for the risk of acne as an adverse effect of these medications. Data Sources: Comprehensive search of Ovid MEDLINE and PubMed databases through January 31, 2023. Study Selection: Inclusion criteria were phase 2 and 3 placebo-controlled RCTs of JAK inhibitors published in English with reported adverse events of acne. Data Extraction and Synthesis: Two reviewers independently reviewed and extracted information from all included studies. Main Outcomes and Measures: The primary outcome of interest was the incidence of acne following JAK inhibitor use. A meta-analysis was conducted using random-effects models. Results: A total of 25 unique studies (10 839 unique participants; 54% male and 46% female) were included in the final analysis. The pooled odds ratio (OR) was calculated to be 3.83 (95% CI, 2.76-5.32) with increased ORs for abrocitinib (13.47 [95% CI, 3.25-55.91]), baricitinib (4.96 [95% CI, 2.52-9.78]), upadacitinib (4.79 [95% CI, 3.61-6.37]), deucravacitinib (2.64 [95% CI, 1.44-4.86]), and deuruxolitinib (3.30 [95% CI, 1.22-8.93]). Estimated ORs were higher across studies investigating the use of JAK inhibitors for the management of dermatologic compared with nondermatologic conditions (4.67 [95% CI, 3.10-7.05]) as well as for JAK1-specific inhibitors (4.69 [95% CI, 3.56-6.18]), combined JAK1 and JAK2 inhibitors (3.43 [95% CI, 2.14-5.49]), and tyrosine kinase 2 inhibitors (2.64 [95% CI, 1.44-4.86]). Conclusions and Relevance: In this systematic review and meta-analysis, JAK inhibitor use was associated with an elevated odds of acne. Patients should be properly counseled on this potential adverse effect of these medications before treatment initiation. Future studies are needed to further elucidate the pathophysiology of this association.

Safety and Effectiveness of Oral Nutraceuticals for Treating Acne: A Systematic Review.

Importance: Patients with acne are interested in nutraceuticals as a potential treatment option. However, there is uncertainty regarding the efficacy and safety of these products. Objective: To evaluate the evidence for oral nutraceuticals in the treatment of acne. Evidence Review: The PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched from inception through January 30, 2023, to identify randomized clinical trials evaluating oral nutraceutical interventions (ie, vitamins and minerals, botanical extracts, prebiotics, and probiotics) in individuals with acne. Clinician-reported outcomes (eg, investigator global assessment, lesion counts), patient-reported outcomes (eg, quality of life), and adverse events were extracted from the included studies. The quality of evidence was assessed using the Cochrane Risk of Bias checklist tool for randomized clinical trials. Based on the Risk of Bias tool, articles were converted to Agency for Healthcare Research and Quality standards of good, fair, or poor quality. Findings: A total of 2582 abstracts were identified in the database search, 42 of which met inclusion criteria (a total of 3346 participants). Studies of fair or good quality showed the potential benefit of vitamins B5 and D, botanical extracts (green tea), probiotics, and ω-3 fatty acids in the treatment of acne. These interventions were most frequently associated with decreased lesion counts or improved investigator global assessment scores. Adverse effects were rare for most of the therapies evaluated, but gastrointestinal tract adverse effects were reported for zinc therapy. Conclusions and Relevance: This systematic review suggests a possible role for nutraceutical supplements in the treatment of acne. Physicians should be prepared to discuss the evidence regarding the potential role of nutraceuticals with patients. Many studies were of small size, and future research should focus on larger randomized clinical trials to assess the utility of nutraceuticals in the treatment of acne.

Comorbid Conditions Associated with Alopecia Areata: A Systematic Review and Meta-analysis.

BACKGROUND: Alopecia areata (AA) is a complex autoimmune condition resulting in nonscarring hair loss. In recent years, many studies have provided new evidence on comorbid diseases present in patients with AA. However, some studies have conflicting results, and analyses conducting a comprehensive approach are lacking. OBJECTIVE: The aim of our study was to provide an updated systematic review and meta-analysis of medical comorbidities associated with AA. METHODS: We searched PubMed, Embase, and Web of Science for case-control, cross-sectional, and cohort studies investigating medical comorbidities in AA published from inception through 1 February 2023. RESULTS: We screened 3428 abstracts and titles and reviewed 345 full text articles for eligibility. Ultimately, 102 studies were analyzed, comprising 680,823 patients with AA and 72,011,041 healthy controls. Almost all included studies (100 of 102 studies) were of satisfactory to high quality (Newcastle-Ottawa scale score ≥ 4). Among patients with AA, comorbidities with the highest odds ratios (OR) compared with healthy controls and data available from more than one study included vitamin D deficiency (OR 10.13, 95% CI 4.24-24.20), systemic lupus erythematous (OR 5.53, 95% CI 3.31-9.23), vitiligo (OR 5.30, 95% CI 1.86-15.10), metabolic syndrome (OR 5.03, 95% CI 4.18-6.06), and Hashimoto's thyroiditis (OR 4.31, 95% CI 2.51-7.40). AA may be a protective factor for certain disorders, for which the AA group had lower odds compared with healthy controls, such as irritable bowel syndrome (OR 0.38, 95% CI 0.14-0.99) and colorectal cancer (OR 0.61, 95% CI 0.42-0.89). CONCLUSION: These findings corroborate and contextualize the risks across comorbidities for patients with AA. Further work should be done to identify the underlying pathophysiology and understand appropriate screening criteria.

Skin phototype of participants in laser and light treatments of cosmetic dermatologic conditions: A systematic review.

BACKGROUND: In cosmetic dermatology, lasers and lights treat a variety of hair and skin conditions, including some that disproportionately affect people of color. AIMS: Our systematic review aims to understand the representation of participants with skin phototypes 4-6 in cosmetic dermatologic trials studying laser and light devices. METHODS: A systematic literature search was conducted using search terms "laser," "light," and multiple laser and light subtypes in the PubMed and Web of Science databases. All randomized controlled trials (RCTs) published between January 1, 2010 and October 14, 2021 that studied laser or light devices for cosmetic dermatologic conditions were eligible for inclusion. RESULTS: Our systematic review included 461 RCTs representing 14 763 participants. Of 345 studies that reported skin phototype, 81.7% (n = 282) included participants of skin phototypes 4-6, but only 27.5% (n = 95) included participants of skin phototypes 5 or 6. This trend of excluding darker skin phototypes persisted when results were stratified by condition, laser of study, study location, journal type, and funding source. CONCLUSIONS: Trials studying lasers and lights for the treatment of cosmetic dermatologic conditions need better representation of skin phototypes 5 and 6.

Clinical Application of Artificial Intelligence for Non-melanoma Skin Cancer.

OPINION STATEMENT: The development and implementation of artificial intelligence is beginning to impact the care of dermatology patients. Although the clinical application of AI in dermatology to date has largely focused on melanoma, the prevalence of non-melanoma skin cancers, including basal cell and squamous cell cancers, is a critical application for this technology. The need for a timely diagnosis and treatment of skin cancers makes finding more time efficient diagnostic methods a top priority, and AI may help improve dermatologists' performance and facilitate care in the absence of dermatology expertise. Beyond diagnosis, for more severe cases, AI may help in predicting therapeutic response and replacing or reinforcing input from multidisciplinary teams. AI may also help in designing novel therapeutics. Despite this potential, enthusiasm in AI must be tempered by realistic expectations regarding performance. AI can only perform as well as the information that is used to train it, and development and implementation of new guidelines to improve transparency around training and performance of algorithms is key for promoting confidence in new systems. Special emphasis should be placed on the role of dermatologists in curating high-quality datasets that reflect a range of skin tones, diagnoses, and clinical scenarios. For ultimate success, dermatologists must not be wary of AI as a potential replacement for their expertise, but as a new tool to complement their diagnostic acumen and extend patient care.

Physician values in alopecia areata treatment decision-making: A qualitative assessment.

Background: Alopecia areata (AA) is a disease of hair loss with multiple treatment options. Physicians play an important role in guiding patients during the decision-making process. Objective: Assess physicians' values and attitudes when helping patients choose an AA treatment. Methods: Semi-structured qualitative interviews were conducted with dermatologists of varying practice type and location. Each interview was coded independently twice using inductive thematic analysis. Interrater reliability and code frequencies were determined. Results: Fourteen participants were interviewed. Interrater reliability was κ = 0.85 to 0.97. Dermatologists wanted patients to consider various treatment factors (ie, efficacy, safety, convenience of use, accessibility) and also assessed patients' AA clinical severity and personality traits. Participants often encountered various barriers to effective communication with patients, which may be mitigated by shared decision-making. Shared decision-making tools were perceived to potentially improve patient care and communication, although physicians expressed concern about lack of individualization, limitations of time, and the appropriateness of information. Conclusion: AA treatment decision-making is a complex process that often utilizes the expertise of a dermatologist, during which shared decision-making tools may be of value to both patients and physicians.

Factors influencing alopecia areata treatment decisions: A qualitative assessment.

Background: Alopecia areata (AA) is a disease of hair loss in which patients may benefit from comprehensive understanding of AA's disease process and therapeutic options during treatment decision-making. Objective: Determine factors influencing patients' AA treatment decision-making. Methods: Qualitative interviews were conducted using semi-structured interview guides. Interviews were coded using inductive thematic analysis. Results: Twenty-one participants with AA were interviewed. Coding interrater reliability was κ = 0.87-0.91, indicating strong-almost perfect agreement. Participants faced multiple barriers, including lack of access to health care (n = 10, 47.6%) and lack of transparency about their condition and treatment options (n = 9, 42.9%). Information about AA was sought from primarily the internet (n = 15, 71.4%) and physician recommendation (n = 15, 71.4%). When choosing AA treatments, patients often considered treatment efficacy (n = 21, 100%), safety (n = 21, 100%), and convenience of use (n = 20, 95.2%). Limitations: Referral and regional biases may be present and limit generalizability. Conclusions: Patients with AA face various challenges including medical uncertainty and lack of information. Patients need trustworthy and accessible sources of information regarding their treatment that also take into consideration their preferences and values.

Treatment of Acne Vulgaris During Pregnancy and Lactation: A Narrative Review.

Acne vulgaris frequently affects women during pregnancy and lactation. Hormonal and physiologic changes in pregnancy contribute to the pathogenesis of acne during the various phases of pregnancy. Several effective acne treatments commonly prescribed in the general population are contraindicated during pregnancy or lactation. There is a lack of guidelines and updated resources on acne management in these populations. In this narrative review, we summarize existing evidence on the safety and efficacy of acne treatments during pregnancy and breastfeeding. Acne management in pregnancy and lactation should follow a stepwise approach based on severity to minimize risk. Topical therapies, such as benzoyl peroxide, azelaic acid, or keratolytics, can be used to treat mild-to-moderate disease. Moderate-to-severe acne may require systemic treatments, including penicillin, amoxicillin, cephalexin, and erythromycin, with special consideration for trimester-specific teratogenicity of medications and relevant medical history of the mother and infant. For refractory cases, oral or intralesional corticosteroids as well as laser and light therapies may be considered. This review provides an updated reference to aid patient-physician decision-making on acne management in these special populations.

The utility of augmented teledermatology to improve dermatologist diagnosis of cellulitis: a cross-sectional study.

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1 month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84 ± 4% with the history and physical to 89 ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76 ± 6% to 88 ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

Complementary and alternative medicine for alopecia areata: A systematic review.

BACKGROUND: Despite high use of complementary and alternative medicine (CAM) for alopecia areata (AA), efficacy and safety remain unclear. OBJECTIVE: To identify all CAM therapies studied for treatment of AA. Outcomes of interest included disease course and psychologic well-being. METHODS: PubMed and Embase were searched to identify English articles containing original data investigating CAM in individuals with AA from 1950-2018. Quality was assessed with Oxford Centre for Evidence Based Medicine criteria. RESULTS: Of 1015 initial citations, 16 articles met inclusion criteria: 5 randomized controlled trials, 5 prospective controlled cohorts, 4 prospective noncontrolled cohorts, 1 retrospective cohort, and 1 case series. CAM therapies with best evidence and efficacy for hair growth in AA include essential oil aromatherapy, topical garlic, and oral glucosides of peony with compound glycyrrhizin. Hypnosis and mindfulness psychotherapy represent low-quality evidence for improvement of psychologic and quality of life outcomes. Adverse events were rare and mild for all therapies evaluated. LIMITATIONS: Inconsistent or poorly reported study methodology and nonstandardized outcomes limit the conclusions that can be made from these studies. CONCLUSIONS: This work serves to inform physician treatment of patients with AA seeking CAM while encouraging further investigation into these therapies to address some of the therapeutic challenges of AA.

Evaluation of Stigma Toward Individuals With Alopecia.

Importance: Perceived stigma among patients with alopecia is associated with impaired quality of life; however, the magnitude of laypersons' stigma toward individuals with alopecia is unknown. Objective: To determine the prevalence and magnitude of laypersons' stigma toward individuals with varying degrees of alopecia and whether stigma increases with increased severity of alopecia. Design, Setting, and Participants: This was a cross-sectional study using an internet survey administered to a convenience sample of adult respondents in the US participating on the Amazon Mechanical Turk platform. Portrait images of 6 individuals without hair loss were created using artificial intelligence and stock images. Each portrait was edited to create 2 additional versions, 1 with scalp hair loss and 1 with complete hair loss, for a total of 18 images. On January 9 to 10, 2020, the survey presented each internet respondent with 1 randomly selected portrait to be used in answering a series of stigma-related questions from 3 domains: stereotypes, social distance, and disease-related myths; the third domain was presented only to respondents who believed that the individual pictured had a medical condition. Main Outcomes and Measures: The main outcome was the prevalence and magnitude of stigma of laypersons toward individuals with alopecia and the percentage of laypersons who believed the individual pictured had a medical condition as recorded in survey responses. Results: The survey was completed by 2015 respondents (99.9% completion rate) with a mean age of 37 (range, 18-78) years; 1014 (50.3%) were men; 1596 (79.2%) were White; and 1397 (69.3%) had a college or postcollege education. Endorsement of every stigma item increased as alopecia severity increased (2.4%-27.6%). Absolute change on the stereotype (0.5-0.6) and social distance scales (0.2-0.5) also increased, indicating more stigma. The percentage of respondents believing the individual pictured had a medical condition increased as alopecia severity increased (33.6%-75.7%; P < .001). Among the subgroup of respondents who were asked to rate their agreement with disease-related myths, the absolute change on the myth scale decreased as alopecia severity increased, indicating decreased stigma (-0.7 to -1.2). Conclusions and Relevance: This cross-sectional survey study found that stigmatizing attitudes of laypersons toward patients with alopecia exist across a multitude of social and professional scenarios. Stigma prevalence and magnitude vary by alopecia severity and possibly by whether alopecia is believed to be a medical condition.