Comparing demographic characteristics and adverse event rates at two dermatologic surgery practices.

BACKGROUND: Patient demographics and operative techniques may contribute to adverse events after surgeries. OBJECTIVE: To identify differences in adverse event rates between different dermatologic surgery centers and potential contributing features affecting these rates. METHODS: Data regarding demographics, procedure type, and adverse events were collected at two dermatologic surgery centers. RESULTS: The most common adverse event at both sites was infection: 2.1% at site 1 versus 0.5% at site 2 (p < .001). Using multivariate logistic regression, procedure type (Mohs surgery), geographic location (being at site 1), older age, and anatomic location of surgery were associated with a higher risk of infection. CONCLUSION: Adverse event rate appears to correlate with patient demographics, procedure type, and setting of surgery more than use of prophylactic antibiotics. Identification of differences in adverse event rates and potential contributing variables at different practices may allow for identification of opportunities to prevent adverse events.

Subcutaneous sarcoidosis without systemic involvement.

Subcutaneous sarcoidosis is a rare variant of cutaneous sarcoidosis, which typically presents as single or multiple, indurated, ill-defined plaques, typically on the upper extremities. Granulomas consisting of macrophages with multinucleated giant cells and sparse lymphocytic inflammation are confined to the subcutaneous tissue, rather than to their usual location within the dermis in typical lesions of cutaneous sarcoidosis. An association between subcutaneous sarcoidosis and systemic involvement has been reported, although response to treatment and prognosis remain good. We report a case of a middle-aged woman with subcutaneous sarcoidosis, with negative work-up for systemic involvement of sarcoidosis. Interestingly, family history was significant for a son who died from complications of pulmonary sarcoidosis. The patient was successfully treated with a tapering course of oral prednisone in combination with hydroxychloroquine.

Are topical keratolytic agents needed in the treatment of scalp psoriasis?

BACKGROUND: Topical corticosteroids are the primary treatment for scalp psoriasis. Keratolytic agents are promoted as adjunctive treatments. However, complex treatment regimens may result in poor adherence and outcomes. OBJECTIVE: To evaluate the evidence for the need for use of topical keratolytic agents as opposed to topical corticosteroid monotherapy in the treatment of scalp psoriasis. METHODS: A review of the literature was performed seeking clinical trials using topical keratolytics, topical corticosteroids or the combination for treatment of scalp psoriasis. RESULTS: Complete clearance of scalp psoriasis can be achieved in 10-78% of patients using topical corticosteroids alone, in 3% of patients using topical keratolytics alone, and in up to 84% using a combination of topical keratolytics and topical steroids. Clinical trials comparing the combination of keratolytics and topical corticosteroids versus topical corticosteroids alone found marginally more efficacy using combination regimens. LIMITATIONS: We could not find any long term study evaluating the efficacy of combination therapy in scalp psoriasis and its effect on the patients' adherence. CONCLUSION: High potency topical corticosteroids are usually effective in treating scalp psoriasis in clinical trials. Poor efficacy in clinical practice may be owing to poor adherence to the treatment regimen. Using a keratolytic agent in conjunction with a topical corticosteroid may provide marginal additional benefit in clinical trials, but that benefit is likely outweighed by the downside of complicating treatment and reducing adherence in the clinical setting, unless a single product containing both medications were used.

Measure of atopic dermatitis disease severity using actigraphy.

BACKGROUND: Analyzing adherence to treatment and outcomes in atopic dermatitis is limited by methods to assess continual disease severity. Atopic dermatitis significantly impacts sleep quality, and monitoring sleep through actigraphy may capture disease burden. PURPOSE: To assess if actigraphy monitors provide continuous measures of atopic dermatitis disease severity and to preliminarily evaluate the impact of a short-course, high-potency topical corticosteroid regimen on sleep quality. METHODS: Ten patients with mild to moderate atopic dermatitis applied topical fluocinonide 0.1% cream twice daily for 5 days. Sleep data were captured over 14 days using wrist actigraphy monitors. Investigator Global Assessment (IGA) and secondary measures of disease severity were recorded. Changes in quantity of in-bed time sleep were estimated with random effects models. RESULTS: The mean daily in-bed time, total sleep time, and wake after sleep onset (WASO) were 543.7 minutes (SEM 9.4), 466.0 minutes (SEM 7.7), and 75.0 minutes (SEM 3.4), respectively. WASO, a marker of disrupted sleep, correlated with baseline (ρ  =  .75) and end of treatment IGA (ρ  =  .70). Most patients did not have marked changes in sleep. IGA scores declined by a median change of 1 point at days 7 (p  =  .02) and 14 (p  =  .008). CONCLUSIONS: Using actigraphy, atopic dermatitis disease severity positively correlated with sleep disturbances. Actigraphy monitors were well tolerated by this cohort of atopic dermatitis subjects.

Recruiting underserved mothers to medical research: findings from North Carolina.

Representative samples are required for ethical, valid, and useful health research. Yet, recruiting participants, especially from historically underserved communities, can be challenging. This paper presents findings from in-depth interviews with 40 mothers about factors that might influence their willingness to participate or allow their children to participate in medical research. Saliency analysis organizes the findings. Frequent and important salient themes about research participation included concerns that it might cause participants harm, hope that participants might gain a health benefit, and recognition that time and transportation resources could limit participation. Ultimately, we propose that a theoretical model, such as the Theory of Planned Behavior (TPB), will facilitate more systematic evaluation of effective methods for recruitment and retention of participants in medical research. Future research should explore the utility of such a model for development of effective recruitment and retention strategies.

Adherence to a five day treatment course of topical fluocinonide 0.1% cream in atopic dermatitis.

BACKGROUND: Adherence in the treatment of chronic inflammatory skin diseases such as atopic dermatitis is poor. Methods to improve adherence have proven difficult. PURPOSE: To determine whether a short course of treatment with a high-potency corticosteroid will improve adherence compared to longer treatment studies and if improvement in disease and itch continues after treatment. METHODS: 10 patients with mild to moderate atopic dermatitis were instructed to apply fluocinonide 0.1% cream twice daily for 5 days. Adherence was self-reported and electronically monitored. Treatment outcomes were assessed in terms of Visual Analog Scale of Itch (VAS), Eczema Area and Severity Index (EASI), and Investigator Global Assessment (IGA) scores. RESULTS: The median adherence rate was 40% (range of 0-100). The median percent change in VAS from baseline measures on days 7 and 14 were 90% (range -13, 100, p=0.02) and 52% (range 0, 100, p=0.004). On days 7 and 14, 20% and 70% patients achieved an EASI-75 and 40% and 60% an IGA of 0 or 1. LIMITATIONS: Small sample size limited subgroup analyses. CONCLUSIONS: Adherence rates with short-term treatment were similar to previously reported rates in longer term treatment studies. However, even non-adherent patients had significant improvement in itch and disease severity.

Quantifying and characterizing adverse events in dermatologic surgery.

BACKGROUND: Although office-based dermatologic procedures are generally considered safe, there is a lack of prospective data on the rate of adverse events (AEs) associated with these procedures. OBJECTIVE: To determine the frequency of AEs after dermatologic surgery and to characterize the most commonly encountered AEs. METHODS: A web-based interface was designed to track AEs with the input of four dermatologic surgeons. Patient demographic and operative data were collected at the time of the dermatologic surgery procedure. AEs occurring at any time during the data collection period were logged according to an a priori categorization scheme. RESULTS: The AE rate was 2.0% in this series of 2,418 subjects undergoing dermatologic surgery from February 1 through December 14, 2010. The most commonly reported AEs were suspicion of infection (64%), postoperative hemorrhage (20%), and wound dehiscence (8%). Suspicion of infection was slightly less frequent in subjects who received prophylactic preoperative antibiotics (0.4%) than in those who did not (1.5%, p = .07). There were no serious AEs and no deaths. CONCLUSION: AEs are uncommon after office-based dermatologic surgery procedures. Preoperative antibiotics may further decrease the infection rate after dermatologic surgery, but the risks and benefits must be weighed given the already low AE rate.

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.

Cardiac manifestations of cutaneous disorders.

A number of cutaneous disorders encountered by the dermatologist have overlapping cardiac pathology. In recent years, many genetic linkages common to pathological processes in the cutaneous and cardiovascular systems have been identified. This review will describe primary cutaneous disorders with potential cardiac manifestations, including congenital syndromes, inherited cutaneous disorders associated with later cardiovascular disease, and syndromes associated with early cardiovascular pathology. The dermatologist may be the first to diagnose cutaneous findings associated with underlying cardiovascular disease; therefore, it is of prime importance for the dermatologist to be aware of these associations and to direct the appropriate workup.

Comparing the lifetime risks of TNF-alpha inhibitor use to common benchmarks of risk.

OBJECTIVE: The study aims to illustrate the range of lifetime risks of lymphoma, tuberculosis (TB), and demyelinating diseases with TNF-α inhibitors in psoriasis patients. METHODS: Previously published data and online resources were used to determine the risk of the TB, demyelinating disease, and lymphoma with and without TNF-α inhibitor treatment. Lifetime risks for heart disease and stroke were collected using a Medline search. All cancer, trauma, and environmental statistics were obtained from the data published by National Cancer Institute, National Safety Council, and the National Oceanic and Atmospheric Administration, respectively. RESULTS: The lifetime risks of TNF-α-inhibitor-linked conditions and comparators are as follows: TNF-α inhibitor-linked conditions: lymphoma with: without TNF-α inhibitors (0.5-4.8%:2.3%), TB with:without TNF-α inhibitors (0-17.1%:0.3%), and demyelinating disease with:without TNF-α inhibitors (0.1-1.7%:0.15%). Comparators: cancer (40.4%), heart disease (36.2%), stroke (18.4%), accidental death (3.0%), motor vehicle death (1.2%), and lightning strike (0.033%). LIMITATIONS: Much of the data on lifetime risks of disease with TNF-α inhibitor were for patients with rheumatoid arthritis and not psoriasis. CONCLUSIONS: The risks of lymphoma, demyelinating diseases, and tuberculosis with TNF-α inhibitors are lower than risks patients face on a regular basis. Screening reduces the risk of tuberculosis in patients receiving TNF-α inhibitors.

Comparative efficacy of biologics in psoriasis: a review.

BACKGROUND: Psoriasis is a chronic, immune-mediated skin disease that also has systemic manifestations. Safe and effective long-term treatments are needed. Biologic treatments that inhibit the immunopathogenesis of psoriasis have helped meet this need. PURPOSE: The purpose of this study was to compare the efficacy of biologic therapies used for psoriasis. METHODS: A literature search was performed using PubMed and the keywords '(PASI-75 OR efficacy) AND psoriasis AND (adalimumab OR alefacept OR etanercept OR infliximab OR ustekinumab).' Randomized, double-blind, and placebo-controlled studies on US FDA-approved biologics were selected. Studies assessing the proportion of subjects achieving 75% improvement in Psoriasis Area and Severity Index (PASI-75) within a 12-week period were included. Studies on pediatric populations and psoriatic arthritis were excluded. The weighted average of PASI-75 for each reported regimen was calculated to determine the efficacy of biologic agents used for moderate-to-severe psoriasis. Tolerance and secondary efficacy measures were also examined for the selected studies. RESULTS: FDA-approved regimens of adalimumab, infliximab, ustekinumab, and alefacept were effective in treating moderate-to-severe psoriasis. Weighted average PASI-75 scores for infliximab, ustekinumab, adalimumab, etanercept, and alefacept were 78.6%, 72.1%, 70.5%, 48.1%, and 21%, respectively. LIMITATIONS: The comparative efficacy of biologic agents data was limited to 12 weeks, thus generalizing the results to longer treatment periods may not be accurate. CONCLUSIONS: Various biologic agents for psoriasis were effective at 12 weeks in placebo-controlled trials. Available data cannot fully account for situations in clinical practice, in which combination and longer duration of therapy may be required. When choosing the most effective or best agent, multiple factors should be considered including patient preference, cost, tolerance, adverse effects, dosing schedule, and mode of administration.

Acitretin in dermatology: a review.

INTRODUCTION: Acitretin is a systemic retinoid drug used in the treatment of severe psoriasis. It has also been used for a spectrum of other difficult-to-treat dermatoses, including hyperkeratotic and inflammatory dermatoses and non-melanoma skin cancers. Here we review the available data regarding both FDA-approved and off-label uses of acitretin, clinically relevant adverse events, precautions and monitoring. METHODS: A PubMed literature search was conducted utilizing the search term "acitretin," which yielded 714 hits. Results were further limited to English language clinical trials in human subjects. Of 78 articles evaluated for relevance, 60 were included for review. RESULTS: Acitretin is effective as monotherapy and in multidrug therapeutic regimens for the treatment of psoriasis and other hyperkeratotic and inflammatory disorders, as well as for malignancy chemoprevention. Its use is limited by its teratogenic potential and other adverse effects, including mucocutaneous effects and hepatotoxicity. Potential adverse effects may be reduced or avoided by using lower doses of acitretin or in combination with other therapies. LIMITATIONS: The reviewed studies include many small trials and case reports of the use of acitretin for psoriasis. Studies of acitretin therapy for the treatment of other cutaneous disorders are limited. CONCLUSION: Acitretin is a beneficial treatment for psoriasis, and should be considered when not contraindicated. Particularly when used in combination with ultraviolet (UV) phototherapy, is a safe and cost effective therapeutic strategy.

Differences in itch characteristics between psoriasis and atopic dermatitis patients: results of a web-based questionnaire.

Differences in itch characteristics between different inflammatory dermatoses are not well described. The aim of this study was to assess differences in itch characteristics between patients with psoriasis and atopic dermatitis using a previously validated web-based questionnaire that was made available through the National Psoriasis Foundation and National Eczema Association for Science and Education websites. Participants rated frequency and intensity of itch, associated symptoms, itch descriptors, and effect of scratching. A total of 524 subjects with atopic dermatitis and 195 subjects with psoriasis completed the survey. Atopic dermatitis responders experienced more frequent and more intense itch. Associated sweating and heat sensation were also more common in atopic dermatitis. Scratching was considered pleasurable in both atopic dermatitis and psoriasis; pleasurability correlated weakly with itch intensity in atopic dermatitis. Psoriasis respondents reported higher embarrassment associated with itch. Itch sensation is experienced differently among patients with atopic dermatitis and psoriasis. Future therapeutic interventions may be developed to target these differences.

Recruiting underserved populations to dermatologic research: a systematic review.

Recruitment of participants to dermatologic research studies can be challenging, particularly with historically underserved populations. Recruitment of these groups is essential to ethical, valid, and useful dermatologic research. This article discusses findings from a review of 78 studies that examined factors influencing participation in health research studies with an emphasis on underserved populations, particularly women and ethnic minorities. The most commonly encountered barriers to research participation are mistrust of research, lack of access to research programs, and culturally incompetent research design. Motives to participate in research include receipt of benefit from participation, perceived opportunities to help others, and culturally competent research design. Practical methods for addressing barriers and enhancing research participation include culturally competent research design, community-based recruitment, and easily understandable informed consent. These factors should be considered when recruiting subjects for dermatologic research, especially when recruitment of underserved populations is desired. In addition, the literature demonstrates a paucity of research among rural residents, infants, and children, as well as within clinical dermatologic research.

Acne in adolescents: quality of life, self-esteem, mood, and psychological disorders.

INTRODUCTION: Acne is a significant adolescent problem and may precipitate emotional and psychological effects. The impact of acne on psychological parameters and implications for acne treatment are not fully understood. METHODS: We performed a MEDLINE search using the terms "acne" and "adolescent" along with "psychological," "depression," or "psychiatric," which yielded 16 reviewed studies. RESULTS: Qualitative review of the selected articles revealed that the presence of acne has a significant impact on self-esteem and quality of life. Depression and other psychological disorders are more prevalent in acne patients and acne treatment may improve symptoms of these disorders. LIMITATIONS: The reviewed studies were semi-quantitative analyses utilizing various standardized surveys or questionnaires. Therefore, quantitative analysis of selected studies was not possible. CONCLUSION: The presence of co-morbid psychological disorders should be considered in the treatment of acne patients and future prospective trials are needed to assess the impact of treatment on psychological outcomes.

Medication adherence among acne patients: a review.

BACKGROUND: Acne is a chronic disease often requiring the use of medications for extended periods of time. In general, adherence decreases over time in patients with chronic diseases, and adherence to topical medications is poor compared to adherence to oral medications, placing individuals using topical medications at increased risk for nonadherence and treatment failure. Poor adherence may also be a common cause of treatment failure in teens with acne. PURPOSE: We reviewed the current literature on medication adherence in teenagers with acne to assess adherence levels and predictors of adherence. We hope to provide a foundation for further research into medication adherence in acne patients. METHODS: A Medline search was conducted using the key words "acne" and "adherence" or "compliance." Studies reporting adherence were included in the analysis. RESULTS: A positive correlation was found between quality of life of patients with acne and medication adherence. Weaker predictors of adherence include increased age, female gender, and employment. The most commonly reported reason for nonadherence was inadequate time to use the treatment medication. Patients taking medications requiring less frequent dosing had better adherence, and medication adherence correlated with better health status among acne patients. A longer duration between office visits may be associated with decreased compliance. Limitations Few studies investigating the prevalence and causes of nonadherence in acne patients were identified. CONCLUSIONS: Adherence to medications is difficult to measure and rates reported by patients often overestimate actual adherence. Patients cite lack of time as a common reason for nonadherence to topical medications.

Assessing adherence to dermatology treatments: a review of self-report and electronic measures.

BACKGROUND: Nonadherence to prescribed medications is a common problem in dermatology, and assessing adherence can be difficult. Electronic monitors are not always practical, but self-report measures may be less reliable. PURPOSE: To review the literature for self-report instruments and electronic monitors used to measure medication adherence in patients with chronic disease. METHODS: A PubMed literature search was conducted using the terms 'scale,''measure,''self-report,''electronic,' and 'medication adherence.' Relevant articles were reviewed and selected if they addressed self-report or electronic measures of adherence in chronic disease. RESULTS: Eleven self-report instruments for the measurement of adherence were identified. Four were validated using electronic monitors. All produced an estimate of adherence that correlated with actual behavior, although this correlation was not strong for any of the measures. None of the scales was tested in patients who had dermatologic disease and/or used topical medications. Several electronic monitoring systems were identified, including pill counts, pharmacy refill logs, and the Medication Event Monitoring System (MEMS). Validity was higher among electronic monitoring systems compared with self-report measures. CONCLUSION: While several self-report measures of adherence have been validated in chronic disease populations, their relevance in dermatology patients has not been studied. A dermatology-specific instrument for the measurement of adherence would contribute to improved outcomes; until such a tool exists, researchers and clinicians should consider nonadherence as a possible factor in skin disease that is not responsive to treatment. Electronic monitoring provides the most reliable means of measuring adherence, and may provide additional clues to identify barriers to adherence.