Dermatology workforce projections in the United States, 2021 to 2036.

BACKGROUND: There has been a growing imbalance between supply of dermatologists and demand for dermatologic care. To best address physician shortages, it is important to delineate supply and demand patterns in the dermatologic workforce. The goal of this study was to explore dermatology supply and demand over time. METHODS: We conducted a cross-sectional analysis of workforce supply and demand projections for dermatologists from 2021 to 2036 using data from the Health Workforce Simulation Model from the National Center for Health Workforce Analysis. Estimates for total workforce supply and demand were summarized in aggregate and stratified by rurality. Scenarios with status quo demand and improved access were considered. RESULTS: Projected total supply showed a 12.45% increase by 2036. Total demand increased 12.70% by 2036 in the status quo scenario. In the improved access scenario, total supply was inadequate for total demand in any year, lagging by 28% in 2036. Metropolitan areas demonstrated a relative supply surplus up to 2036; nonmetropolitan areas had at least a 157% excess in demand throughout the study period. In 2021 adequacy was 108% and 39% adequacy for metropolitan and nonmetropolitan areas, respectively; these differences were projected to continue through 2036. CONCLUSIONS: The findings suggest that the dermatology physician workforce is inadequate to meet the demand for dermatologic services in nonmetropolitan areas. Furthermore, improved access to dermatologic care would bolster demand and especially exacerbate workforce inadequacy in nonmetropolitan areas. Continued efforts are needed to address health inequities and ensure access to quality dermatologic care for all.

Dermatologists' Perspectives on Biosimilars.

BACKGROUND: Biosimilars are biologic agents the Food and Drug Administration (FDA) has deemed to have no clinical difference from their reference biologics. In dermatology,  biosimilars are approved for the treatment of psoriasis and hidradenitis suppurativa. Although dermatologists are high prescribers of biologics, they are more reluctant to prescribe biosimilars than other specialists. This survey-based study sought to characterize dermatologists’ current perspectives on biosimilars.  Methods: A 27-question survey was distributed via email to dermatologists between September and October of 2022.  Results: Twenty percent of respondents would not prescribe a biosimilar for an FDA-approved indication. When asked about the greatest barriers to biosimilar adoption, 61% had concerns about biosimilar safety and efficacy, 24% reported uncertainty about state laws for interchangeability and substitutions, and 20% had concerns about biosimilar safety without concerns about efficacy. Thirty-five percent of respondents felt moderately or extremely knowledgeable about biosimilar interchangeability.  Conclusion: Biosimilars are safe and effective for treating approved dermatological conditions and may lower patient costs compared to their reference products. Patients are not always offered biosimilar therapy as an option, which may be due to unfamiliarity among dermatologists.  This survey suggests a need for more research and educational initiatives, such as modules and workshops that focus on biosimilar safety, efficacy, and interchangeability guidelines. J Drugs Dermatol. 2024;23(4):doi:10.36849/JDD.7755.

EDUCATION FROM DERMATOLOGISTS: THE SIMULTANEOUSLY DEVELOPMENT OF 16 KERATINOCYTIC CANCERS AFTER USE OF METFORMIN IN COMBINATION WITH LOSARTAN/ HYDROCHLOROTHIAZIDE, METOPROLOL AND NIFEDIPINE- IMPORTANT LINKS TO DRUG RELATED (PHOTO)-NITROSO-CARCINOGENESIS AND ONCOPHARMACOGENESIS.

Oncopharmacogenesis and Drug-Induced Skin cancer related Nitrosogenesis are newly introduced concepts in the medical literature that owe their genesis or presence to the carcinogens/ mutagens, also known as nitrosamines/NDSRIs, which are present in a heterogeneous class of drugs. The contribution to the origin of these 2 concepts is entirely due to 1) the functions and efficacy of FDA in terms of control and identification of these carcinogens, and 2) the establishment of clinicopathological correlations by the dermatologists, occurring during drug intake. According to recent FDA data, the concentration of NDMA in just one metformin tablet could be up to more than 5-fold increased. The intake of 3 to 6 tablets per day should result in a carcinogen intake that is 15 to 30 times elevated within the day and within the monomedication alone. It is these circumstances that paraphrase/ ˝betonate˝ concepts such as Onco-Pharmacogenesis and Drug-mediated Nitrosogenesis of skin cancer. Although not officially declared, these mutagens are present and have been in forced tolerance mode for the last 30-40 years. And after their intake, multiple cancers have been found to develop. The concomitant use of other nitrosamine-contaminated drugs such as losartan/hydrochlorothiazide, metoprolol and nefidipine should certainly not be surprising when it could also be associated with the development of exactly 16 keratinocytic tumours as in the case presented by us. Recent evidence in medical literature has linked the nitrosamine N-nitrosomorpholine (NMOR) with the direct development of its subsequent mutagenic action in rodents following irradiation with UVA. This fact leaves open the question of the potentially available photocarcinogenic action of the other nitrosamines in humans found in medicinal preparations. This is what necessitates a clarification of the concept of Photo-Nitroso-Carcinogenesis/ Oncogenesis in humans and its relationship to skin cancer. The overlap of the mutational patterns of some of the nitrosamine-induced mutations in target genes such as p53 and RAS oncogenes, with those of UV light-induced mutations - or practically the same ones mentioned above, suggest a possible significant role of the Drug-Induced Photo-Nitroso-Carcinogenesis of keratinocyte cancer in the context of Onco-Pharmacogenesis. Future analyses should focus on elucidating the photocarcinogenic effect of nitrosamines in drug preparations and differentiating Skin cancer Nitrosogenesis from ˝pure˝ Photo-Carcinogenesis and Nitroso-Photo-Carcinogenesis. The localization of the tumors in the area of the UV-exposed sites within the potential/actual contamination of the 4 preparations (simultaneously) in the described patient are indicative of a possible pathogenetic influence in the context of the already mentioned Nitroso-(Photo)carcinogenesis. Polycontamination of polymedication remains a so far unresolvable problem.

Comparison of visual diagnostic accuracy of dermatologists practicing in Germany in patients with light skin and skin of color.

Visual clinical diagnosis of dermatoses in people of color (PoC) is a considerable challenge in daily clinical practice and a potential cause of misdiagnosis in this patient cohort. The study aimed to determine the difference in visual diagnostic skills of dermatologists practicing in Germany in patients with light skin (Ls) and patients with skin of color (SoC) to identify a potential need for further education. From April to June 2023, German dermatologists were invited to complete an online survey with 24 patient photographs depicting 12 skin diseases on both Ls and SoC. The study's primary outcomes were the number of correctly rated photographs and the participants' self-assessed certainty about the suspected visual diagnosis in Ls compared to SoC. The final analysis included surveys from a total of 129 dermatologists (47.8% female, mean age: 39.5 years). Participants were significantly more likely to correctly identify skin diseases by visual diagnostics in patients with Ls than in patients with SoC (72.1% vs. 52.8%, p ≤ 0.001, OR 2.28). Additionally, they expressed higher confidence in their diagnoses for Ls than for SoC (73.9 vs. 61.7, p ≤ 0.001). Therefore, further specialized training seems necessary to improve clinical care of dermatologic patients with SoC.

Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment.

Importance: Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice. Objective: To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Design, Setting, and Participants: This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024. Main Outcomes and Measures: Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Results: Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship. Conclusions and Relevance: The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.

Comparing preferences for skin cancer screening: AI-enabled app vs dermatologist.

BACKGROUND AND AIM: Skin cancer is a major public health issue. While self-examinations and professional screenings are recommended, they are rarely performed. Mobile health (mHealth) apps utilising artificial intelligence (AI) for skin cancer screening offer a potential solution to aid self-examinations; however, their uptake is low. Therefore, the aim of this research was to examine provider and user characteristics influencing people's decisions to seek skin cancer screening performed by a mHealth app or a dermatologist. METHODS: Two forced-choice conjoint experiments with Nmain = 1591 and Nreplication = 308 participants from the United States were conducted online to investigate preferences for screening providers. In addition to the provider type (mHealth app vs dermatologist), the following provider attributes were manipulated: costs, expertise, privacy policy, and result details. Subsequently, a questionnaire assessed various user characteristics, including demographics, attitudes toward AI technology and medical mistrust. RESULTS: Outcomes were consistent across the two studies. The provider type was the most influential factor, with the dermatologist being selected more often than the mHealth app. Cost, expertise, and privacy policy also significantly impacted decisions. Demographic subgroup analyses showed rather consistent preference trends across various age, gender, and ethnicity groups. Individuals with greater medical mistrust were more inclined to choose the mHealth app. Trust, accuracy, and quality ratings were higher for the dermatologist, whether selected or not. CONCLUSION: Our results offer valuable insights for technology developers, healthcare providers, and policymakers, contributing to unlocking the potential of skin cancer screening apps in bridging healthcare gaps in underserved communities.

Improving access to dermatology specialist care: review of a dermatologist- and general practitioner-integrated clinic model.

Introduction This study presents an innovative model of integrated dermatology service delivery. Kauri HealthCare (KHC) is a general practice serving around 19 000 patients in Palmerston North, New Zealand. A 'mini clinic' is provided by an on-site dermatologist that is available for patients of KHC. Referring practitioners are required to attend with the patient to present their case and seek dermatologist input. This allows for patients to receive a specialist opinion, as well as for the referrer to receive practical and academic teaching, record findings, and arrange any further investigations, follow-up, or management. Aim To describe the nature of patient presentations and clinical outcomes of a novel dermatologist-general practitioner integrated clinic based in a provincial healthcare practice. Methods Descriptive analysis of all referrals to the Kauri HealthCare dermatology mini clinic from April 2017 to December 2022. Results During the study period, 964 diagnoses were recorded across 806 patients booked into the mini clinic. The most common presenting conditions were: (1) eczema; (2) psoriasis; (3) actinic keratoses; (4) naevi; and (5) seborrheic keratosis. Practitioners sought dermatology opinion on the diagnosis and/or management of skin conditions. Further referral to secondary care was not required for 86% of patients. Discussion Improvements could be made to better serve those of Maori and Pacific ethnicity, or living in high socioeconomic deprivation. Results indicate where teaching could be prioritised for practitioners, postgraduates, and medical students. Overall, this is an innovative clinic model, which seeks to provide equitable care, medical education, and collaboration between primary and secondary services.

"Our Hair, Our Strength, Our Identity": Native American reflections and what dermatologists can learn.

Issues of health equity are rightfully in the national spotlight. Here we present a narrative piece on the sacred importance of hair and its ties to cultural identity among many Native communities in the United States. We introduce unique values ascribed to hair in some Native cultures, and include examples of how hair has played an important role in both abuse and generational trauma for many individuals and families. By sharing experiences, we hope to illuminate perspectives often underrepresented, and to enable more culturally humble, responsive, and informed dermatologic care.

Monkeypox: What the Dermatologist Needs to Know.

Monkeypox, an endemic disease in some African countries, has provoked public health activeness on a global scale that even the World Health Organization (WHO), invoking international health regulations, declared it a public health emergency of international concern (PHEIC). The WHO called attention of member states to exert maximum surveillance over the disease, its patients, and contact persons in order to standardize control measures. A need was directed to provide complete knowledge about the disease, allowing the administration of prior diagnoses as well as isolation and more effective epidemiologic control measures. An updated review on monkeypox emphasized upon having the fundamental aspects of the lesions caused by the disease, and appropriate management of patients upon clinical and epidemiologic evaluation.

[Translated article] Approach to the Epidemiology, Disease Management, and Current Challenges in the Management of Generalized Pustular Psoriasis Through a Survey Conducted Among Spanish Dermatologists.

BACKGROUND: Generalized pustular psoriasis (GPP) is a rare and severe inflammatory skin disease characterised by recurrent or intermittent flares. Epidemiological and disease management data in Spain are limited. Our goal was to estimate the epidemiology of GPP, explore its management, and reach consensus on the current challenges faced in Spain. METHODS: An electronic survey was submitted to dermatologists from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group. This group is experienced in the management of GPP. It included a Delphi consensus to establish the current challenges. RESULTS: A total of 33 dermatologists responded to the survey. A 5-year prevalence and incidence of 13.05 and 7.01 cases per million inhabitants, respectively, were estimated. According to respondents, the most common GPP symptoms are pustules, erythema, and desquamation, while 45% of patients present > 1 annual flares. A total of 45% of respondents indicated that flares often require a length of stay between 1 and 2 weeks. In the presence of a flare, 67% of respondents often or always prescribe a non-biological systemic treatment as the first-line therapy [cyclosporine (55%); oral retinoid (30%)], and 45% a biological treatment [anti-TNFα (52%); anti-IL-17 (39%)]. The dermatologists agreed that the main challenges are to define and establish specific therapeutic goals to treat the disease including the patients' perspective on the management of the disease. CONCLUSION: Our study describes the current situation on the management of GPP in Spain, increasing the present knowledge on the disease, and highlighting the current challenges faced at the moment.

Topical steroid withdrawal: a survey of UK dermatologists' attitudes.

The term topical steroid withdrawal (TSW) refers to a condition widely discussed on social media, but rarely mentioned in the medical literature. It typically involves a patient with chronic eczema who abruptly discontinues topical corticosteroids (TCS) believing they are ineffective and damaging. Symptoms include an acute eruption, worse than the previous eczema, of painful erythema followed by oozing, crusting, desquamation and sometimes prolonged systemic weakness. Patients self-diagnose and often avoid healthcare professionals who dismiss the diagnosis and persist in offering TCS, leaving them unsupported. We analysed 121 responses to a survey of UK dermatologists' attitudes to TSW. Views on aetiology included relapsed eczema, erythroderma and a social construct. A total of 88.4% (107/121) agreed that TSW needs better understanding and more research. Respondents earlier in their careers are more cautious than senior respondents about prescribing TCS long term because of TSW, suggesting a trend that might lead to better understanding, communication and management.

Treatment for central centrifugal cicatricial alopecia-Delphi consensus recommendations.

BACKGROUND: There is no established standard of care for treating central centrifugal cicatricial alopecia (CCCA), and treatment approaches vary widely. OBJECTIVE: To develop consensus statements regarding the use of various pharmacological therapies in treating adults with CCCA. METHODS: We invited 27 dermatologists with expertise in hair and scalp disorders to participate in a 3-round modified Delphi study between January and March 2023. Statements met strong consensus if 75% of respondents agreed or disagreed. Statements met moderate consensus if 55% or more but less than 75% agreed or disagreed. RESULTS: In round 1, 5 of 33 (15.2%) statements met strong consensus, followed by 9 of 28 (32.1%) in round 2. After the final round 3 meeting, strong consensus was reached for 20 of 70 (28.6%) overall statements. Two statements achieved moderate consensus. LIMITATIONS: This study included only English-speaking, US-based dermatologists and did not consider nonpharmacological therapies. CONCLUSION: Despite varying opinions among dermatologists, consensus was reached for several statements to help clinicians manage CCCA. We also highlight areas that lack expert consensus with the goal of advancing research and therapeutic options for CCCA.

Ingrown Toenails: A Survey Among Dermatologists on Current Treatments.

BACKGROUND: To date, there is no formal consensus on how to treat ingrown toenails. Despite the risk of causing irreparable damage to the nail, highly invasive procedures are still common. Less-invasive, matrix-directed techniques with shorter downtime and high cure rates exist, but, perhaps because of a lack of awareness, appear not to have been universally adopted. OBJECTIVE: The authors' study sought to generate data on common practices in the treatment of ingrown toenails. MATERIALS AND METHODS: The authors developed and conducted an online survey to ask dermatologists/dermatosurgeons how they would proceed in 9 different cases of ingrown toenails based on photographs. RESULTS: The authors received 154 replies. Nonsurgical interventions, including advice on nail care/foot baths/ointments/wraps/padding, were always the most frequently chosen option. Removal of the lateral nail plate followed by chemical partial matricectomy (phenolization) was the most or second-most frequently chosen surgical intervention. The answers were highly heterogeneous, and there was no unanimity based on morphology alone. CONCLUSION: Except for a preference for nonsurgical interventions, the authors could not identify any clear treatment standards. The heterogeneity of treatment approaches suggests the need for a guideline.

Management of tinea capitis in infants and children in the United States: A national survey of pediatric dermatologists.

This study aimed to evaluate the current management of tinea capitis in the United States, specifically focusing on patients aged 0-2 months, 2 months to 2 years, and 2 years to 18 years. An online survey, distributed through the Pediatric Dermatology Research Alliance and the Society of Pediatric Dermatology, revealed the following preferences: fluconazole for those under 2 months, griseofulvin for those aged 2 months to 2 years, and terbinafine for those aged 2 years and older. There exists inter-provider variation in tinea capitis treatment regimens within the pediatric dermatology community.

Perceptions and impact of patient reviews: a survey of academic dermatologists.

BACKGROUND: Patient reviews (PRs) have emerged as a method to assess patient experiences with healthcare in order to improve the quality of care. Both institutional and third-party organizations collect quantitative data and comments from these patient surveys, usually accessible to the public for review. Our study examined dermatologists' perceptions of PRs and assessed their impact on dermatologists. METHODS: A survey was sent to the Association of Professors of Dermatology listserv (response rate 30%). RESULTS: Most respondents disagreed with the statements that PRs are good for doctors (63%), good for patients (58%), helpful for doctors (58%), or that high PRs indicate being a good doctor (65%). The majority disagreed that PRs should be available publicly (60%). Respondents agreed that PRs contribute to depersonalization (60%), energy depletion or exhaustion (55%), added stress at work (70%), negativism/cynicism about work (60%), and diminished professional efficacy (29%). Self-identified female respondents were more likely to agree that PRs added stress to work compared to self-identified males (66% vs. 42%, P < 0.05). CONCLUSIONS: Overall, these findings suggest that PRs may negatively impact dermatologists' well-being and perceived stress levels.