A Single-Institution Cohort Study With Nevi of Special Site: Recurrence, Progression to Melanoma, and Patterns of Management.

ABSTRACT: Nevi of specialized sites (NOSS) occur on the scalp, ears, flexural, acral, and genital areas and display atypical clinical and histologic features. We assessed NOSS recurrence and progression to melanoma, management patterns, and associations between histologic features and treatment recommendations. We queried all histologic diagnoses of NOSS (n = 275) from 2012 to 2017 from a large U.S. academic medical center with reference dermatopathology laboratory and matched these to clinical records. A blinded panel of dermatopathologists re-evaluated lesions, catalogued histologic findings, and gave management recommendation. Associations with dermatopathologist decision and concordance between new and original recommendations were assessed. Of 117 cases with follow-up, 2 locally recurred (1.46%) and none eventuated in melanoma. Clinical features were not associated with original treatment recommendations. After histopathologic review, large melanocytes [odds ratio ratio (ORR) = 8.00, 95% CI, 1.35-47.4] and junctional mitotic figures (ORR = 65.0, 6.5-650) predicted excision recommendation. Likewise, accumulation of many (>9) high-risk features was associated with excision recommendation. Panel review changed treatment recommendation in 27% of cases. Fair concordance existed between original and panel recommendations (κ = 0.29, 0.15-0.44). The low rate of recurrence and lack of melanoma occurrence suggest that despite an atypical clinical and histopathologic appearance, these nevi have limited potential for malignant transformation. Histopathologic findings seem to be principal drivers behind the recommendation for excision in this analysis. Variability existed in treatment recommendations; the panel's consensus recommendation tended to downgrade treatment. This highlights the importance of further outcomes-based studies to identify true high-risk features and refine management guidelines.

Quality of Life Among Family of Patients with Atopic Dermatitis and Psoriasis.

BACKGROUND: Chronic inflammatory skin diseases like atopic dermatitis (AD) and psoriasis can severely impact patients' quality of life (QOL). However, the effect of these diseases can diminish the QOL of patients' family members as well. The objective of this study was to understand the impact on QOL for family members of patients diagnosed with AD or psoriasis. METHODS: We conducted focus groups and interviews with 23 individuals; 12 had a family member with AD, and 11 had a family member with psoriasis. After investigators independently coded the transcripts, thematic analysis was conducted. RESULTS: Three major themes emerged: (1) lifestyle consequences-many daily activities for family members, including but not limited to leisure activities, sleep, and cleaning, were affected by AD or psoriasis; (2) emotional consequences-family members felt frustrated, worried, or embarrassed, among other concerns, because of their loved ones' AD or psoriasis; (3) relationships-relationships between family members and their loved ones with AD or psoriasis could become strained, and though family members might try to be sympathetic, doing so could be difficult because of their lack of understanding of how these diseases feel and personally affect their loved ones. CONCLUSIONS: This study highlights the impacts of AD and psoriasis on the whole family. Clinicians should be mindful of the effects on QOL not only for patients but also for family members who live with and care about these patients. Especially when family members assist with treatments, it is important to understand family members' experiences when making treatment decisions.

Clinicians' perspectives on the integration of electronic patient-reported outcomes into dermatology clinics: a qualitative study.

BACKGROUND: Skin conditions can have profound negative symptomatic and psychological effects. Failure to address these effects can lead to poor treatment adherence and/or patient dissatisfaction. Despite patient-reported outcome (PRO) use being highly recommended, real-world adoption has been slow. OBJECTIVES: To assess clinicians' perceived facilitators and barriers to using PROs in daily practice. METHODS: We conducted in-person semi-structured interviews with 19 clinicians and thematic analysis of transcripts. RESULTS: Three main themes emerged: (1) clinicians' attitudes about the value of Skindex-16 in daily practice, (2) patient attitudes influencing clinicians' use of Skindex-16, and (3) clinicians' perceptions of their ability to use PROs successfully for clinical care. Clinicians recognized benefits to using Skindex-16, such as revealing patients' hidden concerns and highlighting discrepancies with the clinician's severity assessments. Conversely, clinicians also identified limitations, such as time constraints and lack of relevance for some skin conditions. Patient complaints about PRO relevance have influenced clinicians' use of Skindex-16 negatively. Finally, some clinicians recognized the need for more training in score interpretation and implementation strategies for optimal clinical flow. CONCLUSIONS: While most clinicians believed PROs like Skindex-16 can be useful for patient care, barriers need to be addressed to make PROs more practical for routine clinical care.

Disseminate and Recurrent Infundibulofolliculitis: An Under-Recognized Yet Treatable Entity.

Disseminate and recurrent infundibulofolliculitis (DRIF) is a pruritic papular eruption that predominantly affects young adults with Fitzpatrick skin types 4-6. Due to DRIF’s rarity and under-recognition, no standardized treatment guidelines exist. However, several oral agents have been used, including vitamin A, antibiotics, and retinoids. Topical agents, such as calcineurin inhibitors and mid-potency steroids, can also be efficacious. This brief communication summarizes treatments for DRIF in the published literature. J Drugs Dermatol. 2021;20(12):1353-1354. doi:10.36849/JDD.6173.

The continued inappropriate use and overuse of combination topical clotrimazole-betamethasone.

OBJECTIVE: Combination topical clotrimazole/ betamethasone dipropionate (C-BM) contains a high-potency topical corticosteroid and is not infrequently prescribed for inappropriate patient groups and body sites. Use of C-BM can lead to inadequate clearance or exacerbation of fungal infections as well as cutaneous atrophy, striae, and other skin maladies. METHODS: We performed a retrospective chart review of 1,978 clinical visits where C-BM was prescribed within the University of Utah Health system between 2014 and 2018 to better understand current prescribing patterns. RESULTS: 1,974 prescriptions were written for C-BM. 91.6% of patients were at least the recommended age of 17 years. C-BM was most commonly prescribed for rashes of an inflammatory (42.2%) or fungal nature (38.1%). Clotrimazole/betamethasone dipropionate was prescribed for sensitive areas (face, axillae, groin or diaper region) in 48.9% of patients. Family medicine clinicians prescribed 58.3% of C-BM prescriptions, whereas dermatology clinicians accounted for 3.4%. CONCLUSION: We strongly recommend clinicians use alternative treatments for rashes or refer to dermatologists.

Melanoma prognosis in the United States: Identifying barriers for improved care.

BACKGROUND: Despite improvements in melanoma mortality, disparities in melanoma survival persist. We evaluated possible sociodemographic and health care-based predictors of differences in melanoma survival in the United States by using the melanoma mortality-to-incidence ratio (MIR). METHODS: State-based MIRs were calculated by using US cancer statistics data from 1999 to 2014. Pearson correlations and linear regressions were used to determine associations between MIR and dermatologist density, primary care provider density, number of physicians by state, number of National Cancer Institute-designated cancer centers, health care spending per capita, average household income, racial/ethnic makeup of the population, percentage of uninsured individuals, and percentage with a bachelor's degree. RESULTS: The mean overall MIR was 0.15 ± 0.04; only Alaska was an outlier (0.24). No state MIRs increased significantly over time; MIR decreased for most states. Multivariable analysis revealed that states with more active physicians (P = .02) and a higher percentage non-Hispanic whites (P = .004) had higher MIRs (poorer survival). Significant Pearson correlations were seen between MIR and melanoma incidence (r = -0.72, P < .001), melanoma mortality (r = 0.38, P < .001), dermatologist density (r = 0.32, P < .001), and National Cancer Institute-designated cancer center count (r = -0.12, P = .001). CONCLUSIONS: Melanoma survival is improved in higher-incidence areas and areas with higher dermatologist density. These findings highlight areas of poorer melanoma survival and the need for local studies evaluating disparities in melanoma survival.

An international comparison of Google searches for sunscreen, sunburn, skin cancer, and melanoma: Current trends and public health implications.

BACKGROUND: Google Trends® (GT) offers insight into public interests and behaviors and holds potential for guiding public health campaigns. OBJECTIVES: This study explored international trends in English-speaking countries (United States, United Kingdom, Canada, Australia, New Zealand) in searches for sunscreen, sunburn, skin cancer, and melanoma to better guide skin cancer prevention campaigns. METHODS: Google Trends® was queried for search terms from January 1, 2004 to December 31, 2017. Respective national databases were queried for melanoma outcome data from 2004 to 2014 and compared with time-matched search data. Correlations between search terms, time, and melanoma outcomes were assessed for each country. Quantitative analyses were performed to evaluate differences in search volumes between countries with varying melanoma incidence. RESULTS: In all countries, the strongest intra-term correlation was between sunscreen and sunburn. Searches for sunscreen and sunburn are increasing for all countries. For all countries except the United Kingdom and New Zealand, searches for skin cancer and melanoma are decreasing for one or both terms. Correlations between search terms and melanoma outcomes were variable and specific to each country. Quantitative analysis revealed that countries with higher melanoma incidence had higher search volumes for all terms. Search volumes were especially high for skin cancer and melanoma in Australia compared with other countries. Comparisons between moderate melanoma incidence countries were less clear. CONCLUSIONS: Online skin cancer prevention campaigns should focus on the search terms sunburn and sunscreen, especially given the declining interest between 2004 and 2016 in the terms skin cancer and melanoma seen in multiple countries. Search term interests varied with melanoma outcomes and between countries, suggesting the importance of customizing approaches based on local population interests and geographic areas.

Similar survival of patients with multiple versus single primary melanomas based on Utah Surveillance, Epidemiology, and End Results data (1973-2011).

BACKGROUND: Survival data are mixed comparing patients with multiple primary melanomas (MPM) to those with single primary melanomas (SPM). OBJECTIVES: We compared MPM versus SPM patient survival using a matching method that avoids potential biases associated with other analytic approaches. METHODS: Records of 14,138 individuals obtained from the Surveillance, Epidemiology, and End Results registry of all melanomas diagnosed or treated in Utah between 1973 and 2011 were reviewed. A single matched control patient was selected randomly from the SPM cohort for each MPM patient, with the restriction that they survived at least as long as the interval between the first and second diagnoses for the matched MPM patient. RESULTS: Survival curves (n = 887 for both MPM and SPM groups) without covariates showed a significant survival disadvantage for MPM patients (chi-squared 39.29, P < .001). However, a multivariate Cox proportional hazards model showed no significant survival difference (hazard ratio 1.07, P = .55). Restricting the multivariate analysis to invasive melanomas also showed no significant survival difference (hazard ratio 0.99, P = .96). LIMITATIONS: Breslow depth, ulceration status, and specific cause of death were not available for all patients. CONCLUSIONS: Patients with MPM had similar survival times as patients with SPM.

Comprehensive outreach, prevention education, and skin cancer screening for Utah ski resorts.

Outdoor recreation can lead to substantial sun exposure. Employees of outdoor recreation establishments with extended time outdoors have amplified cumulative exposure to ultraviolet (UV) radiation and an increased risk of skin cancer. The "Sun Safe on the Slopes" program was created by Huntsman Cancer Institute at the University of Utah and the Utah Cancer Action Network to address increased UV exposure and skin cancer risk with free skin cancer screenings, outreach, and prevention education to local ski resorts. Herein, we describe the processes and barriers to implementation of a ski resort skin screening and education program and our 5-year report of the experience and screening data. Nine free skin cancer screenings were held at Utah ski resorts between 2011 and 2016, resulting in the presumptive diagnosis of 38 skin cancers (9.6%) in 394 participants. Behavioral data collected from participants indicates suboptimal sun safety practices, including underuse of sunscreen and protective clothing. Ski resort employees who experience sun exposure during peak hours at high altitudes and UV reflection from the snow are at an increased risk of skin cancer. These data indicate a need for emphasis on sun safety education and screening and can serve as a model for future endeavors.

A survey of United States dermatologists' knowledge, attitudes, and practices with intramuscular triamcinolone.

Since the 1970s, intramuscular triamcinolone (IMT) has been available as an option for systemic corticosteroid use in dermatology. Although shown to be safe and effective in early studies, this method of systemic corticosteroid delivery fell out of favor in the 1980s in many United States residency programs. To identify factors associated with US dermatologists' preferences for and use of IMT we surveyed a random sample of US board-certified dermatologists to assess knowledge, attitudes, and practices regarding IMT in dermatologists' daily clinical practice. A total of 844 out of 2000 dermatologists completed the survey (42.2%). Only 55.0% reported feeling comfortable using IMT for steroid-responsive dermatoses, while 90.4% felt comfortable using oral corticosteroids for steroid-responsive dermatoses. Most participants (59.2%) did not prefer IMT over oral corticosteroids when both were indicated. One third (33.3%) of the participants reported that none of the faculty during their residency advocated using IMT. Receiving education on IMT indications (OR = 1.96 [95% CI: 1.46-2.63]) and encouragement to use IMT (OR = 4.29 [95% CI: 3.01-6.11]) during residency were positively associated with use of IMT at least once a month in current practice. Current knowledge, attitudes, and practices surrounding IMT vary amongst practicing dermatologists. Modifiable factors such as training could improve comfort with use of this short-term systemic steroid treatment modality.

Methods Reporting Quality and its Association with Methods Section Length: A Cross-sectional Assessment of STROBE and CONSORT Reporting Adherence in Top-cited Dermatology Journals.

Background: Adequate methods reporting in observational and trial literature is critical to interpretation and implementation. Objective: Evaluate methodology reporting adherence in the dermatology literature and compare this to internal medicine (IM) literature. Methods: We performed a cross-sectional review of randomly-selected dermatology and IM manuscripts published between 2014-2018. Observational and trial articles were retrieved from PubMed. The primary outcome was percent adherence to STROBE or CONSORT methods-related checklist items (methods reporting score, MRS). Secondary outcomes included the relationship between methods section length (MSL) and MRS. We additionally compared these with IM literature. MRS and MSL were compared by overall article length, checklist type, field, journal, study topic, and funding source. Comparisons were assessed using univariable and multivariable linear regression. Results: We identified 389 articles (172 dermatology and 217 IM). Within dermatology, we identified 83 clinical trials and 89 observational studies. Mean MRS was 61.4 percent. A one word increase in MSL corresponded to a 0.02 percent increase MRS (ß=0.02, 95% CI 0.01-0.03). Mean MRS was 12.8 percent lower in the dermatology literature compared with IM (ß=-12.8%, -15.6-[-9.91]). Mean dermatology MSL was 345 words shorter (ß=-345, -413-[-277]). Studies from JAMA Dermatology, Journal of Investigative Dermatology, and British Journal of Dermatology, with government funding, and having supplemental methods had higher mean MRS's. Conclusion: Methods reporting quality was low in dermatology. A weak relationship between MRS and MSL was observed. These data support enhancing researcher emphasis on methods reporting, editorial staff, and peer reviewers that more strictly enforce checklist reporting.

Patient-Reported Outcome Measures and Their Clinical Applications in Dermatology.

With more disease- and symptom-specific measures available and research pointing to increased usefulness, patient-reported outcome measures (PROMs) can be routinely used in clinical care. PROMs increase efficiency in healthcare, improve the clinician-patient relationship, and increase patient satisfaction with their care. PROMs can be administered before, during, and after clinic visits using paper-and-pencil, mobile phones, tablets, and computers. Herein, we combine available literature with expert views to discuss overcoming barriers and helping dermatologists incorporate PROMs into routine patient-centered care. We believe dermatology patients will benefit from broader PROM implementation and routine clinical use. However, a few major barriers exist: (1) cost to implement the technology, (2) selecting the right PROMs for each disease, and (3) helping both patients and clinicians understand how PROMs add to and complement their current clinical experience. We provide recommendations to assist dermatologists when considering whether to implement PROMs in their practices.

Skin-Related Quality of Life During Autoimmune Bullous Disease Course.

Importance: Autoimmune bullous diseases (AIBDs) are chronic relapsing-remitting conditions with significant morbidity. Skin-related quality of life (SRQL) may vary by AIBD subtype and disease type. Disease severity and flare severity can be difficult to define; SRQL can offer a key insight. Objectives: To investigate the Skindex-16 score as an SRQL measure in AIBD subtypes during flare and nonflare states and to evaluate Skindex-16 construct validity. Design, Setting, and Participants: This retrospective cross-sectional study was conducted from September 1, 2016, to February 1, 2020, among 192 patients at the University of Utah Health autoimmune dermatology clinic with pemphigoid, pemphigus, dermatitis herpetiformis, and linear immunoglobulin A disease. Patients had an encounter-associated diagnosis, Skindex-16 scores, and self-reported flare status. Statistical analysis was performed from March 2022 to June 2023. Exposure: Autoimmune bullous disease subtype and patient-reported flare status. Main Outcomes and Measures: Skindex-16 domain scores (emotions, symptoms, and functioning; range, 0-100, where 0 indicates no effect on SRQL and 100 maximum effect) and individual item scores were described by disease and flare status. Flare scores were expected to be higher by at least the standard error of measurement (SEm). Convergent validity was assessed using Spearman correlation among Skindex-16 scores, serologic titers, and other patient-reported outcome measures. Floor or ceiling domain scores (<20% of sample scoring either lowest or highest possible domain scores, respectively) were assessed for Skindex-16. Structural validity was assessed using confirmatory factor analysis (CFA). Results: The study included 192 patients with 212 visits (median age, 68 years [IQR, 58-76 years]; 123 of 212 women [58.0%]) with Skindex-16 scores (64 in flare state and 148 in nonflare state). Median Skindex-16 domain scores were higher for all disease categories among patients in the flare state compared with those in the nonflare state (pemphigoid [emotions: flare, 52.4 (IQR, 38.1-69.0); nonflare, 7 (IQR, 0-17); symptoms: flare, 37.5 (IQR, 29.2-58.0); nonflare, 13 (IQR, 0-25); functioning: flare, 26.7 (IQR, 10.0-56.7); nonflare, 0 (IQR, 0-3)]; pemphigus [emotions: flare, 54.8 (IQR, 31.0-81.0; nonflare, 0 (IQR, 0-19); symptoms: flare, 58.3 (IQR, 41.7-70.8); nonflare, 4 (IQR, 0-12.5); functioning: flare, 26.7 (IQR, 13.3-83.3); nonflare, 0 (IQR, 0-3.33)]; dermatitis herpetiformis [emotions: flare, 72.6 (IQR, 34.7-90.5); nonflare, 14.3 (IQR, 2.4-26.2); symptoms: flare, 69 (IQR, 31.3-85.4); nonflare, 12.5 (IQR, 0-29.2); functioning: flare, 38.3 (IQR, 5.0-63.2); nonflare, 0 (IQR, 0-13.3)]. This difference exceeded SEm cut points. Cronbach α was greater than 0.80 for all domains and AIBDs. Moderate or low correlations were seen with desmoglein 1 and bullous pemphigoid 180 titers. Moderate correlation existed between Skindex-16 and Patient-Reported Outcomes Measurement Information System Depression scores (emotions: ρ = 0.40; symptoms: ρ = 0.41; functioning: ρ = 0.48), and strong correlation existed between Skindex-16 and patient-reported disease severity (emotions: ρ = 0.71; symptoms: ρ = 0.73; functioning: ρ = 0.66). Floor domain scores greater than 20% were seen among patients in the nonflare state, but ceiling domain scores were rare (<10% for all domains); CFA model fit was poor. Conclusions and Relevance: In this cross-sectional study, SRQL was highly associated with flare of AIBDs. Skin-related quality of life was worse during periods without flare among patients with pemphigoid and dermatitis herpetiformis compared with pemphigus, highlighting residual SRQL morbidity. Skindex-16 showed good construct validity, but the poor CFA model fit needs further research. Clinical measurement of SRQL in AIBDs can add critical disease-severity information.