Assessing the Impact of Prior Authorizations on Dermatology Residents.

INTRODUCTION: Prior authorizations (PAs) are administrative tasks commonly required by insurers to approve medications or therapies for patients. Dermatology practices frequently employ coordinators to focus on completing PAs, among other solutions. The degree to which this support is offered in academic centers and, importantly, how much time dermatology residents spend on PAs over educational pursuits is largely unknown. The authors sought to identify the impact of PAs on dermatology residents. METHODS: An IRB-approved (#NCR213814) 13-question survey was distributed nationwide to dermatology residents regarding the impact of PAs on aspects of clinical and scholarly activities.  Results: 150 of 1462 dermatology residents, 10.3%, responded to the survey. 70% of responding residents contribute to obtaining PAs. 58.7% indicated that their program employed a PA coordinator; though, of these, 63.6% still relied on residents for PAs. 84% indicated that for the following month they feared the burden of PAs would lead to a lapse in treatment for patients. 72.7% avoided prescribing certain medications due to PAs. 64% indicated the PA burden impedes their ability to perform scholarly activities. 80.7% indicated the PA burden contributed to burnout or decreased morale. CONCLUSION: Our data highlight that dermatology residents are negatively impacted by the burden of PAs, resulting in reduced time to study, research, and best care for their patients. Dermatology residents and patients would benefit from reducing the burden of PAs, especially on residents by reforms or regulations that reduce dermatologic PAs, or by academic institutions removing these responsibilities from residents as best as possible. Drugs Dermatol. 2024;23(6):485-488.    doi:10.36849/JDD.7617.

Rx -to- OTC switch increased access and lowered cost of topical adapalene.

Topical adapalene gel is an effective and well tolerated acne treatment that transitioned from prescription to over-the-counter (OTC) availability in 2016. Historically, prescription to OTC transitions have lowered costs to patients and payers and increased access to medications. This study used sales and prescriber data to assess access to topical retinoid therapies and their costs in the pre- and post- Rx-to-OTC transition. We demonstrate that the prescription to OTC transition of adapalene gel increased access to this medication, while lowering costs to patients and payers, including Medicare patients. These results provide a necessary call to action for future OTC shifts with other high safety profile, well-tolerated medications in ultimate efforts and hopes of cost savings for patients, insurers, and Medicare within our healthcare industry.

Evaluation of a Moisturizing Cream with 20% Urea for Keratosis Pilaris.

BACKGROUND: Keratosis pilaris (KP) is a benign dermatosis consisting of folliculocentric keratotic papules or pustules with surrounding erythema, often on proximal extensor surfaces of extremities. Management strategies for KP largely center on moisturization and exfoliation. Urea, a well-established ingredient in topical skincare, is a component of the natural moisturizing factors with concentration-dependent humectant, emollient, and exfoliative properties.  Given the overlap of urea’s properties and management goals of KP, a 4-week, open-label, noncomparative clinical study was conducted to evaluate a moisturizing cream formulated with 20% urea for use in KP.  Thirty participants aged 18 to 65 years with KP completed this study. After a 5-day washout period, study participants applied a 20% urea cream once daily to areas of KP for 4 weeks. At baseline, 1-week, and 4-week visits, clinical grading of skin texture, adverse event monitoring, and participant satisfaction questionnaires were conducted. After 1 week and 4 weeks of product use, the percent change in skin smoothness/texture from baseline was significant (P≤0.001). Furthermore, after 4 weeks of use, the majority of participants indicated satisfaction with the feel of their skin, as well as improved confidence and decreased embarrassment related to their skin. No significant adverse events were reported. Overall, the results of this study support that 20% urea cream is generally well tolerated and suitable for use in treating KP. J Drugs Dermatol. 2024;23(1):1274-1277.     doi:10.36849/JDD.7806.

Insights from a joint pediatric dermatology-gynecology vulvar clinic: A retrospective study.

BACKGROUND/OBJECTIVES: Pediatric vulvar disease has not been widely explored in the medical literature. Few studies focus on vulvar disease in skin of color. The vulvar disease can be distressing for young patients given the sensitive location, and providers may lack experience in diagnosing and managing vulvar dermatoses. We sought to characterize the conditions seen, diagnostic challenges encountered, and the racial and ethnic factors associated with vulvar diseases in our multidisciplinary pediatric dermatology-gynecology vulvar clinic at Children's National. METHODS: Medical records of 220 patients who presented to our multidisciplinary pediatric dermatology-gynecology clinic were reviewed retrospectively. RESULTS: Lichen sclerosus (LS) (36%, n = 80), inflammatory vulvitis (11%, n = 23), and vitiligo (9%, n = 19) were the three most frequent conditions observed. These conditions were often misdiagnosed as one another. There was a mean delay in diagnosis after symptom onset in LS patients of 16.43 months. CONCLUSIONS: LS, inflammatory vulvitis, and vitiligo are common vulvar diseases among pediatric patients. Accurate diagnosis is important because LS must be treated aggressively to prevent sequelae. Further studies are warranted to help differentiate LS and vitiligo with consideration of skin tone.

Keratosis Pilaris: Treatment Practices of Board-Certified Dermatologists.

Keratosis pilaris (KP) is a chronic disorder of follicular hyperkeratinization and perifollicular erythema with lesions affecting the extensor surfaces of arms, upper legs, and buttocks. While there is some evidence that laser therapies and topical therapies such as lactic acid reduce the follicular papules of KP, support is limited with respect to which topical treatments dermatologists utilize and their perception of efficacy. A 16-question survey was distributed to a random sampling of the ODAC Conference listserv to determine which topical treatments dermatologists utilize the most, the duration of therapy needed with various treatment modalities, and the effectiveness of topical and laser therapy for treating KP. Our study found topical lactic acid is the most used first-line therapy for KP (43.63% of survey respondents), followed by salicylic acid (20.72%). Laser therapy is only utilized by 8.76% of survey respondents, with a lack of insurance coverage and proper equipment limiting its use. KP is often recalcitrant to treatment, and our study demonstrated that over 60% of respondents found recurrence of KP lesions within three months of stopping salicylic acid treatment and OTC moisturizer treatment. The data herein can be used to better utilize the selection of topical and laser therapies for the treatment of KP. J Drugs Dermatol. 2023;22(10):985-989 doi:10.36849/JDD.7534.

Participant Satisfaction of a Community-based Telehealth Clinic for Atopic Dermatitis.

Atopic dermatitis (AD), a chronic, relapsing inflammatory disease that affects more than 30 million children and adults in the US, disproportionally impacts African American (AA) and Hispanic children, with a higher prevalence of severe AD in these populations than in white children.1,2 Visits to urgent care, emergency departments, and hospitalizations for AD in the United States were more common among AA and Hispanic adults, and those with lower socioeconomic status.1,3 In Washington DC, outcomes and access to care among the District's poor and underrepresented minorities lag far behind other groups. Ward 8, for example, which is 89% Black, has the District's highest per capita rate of coronavirus-related deaths - 6 for every 10,000 residents.4 These disparities have been long-lived and pervasive in all areas of medicine, including dermatology.5.

Nano-encapsulated anandamide reduces inflammatory cytokines in vitro and lesion severity in a murine model of cutaneous lupus erythematosus.

Cutaneous lupus erythematosus (CLE) is a heterogeneous autoimmune skin disease which occurs independently and in conjunction with systemic lupus erythematosus. Drug development for CLE is severely lacking. Anandamide (AEA) is a primary endocannabinoid which exhibits immunomodulatory effects through mixed cannabinoid receptor agonism. We evaluated AEA as topical treatment for CLE and assessed benefits of nanoparticle encapsulation (AEA-NP) on cutaneous drug penetration, delivery and biological activity. Compared to untreated controls, AEA-NP decreased IL-6 and MCP-1 in UVB-stimulated keratinocytes (p < 0.05) in vitro. In BALB/c mice, AEA-NP displayed improved cutaneous penetration, extended release and persistence of AEA in the follicular unit extending to the base after 24 h. Utilizing the MRL-lpr lupus murine model, twice weekly treatment of lesions with topical AEA-NP for 10 weeks led to decreased clinical and histologic lesion scores compared to unencapsulated AEA and untreated controls (p < 0.05). Prophylactic application of AEA-NP to commonly involved areas on MRL-lpr mice similarly resulted in decreased clinical and histologic scores when compared to controls (p < 0.05), and reduced C3 and IBA-1 in lesional tissue (p < 0.05). The demonstrated clinical and immunomodulatory effects of treatment with AEA support its potential as therapy for CLE. This work also suggests that encapsulation of AEA improves penetration and treatment efficacy. Future studies will be conducted to assess full therapeutic potential.

Syringotropic Mycosis Fungoides: A Variant of Folliculotropic or a Distinct Subtype of Adnexotropic Mycosis Fungoides?

Mycosis fungoides (MF) is a slowly progressive form of cutaneous T-cell lymphomas (CTCL). MF is classified into 4 subtypes including folliculotropic MF (FMF). Infiltration of both hair follicles and eccrine glands is included in the FMF classification and designated as syringotropic MF (STMF), an exceedingly rare form of CTCL. We report an additional case of STMF. The clinical course of syringotropic CTCL is more benign than FMF, suggesting that despite similar clinical presentations, they are molecularly distinct diseases. Clinical characteristics can help differentiate STMF from FMF. Skin-directed therapies are less effective in STMF than FMF. With distinct clinical characteristics, histopathologic findings, and disease course, syringotropic CTCL should be considered a subtype entity in the spectrum of adnexotropic MF. J Drugs Dermatol. 2022;21(12):1362-1364. doi:10.36849/JDD.6779.

A Survey of Patient Attitudes Towards Topical Minoxidil in the Treatment of Hair Loss.

Hair loss, specifically androgenetic alopecia (AGA), is a common outpatient dermatology complaint. AGA occurs in men and women, results from the effect of dihydrotestosterone miniaturizing scalp follicles, and commonly presents with thinning of the bitemporal, frontal, and vertex scalp.

Supplement Article: The Role of Epidermal Barrier Dysfunction and Cutaneous Microbiome Dysbiosis in the Pathogenesis and Management of Acne Vulgaris and Rosacea.

BACKGROUND: Dysregulation of either the cutaneous microbiome (CM) or epidermal barrier function (EBF) is thought to play an increasingly important role in acne vulgaris (AV) and rosacea pathogenesis. OBJECTIVE: To review the literature regarding epidermal barrier dysfunction (EBD) and cutaneous dysbiosis in AV and rosacea and provide clinical pearls for dermatologists. METHODS: A Medline literature search was performed for relevant literature regarding EBD and dysbiosis and either AV or rosacea. An expert consensus panel was then convened to discuss article merits and distill findings into clinical pearls. RESULTS: Final review included 138 articles. Puberty may alter natural stratum corneum lipid ratios, instigating and/or exacerbating EBD in AV. Patients with severe AV have an abundance of virulent Cutibacterium acnes phylotype IA1. EBD may manifest as classic signs of rosacea and improve with treatment. While several microbial populations are dysregulated in rosacea, the effect from any singular species is unclear. Current AV and rosacea treatment regimens may mitigate inflammation but may also indiscriminately damage CM and EBF. Physiologic moisturizers and cleansers that harness pre-/pro-/postbiotics may have a role in restoring CM, EBF, and potentially improving dermatosis severity. LIMITATIONS: Limited prospective clinical trial data especially regarding over-the-counter (OTC)/non-prescription skincare products. CONCLUSION: Appropriately developed prescription and OTC preparations may selectively influence the microbiome and potentially maintain/restore EBF. By understanding this relationship, dermatologists will be better able to educate patients on the importance of appropriate skin care.J Drugs Dermatol. 2022;21:9(Suppl 2):s5-14.

An Up-to-Date Approach to the Management of Dissecting Cellulitis.

Dissecting cellulitis of the scalp (DCS) also known as perifolliculitis capitis abscedens et suffodiens (PCAS) is a chronic, relapsing, inflammatory dermatosis consisting of edematous sterile pustules and nodules resulting in sinus tracts and scarring alopecia. Although first described as infectious in 1903, DCS is primarily an inflammatory process that can precede a secondary infection; this is similarly true of the other conditions within the follicular occlusion tetrad: hidradenitis suppurativa (HS), acne conglobata, and pilonidal sinus.

Offering an Off-Label Therapeutic Algorithm for Lichen Planus.

Lichen planus (LP) is a poorly characterized, chronic inflammatory dermatosis notable for violaceous to brown/ black polygonal pruritic papules and plaques, often with lacey scale, and reticular white erosions involving mucosal sites.

mTOR Inhibitor-Induced Transient Acantholytic Dermatitis.

A 61-year-old Caucasian male with a medical history of metastatic carcinoid presented to dermatology with a new onset severely pruritic “breakouts” on the arms, neck, and chest. Approximately ten years prior, he was diagnosed with a small bowel carcinoid tumor and liver metastases treated with a combination of resection and ablation.

A Giant Cutaneous Horn: One of the Largest Recorded

We present a case of one of the largest cutaneous horns recorded in the known literature as an opportunity to explore diagnostic considerations and treatment options. Cutaneous horns are common exophytic neoplasms composed of dense keratin that are always secondary to primary lesions, which can be benign or malignant. Due to the variance of the primary lesion, diagnostic biopsies are necessary to rule out a malignant origin. Several case reports of giant cutaneous horns may suggest that a larger size indicates a verrucous origin, although a biopsy is necessary as this association has only been noted in very few cases. If the primary lesion is found to be malignant and extending to the biopsy margins, further treatment is required, whereas a benign origin usually requires no further treatment. J Drugs Dermatol. 2019;18(7):697-698.