------Topical Antifungal Prescribing for Medicare Part D Beneficiaries - United States, 2021.

Incorrect use of topical antifungals and antifungal-corticosteroid combinations is likely contributing to the global emergence and spread of severe antimicrobial-resistant superficial fungal infections, which have recently been detected in the United States. Understanding prescribing patterns is an initial step in establishing and promoting recommended use of these medications. Using 2021 Medicare Part D data, CDC examined prescription volumes, rates, and costs for topical antifungals (including topical combination antifungal-corticosteroid medications). Total prescription volumes were compared between higher-volume prescribers (top 10% of topical antifungal prescribers by volume) and lower-volume prescribers. During 2021, approximately 6.5 million topical antifungal prescriptions were filled (134 prescriptions per 1,000 beneficiaries), at a total cost of $231 million. Among 1,017,417 unique prescribers, 130,637 (12.8%) prescribed topical antifungals. Primary care physicians wrote the highest percentage of prescriptions (40.0%), followed by nurse practitioners or physician assistants (21.4%), dermatologists (17.6%), and podiatrists (14.1%). Higher-volume prescribers wrote 44.2% (2.9 million) of all prescriptions. This study found that enough topical antifungal prescriptions were written for approximately one of every eight Medicare Part D beneficiaries in 2021, and 10% of antifungal prescribers prescribed nearly one half of these medications. In the setting of emerging antimicrobial resistance, these findings highlight the importance of expanding efforts to understand current prescribing practices while encouraging judicious prescribing by clinicians and providing patient education about proper use.

Diagnosis and Management of Longitudinal Erythronychia: A Clinical Review by an Expert Panel.

Longitudinal erythronychia (LE) is defined as a longitudinal red band of the nail(s) and is classified as localized (involvement of one nail) or polydactylous (involvement of more than one nail). The differential diagnosis is distinct for these classifications. The etiologies of localized longitudinal erythronychia (LLE) are most frequently benign subungual neoplasms, and less often malignancies. Polydactylous longitudinal erythronychia (PLE) is typically secondary to regional or systemic diseases, including lichen planus and Darier disease. LE is a common, but underrecognized clinical finding. Increased dermatologist awareness of the clinical characteristics and differential diagnosis for LE is necessary given the possibility for malignancy and associated systemic disease. In this clinical review, the clinical features, differential diagnosis, evaluation, and management of LE are described.

Nail psoriasis and nail lichen planus: Updates on diagnosis and management.

BACKGROUND: Inflammatory diseases of the nail, including nail psoriasis and nail lichen planus, are associated with significant disease burden and have a negative impact on quality of life. Diagnosis is often delayed, especially when patients present without cutaneous findings. Therefore, recognizing clinical signs and symptoms of inflammatory nail diseases, and initiating timely and appropriate treatment, is of utmost importance. OBJECTIVE: We review recent studies on diagnostic techniques, discuss severity grading and scoring systems, and describe consensus treatment recommendations for nail psoriasis and nail lichen planus. METHODS: An updated literature review was performed using the PubMed database on studies assessing diagnostic techniques or treatment modalities for nail psoriasis and nail lichen planus. RESULTS: Recent studies on diagnostic techniques for inflammatory nail disease have focused on use of dermoscopy, capillaroscopy, and ultrasound modalities. Treatment of these conditions is dichotomized into involvement of few (≤3) or many (>3) nails. Recent psoriatic therapeutics studied for nail outcomes include brodalumab, tildrakizumab, risankizumab, deucravacitinib, and bimekizumab, while emerging treatments for nail lichen planus include JAK inhibitors and intralesional platelet rich plasma injections. CONCLUSIONS: We emphasize the need for increased awareness and expanded management strategies for inflammatory nail diseases to improve patient outcomes.

Dermatologic Fungal Neglected Tropical Diseases-Part I. Epidemiology and Clinical Features.

In this part 1 of a 2-part continuing medical education series, the epidemiology, clinical features, and diagnostic methods for fungal skin neglected tropical diseases (NTDs), which include eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis, are reviewed. These infections, several of which are officially designated as NTDs by the World Health Organization (WHO), cause substantial morbidity and stigma worldwide and are receiving increased attention due to the potential for climate change-related geographic expansion. Domestic incidence may be increasing in the setting of global travel and immunosuppression. United States dermatologists may play a central role in early detection and initiation of appropriate treatment, leading to decreased morbidity and mortality.

Dermatologic Fungal Neglected Tropical Diseases-Part II. Management and Morbidity.

In this part 2 of a 2-part continuing medical education series, the management, outcomes, and morbidities for fungal skin neglected tropical diseases (NTDs), including eumycetoma, chromoblastomycosis, paracoccidioidomycosis, sporotrichosis, emergomycosis, talaromycosis, and lobomycosis are reviewed. While fungal skin NTDs are associated with poverty in resource-limited settings, they are more often associated with immunosuppression and global migration in the United States. These infections have a high morbidity burden, including disfigurement, physical disability, coinfection, malignant transformation, mental health issues, and financial impact. For most fungal skin NTDs, management is difficult and associated with low cure rates. Dermatologists play a central role in initiating appropriate treatment early in disease course in order to improve patient outcomes.

Retrospective analysis of onychomycosis prescribing patterns using the medicare part D prescribers database 2016-2020.

Onychomycosis, defined as a fungal nail infection, affects 5.5% of the global population. Our objectives were to analyse prescription trends of onychomycosis medications using the Medicare Part D Prescribers database from 2016 to 2020, stratified by physician specialty. There was a 4% annual increase in the total cost of onychomycosis medications, with a notable decrease of 12.8% in 2020 during the COVID-19 pandemic. Physicians demonstrated a strong consideration for price when selecting treatments, with the least expensive medications (ciclopirox and terbinafine) accounting for nearly 99% of all prescriptions. In contrast, the more costly medications (efinaconazole and tavaborole) were rarely prescribed. In addition, physicians often opted for the less costly generic versions of ciclopirox and itraconazole, prescribing them 99% and 91% of the time, respectively. Notably, physician assistants and nurse practitioners had higher overall increases in prescription rates, at 15%, compared to 1%-6% for other specialties. There are no recent United States onychomycosis guidelines, and our study emphasizes cost considerations when prescribing onychomycosis treatments.

Treatment of onychomycosis in an era of antifungal resistance: Role for antifungal stewardship and topical antifungal agents.

A growing body of literature has marked the emergence and spread of antifungal resistance among species of Trichophyton, the most prevalent cause of toenail and fingernail onychomycosis in the United States and Europe. We review published data on rates of oral antifungal resistance among Trichophyton species; causes of antifungal resistance and methods to counteract it; and in vitro data on the role of topical antifungals in the treatment of onychomycosis. Antifungal resistance among species of Trichophyton against terbinafine and itraconazole-the two most common oral treatments for onychomycosis and other superficial fungal infections caused by dermatophytes-has been detected around the globe. Fungal adaptations, patient characteristics (e.g., immunocompromised status; drug-drug interactions), and empirical diagnostic and treatment patterns may contribute to reduced antifungal efficacy and the development of antifungal resistance. Antifungal stewardship efforts aim to ensure proper antifungal use to limit antifungal resistance and improve clinical outcomes. In the treatment of onychomycosis, critical aspects of antifungal stewardship include proper identification of the fungal infection prior to initiation of treatment and improvements in physician and patient education. Topical ciclopirox, efinaconazole and tavaborole, delivered either alone or in combination with oral antifungals, have demonstrated efficacy in vitro against susceptible and/or resistant isolates of Trichophyton species, with low potential for development of antifungal resistance. Additional real-world long-term data are needed to monitor global rates of antifungal resistance and assess the efficacy of oral and topical antifungals, alone or in combination, in counteracting antifungal resistance in the treatment of onychomycosis.

Analysis of Utilization, Cost, and Prescription Trends of Common Immunosuppressive Medications Among Medicare Patients 2013 to 2019.

Immunosuppressive medications are commonly used to manage dermatological conditions, including atopic dermatitis, psoriasis, and bullous diseases. However, cost and adverse effect profile, including increased risk of infections, are important considerations.

Number of Affected Nails Is the Primary Determinant of Efinaconazole 10% Solution Usage for Onychomycosis.

Good adherence to treatment is necessary for the successful treatment of onychomycosis and requires that an appropriate amount of medication be prescribed. Most prescriptions for efinaconazole 10% solution, a topical azole antifungal, are for 4 mL per month but there are no data on patient factors or disease characteristics that impact how much medication is needed. Data from two phase 3 studies of efinaconazole 10% solution for the treatment of toenail onychomycosis were pooled and analyzed to determine monthly medication usage based on the number of affected toenails, percent involvement of the target toenail, body mass index (BMI), and sex. Participants with two or more affected nails required, on average, >4 mL of efinaconazole per month, with increasing amounts needed based on the number of nails with onychomycosis (mean: 4.39 mL for 2 nails; 6.36 mL for 6 nails). In contrast, usage was not greatly impacted by target toenail involvement, BMI, or sex. Together, these data indicate that the number of affected nails should be the major consideration when determining the monthly efinaconazole quantity to prescribe. J Drugs Dermatol. 2024;23(2):110-112.    doi:10.36849/JDD.7676.

No seroconversion in a retrospective study analyzing QuantiFERON TB-gold testing in pediatric psoriasis and hidradenitis suppurativa patients taking biologic therapy at an academic center in New York City.

Guidelines are inconsistent regarding annual QuantiFERON® TB Gold (QFT) tests in children taking biologics for dermatological conditions, and there is limited research on seroconversion, especially in regions with high tuberculosis (TB) prevalence. A retrospective review of pediatric patients taking biologic treatment for psoriasis or hidradenitis suppurativa (HS) who had one baseline and at least one follow-up QFT test was conducted to assess for seroconversion during treatment. Thirty-two patients were included, with no instances of seroconversion. These findings suggest that routine annual TB rescreening for pediatric patients taking biologic therapy for dermatologic conditions may not be necessary without additional TB exposure risks or symptomatology.

Home Is Where the Match Is: Mentorship and Dermatology Residency Match Trends Before and During the COVID-19 Pandemic.

Dermatology is one of the most competitive residencies for matching among medical school applicants. A strong connection with a residency program through research or clinical rotations may distinguish between similarly qualified applicants. Our previous study of research-mentor relationships among matched dermatology applicants corroborated the importance of program connections.1 However, the 2020-2021 residency match cycle was uniquely affected by the COVID-19 pandemic, which prevented applicants from fostering connections with faculty at outside institutions. Our study objectives were to evaluate research-mentor relationships among matched dermatology applicants in the 2020-2021 pandemic match cycle with comparisons to pre-pandemic match cycles.

Onychomycosis Treatment Prescribed at Only Twenty Percent of Visits: A Cross-Sectional Analysis of the National Ambulatory Medical Care Survey 2007 to 2016.

BACKGROUND: Onychomycosis represents the highest proportion of nail disorders seen in clinical practice. Onychomycosis management may differ amongst specialties, with impact on patient outcomes and quality of life (QoL). OBJECTIVE: We aimed to characterize onychomycosis treatment across specialties, accounting for patient demographics, to assess for potential onychomycosis practice gaps. MATERIALS/METHODS: We conducted a population based cross-sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) 2007 to 2016 (the most recent years available). RESULTS: Overall, 71.6% of onychomycosis visits were with general practitioners (GPs), 25.8% with dermatologists, and 2.58% with pediatricians. No onychomycosis treatment was prescribed at 82.0% of dermatology visits and 78.9% of GP visits. Dermatologists (Odds Ratio (OR):2.27 [95% Confidence Interval (CI):[2.14-2.41]; P<0.0001) and GPs (OR:2.32 [2.21-2.44]; P<0.0001) were more likely than pediatricians to prescribe treatment vs no treatment. Dermatologists were more likely than GPs to prescribe both no treatment vs treatment and topical vs oral antifungals (OR:1.33 [1.16-1.52]; P<0.0001 and OR:4.20 [3.80-4.65]; P<0.0001), respectively. DISCUSSION: Our study showed that there is a low treatment rate for onychomycosis, with treatment prescribed at only 20% of visits. Untreated onychomycosis might result in secondary infection, pain, and negative QoL impact.1 Although dermatologists are specialists in nail disease management, they saw only about 25% of onychomycosis visits. Future efforts should be directed towards promoting onychomycosis therapy, and educating both patients and referring physicians that dermatologists are primary resources for nail disorder treatment.J Drugs Dermatol. 2023;22(10):1040-1045 doi:10.36849/JDD.6770.

Bacterial infections are common among eczema herpeticum inpatients in a cross-sectional analysis of the 2016 Kids' Inpatient Database.

Eczema herpeticum (EH) is a cutaneous infection with herpes simplex virus, typically in the context of atopic dermatitis. Pediatric hospitalizations for EH have increased over the past several decades, yet few studies have investigated comorbidities or epidemiology of pediatric EH inpatients. We searched the 2016 Kids' Inpatient Database and recorded demographics, comorbidities, and associated costs for patients with EH. We found bacterial infections were a common comorbidity which affected nearly half (47.4%) of hospitalized patients, suggesting the importance of regular monitoring of pediatric EH inpatients for bacterial coinfection.

Intralesional steroid injections for inflammatory nail dystrophies in the pediatric population.

Intralesional injections of triamcinolone acetonide are widely used to successfully treat several inflammatory nail conditions. This procedure is well described in adults, but less frequently reported in children and teenagers, being largely considered too invasive and fear-provoking for pediatric patients. Our report shows how this procedure is feasible and successful in children, even without a digital block. The step-by-step technique and tips to reduce pain should encourage clinicians to offer it as an alternative option to children with inflammatory nail disorders.

Clinical and dermoscopic findings of benign longitudinal melanonychia due to melanocytic activation differ by skin type and predict likelihood of nail matrix biopsy.

BACKGROUND: Longitudinal melanonychia (LM) is a common dermatologic finding in clinical practice with a broad differential diagnosis. Melanocytic activation is the most common LM etiology. OBJECTIVE: To investigate clinical and dermoscopic differences of benign LM based on Fitzpatrick skin type and in biopsied versus nonbiopsied patients. METHODS: A 10-year retrospective cohort of 248 benign LM cases at Weill Cornell Dermatology was identified and analyzed. RESULTS: Darker-skinned versus lighter-skinned patients had higher band width percentage (P = .0125), had lower band brightness (P < .001), had more band changes (P = .0071), and received more biopsies (P = .032). Biopsied (n = 47) versus nonbiopsied patients (n = 201) had less multidigit band involvement (P = .0008), higher band width percentage (P = .0213), lower band brightness (P = .0003), and more band changes (P < .0001). Darker skin types more often had brown versus gray coloration on dermoscopy (P = .0232). The mean band width percentage for all biopsied patients was 30.81% (range: 5.80%-100%). LIMITATIONS: Single-center retrospective design. Subungual melanoma and other benign LM etiologies were not analyzed. Only 18.95% of patients received a biopsy. CONCLUSION: Darker versus lighter skin types more often present with darker and wider bands, present with brown versus gray coloration on dermoscopy, and receive more biopsies. Multi-institutional studies on LM are needed to determine nail matrix biopsy criteria in different skin types.

Review of Telemedicine for Management of Acne Patients.

Accelerated by the COVID-19 pandemic, telemedicine has changed the landscape of dermatology practice. This manuscript aims to review the role of telemedicine in acne management and provide management recommendations. A literature search of the PubMed and Scopus databases was conducted using keywords "acne," "telemedicine," "teledermatology," "telehealth," "virtual," and "video." Eight articles directly related to telemedicine and acne management were included in the study. In-person vs. telemedicine management of acne patients had high diagnostic concordance and similar efficacy and remission rates. Survey-based studies of acne patients reported high interest and satisfaction and no safety concerns with acne management via telemedicine. Telemedicine was reported as an effective triage tool. Prescription patterns for acne medications during telemedicine vs. in-person visits varied. It is likely that dermatologists will continue to treat acne and other common skin conditions via teledermatology. Therefore, it is important for dermatologists to gain comfort in utilizing virtual visits to diagnose and manage acne patients. Further studies are needed to establish a standardized structural framework for telemedicine visits to optimize patient care and outcomes for acne patients.

Altmetric Analysis of Skin of Color Articles: A Cross-Sectional Study.

BACKGROUND: Publication and dissemination of peer-reviewed articles are essential for delivering up-to-date high-quality care to diverse populations. Online attention and publication trends for skin of color (SOC) articles have not been studied. OBJECTIVE: To investigate SOC article online attention and publication trends. METHODS: Terms "skin of colo(u)r", "ethnic skin", "dark skin", and "darker skin" were searched on Altmetric. Abstracts were reviewed to exclude non-SOC articles. Altmetric attention score (AAS), media outlets, citations, page views, and journal impact factor were extracted. RESULTS: A total of 425 articles, published in 114 journals, were included, with average AAS 13 (0-423), citations 42 (0-1214) and page views 2728 (7-15000). There was a 7.8-fold increase in the number of SOC articles published in the first-half (1993-2006) vs. second-half (2007-2021) of the study period. The number of SOC articles increased by 57%, 2011-2015 to 2016-2020. AAS was significantly correlated with citations (R = .21), page views (R = .23) and impact factor (R = .35) (P < .05 for all). The top 50 AAS articles had an average AAS 83 (21-423), with 35 (70%) published in the last 5 years (2016-2021) and 47 (94%) published in the second-half of the study period. Top four AAS articles focused on SOC representation in educational resources. CONCLUSION: It is promising that increased numbers of SOC articles have been published in recent years and are garnering more attention, however they are less popular than other dermatology articles. Increased efforts are needed to study and publish on skin diseases in diverse populations to build knowledge and practices that improve patient care.

Bioinformatics and immunoinformatics to support COVID-19 vaccine development.

Severe acute respiratory syndrome coronavirus 2 has infected over 109 000 000 people with 2 423 443 deaths as of February 17, 2021. Currently, there are no approved or consistently effective treatments, and conventional vaccines may take several years for development and testing. In silico methods of bioinformatics, vaccinogenomics, immunoinformatics, structural biology, and molecular simulations can be used for more rapid and precise vaccine design. This paper highlights two major immunoinformatics strategies that are used in designing novel and effective vaccines and therapeutics: reverse vaccinology and structural vaccinology.

Effect of onychomycosis and treatment on patient-reported quality-of-life outcomes: A systematic review.

BACKGROUND: Onychomycosis is the most common nail disorder, often causing physical, emotional, and aesthetic consequences. The effect of both the condition itself and treatment on quality of life has not been well studied. OBJECTIVE: The objectives of this study were to systematically review the available literature describing the effect of onychomycosis and treatment on quality of life. METHODS: We performed a search of the onychomycosis literature published before April 13, 2020. Articles were included in the review if primary data were presented, patient-reported outcome measures were used, and onychomycosis was specifically examined. RESULTS: Thirty studies were included in the final analysis. Poorest quality-of-life scores were associated with women and fingernail involvement. Quality-of-life scores improved from baseline with all treatment types; there were greater improvements reported with oral treatments compared with topical ones. CONCLUSIONS: This review affirms that onychomycosis significantly influences quality of life, warranting effective treatment. All treatments resulted in quality-of-life improvements; however, studies on oral and topical therapies were of higher quality than those evaluating devices. Increased efforts are needed to understand the effect of the disease and therapy as assessed by validated, nail-specific outcome measures that accurately assess patients' cosmetic, physical, and social difficulties.

Retrospective analysis of nail biopsies performed using the Medicare Provider Utilization and Payment Database 2012 to 2017.

Subungual melanoma (SUM) is subset of acral melanoma that develops within the nail unit and is associated with a poor prognosis. Nail biopsy is the only way to definitively diagnosis SUM. Our objectives were to analyze the Medicare database for nail biopsy utilization and to compare the annual nail biopsy rate with the estimated incidence of SUM in the United States. A retrospective study on nail biopsy data was performed using the Medicare Provider Utilization and Payment Database 2012 to 2017. The number of nail biopsies performed per 100 000 people was compared to SUM incidence per 100 000 people. Podiatrists, dermatologists, other physicians, and NP/PAs respectively performed 12.12, 0.42, 0.08, 0.07 nail biopsies per 100 000 people annually. Dermatologists performed adequate nail biopsies to cover the minimum (0.7%), but not the maximum (3.5%) estimated incidence of SUM. Only 0.28% and 1.01% of general dermatologists and Mohs surgeons, respectively, performed nail biopsies in 19/50 (38.00%) states and 69/929 (7.42%) zip codes. Limitations of our study were that nail biopsies on patients less than 65 years, and those with no or commercial health insurance were not analyzed. In sum, very few dermatologists performed nail biopsies in the Medicare database. Increased efforts are needed to educate dermatologists on nail surgery.