Teledermatology Platforms Usage and Barriers: A Cross-Sectional Analysis of United States-Based Dermatologists Pre- and Post-COVID-19.

BACKGROUND: During the global COVID-19 pandemic, dermatologists increasingly adopted teledermatology to facilitate patient care. OBJECTIVE: To identify differences in teledermatology platform usage and functionality among dermatologists as a means of understanding the potential effect on virtual healthcare access. METHODS: Results from a 2021 cross-sectional pre-validated survey distributed to actively practicing United States dermatologists were analyzed based on timepoint when teledermatology was adopted relative to COVID-19, previous/currently used platforms, self-reported platform functionality, and barriers to teledermatology implementation. Analysis was performed using chi-square and odds ratios (OR) with 95% confidence intervals (95% CI) for categorical data and single-factor analysis of variance (ANOVA) with post-hoc Tukey-Kramer for continuous data. P<.05 was considered significant. RESULTS: Early adopters (EAs) trialed significantly more (2.3 vs 1.9, P=0.02) platforms than (post) COVID adopters (CAs) before choosing their current platform. More EAs reported using platforms capable of uploading images (P=.002), required a mobile application (P=.006), and allowed staff to join patient encounters (P<.001). While poor image quality was the most cited barrier to implementation, CAs and non-adaptors (NAs) were materially more likely to cite it as their largest barrier to teledermatology. LIMITATIONS: The retrospective nature of the study and potential response bias. CONCLUSION: Dermatologists' use of teledermatology materially correlates with their teledermatology-adoption timepoint, and future usage may be materially impacted by the end of the COVID-19 public health emergency. Future studies should aim at how implementation and barriers to teledermatology usage may impact access to care. J Drugs Dermatol. 2024;23(2): doi:10.36849/JDD.7819e.

Mpox virus and coinfections: An approach to rapid diagnosis.

We report a case of a 42-year-old immunocompromised (human immunodeficiency virus [HIV], CD4 count 86 cells/µL) Black male who presented with fever, oropharyngeal candidiasis, and phimosis, followed by eruption of umbilicated papulovesicles most concentrated on the face. The patient was diagnosed with Mpox (MPXV, formerly monkeypox), herpes simplex virus 1 (HSV1), varicella-zoster virus (VZV), and late latent syphilis. Tzanck smear of a Mpox lesion proved a useful and rapidly obtained pertinent negative test, lacking the typical changes of HSV/VZV (multinucleation, margination, and molding). A biopsy specimen showed viral changes consistent with both Mpox (ballooning degeneration and multinucleated keratinocytes) and herpesvirus (multinucleated epithelial giant cell within a zone of follicular necrosis). Lesion PCR was positive for HSV1 and MPXV, and negative for HSV2 and VZV. Immunohistochemistry was positive for VZV and orthopoxvirus. Empiric treatment for HSV/VZV in patients with suspected or confirmed Mpox should be considered for patients with HIV or other immunocompromised patients. It is important to recognize that MPXV, HSV, and VZV may all be present and difficult to distinguish clinically. More than one test modality (PCR, H&E, immunohistochemistry, and Tzanck) and multiple lesion samples may be required to thoroughly evaluate widespread papulovesicular eruptions, especially in immunocompromised patients.

Telemedicine Versus Teledermatology Usage and Perception Among US-Based Physicians: A Survey Study.

The COVID-19 pandemic has sparked an increase in focus and use of telemedicine in several patient care settings. This survey study was distributed to actively practicing US-based physicians and examines telehealth use 2 years after the beginning of the COVID pandemic from a physician’s perspective. Notable findings include telehealth benefits which include increased patient access and the ability to work from home. A continued drawback in telehealth visits is the limitations on a complete physical examination, a drawback that was emphasized by the dermatology community. While this study sheds light on the developing nature of telehealth, it is limited by its retrospective nature and sample size. Future research with larger sample sizes focusing on economic incentives and telemedicine training may help to overcome barriers to using telehealth.  J Drugs Dermatol. 2023;22(11):e4-e8    doi:10.36849/JDD.7386e.

The Impact of the COVID-19 Pandemic on Physician-Pharmaceutical Office-Based Interactions.

BACKGROUND: COVID-19 has had significant negative economic ramifications on dermatologic care delivery, including curtailing live on-site physician-pharmaceutical-representative interactions (PPRI). OBJECTIVE: To determine the impact of COVID-19 and pandemic regulations on current and future PPRI. METHODS: Cross-sectional survey-based study that analyzed data from 400 surveyed dermatologists using a pre-validated questionnaire sent via email. Data regarding PPRI were collected over 1 week in July 2020 to compare demographics and practice standards from April 2019, April 2020, July 2020, and predictions for 2021. RESULTS: Virtual-only PPRI increased from 7.8% in April 2019 to 26.5% during April 2020 (mean difference, 18.8%; 95% confidence interval, 13.6%–23.9%). Virtual-only PPRI remained elevated at 24.5% while hybrid PPRI increased, eventually surpassing the April 2019 mark (27.0%). These trends persisted among all studied practice types and levels of experience. Practices predicted no significant percent differences in participation in PPRI (87.3% vs 90.3%; P=0.0834), but a significant shift in method of delivery where the odds ratio of incorporating a virtual component into PPRI in 2021 increased by a factor of 3. LIMITATIONS: Relatively small sample size, especially among subgroups. Responses may have been retrospective estimates. There may also be selection bias given slightly increased representation of more experienced dermatologists. CONCLUSION: PPRI materially decreased during the initial COVID-19 peak but will likely return to baseline volume moving forward with a significant component being hybrid PPRI. Further studies may better elucidate the economic and clinical impact associated with these changes and their effect on dermatologists’ ability to provide patients with samples and educational materials. J Drugs Dermatol. 2021;20(2):215-223. doi:10.36849/JDD.5651.

Advances and Considerations in the Management of Actinic Keratosis: An Expert Consensus Panel Report.

BACKGROUND: Actinic Keratosis (AK) is a potentially pre-malignant tumor with a poorly defined risk of progression to invasive squamous cell carcinoma (SCC). Because of the typical need for recurrent cycles of AK treatment, outcomes can be limited by both therapeutic efficacy and patient adherence. OBJECTIVE: To synthesize the available and most current literature into overarching principles to provide guidance on the management of AKs, improving patient experiences and treatment outcomes. METHODS: A systematic review querying epidemiology, natural history, prognosis, management of AKs as well as the mechanism of action of and adherence to current AK therapy was conducted. After reviewing the literature, an expert consensus panel consisting of 10 expert dermatologists and dermatopathologists used a modified Delphi process to develop statements regarding the pathogenesis and management of AKs. Final statements were only adopted with a supermajority vote (≥7/10). RESULTS: The panel developed 7 consensus statements regarding AKs pathogenesis and management. CONCLUSION: The poorly defined risk for AK progression into invasive SCC without universally accepted clinical-histopathological factors highlights the importance of long-term efficacious treatment. To effectively counsel and treat patients with actinic keratoses, dermatologists must understand how newer therapeutic approaches with mechanisms of action that have more rapid onset of action, shorter treatment courses, and less intense local skin reaction (LSRs) may promote adherence and improve long-term outcomes. J Drugs Dermatol. 2021;20(8):888-893. doi:10.36849/JDD.6078 THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL fTEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

Revisiting Handwashing - As It Is Absolutely Essential.

As the coronavirus pandemic continues into the second half of 2020, states across the US remain steadfast in their search to determine the safest methods of returning to normalcy. Without a readily available, effective COVID-19 vaccine, and as the numbers of infected individuals continues to climb, the best practices to ensure public safety are rooted in good personal hygiene and prevention of transmission of the novel coronavirus SARS-CoV-2. To that end, in addition to properly wearing adequate facial covering, individuals should properly wash their hands to prevent direct auto-inoculation. J Drugs Dermatol. 2020;19(11): 1127-1129 doi:10.36849/JDD.2020.5557.

Temporally defined neocortical translation and polysome assembly are determined by the RNA-binding protein Hu antigen R.

Precise spatiotemporal control of mRNA translation machinery is essential to the development of highly complex systems like the neocortex. However, spatiotemporal regulation of translation machinery in the developing neocortex remains poorly understood. Here, we show that an RNA-binding protein, Hu antigen R (HuR), regulates both neocorticogenesis and specificity of neocortical translation machinery in a developmental stage-dependent manner in mice. Neocortical absence of HuR alters the phosphorylation states of initiation and elongation factors in the core translation machinery. In addition, HuR regulates the temporally specific positioning of functionally related mRNAs into the active translation sites, the polysomes. HuR also determines the specificity of neocortical polysomes by defining their combinatorial composition of ribosomal proteins and initiation and elongation factors. For some HuR-dependent proteins, the association with polysomes likewise depends on the eukaryotic initiation factor 2 alpha kinase 4, which associates with HuR in prenatal developing neocortices. Finally, we found that deletion of HuR before embryonic day 10 disrupts both neocortical lamination and formation of the main neocortical commissure, the corpus callosum. Our study identifies a crucial role for HuR in neocortical development as a translational gatekeeper for functionally related mRNA subgroups and polysomal protein specificity.

Advances in Photodynamic Therapy for the Treatment of Actinic Keratosis and Nonmelanoma Skin Cancer: A Narrative Review.

Photodynamic therapy (PDT) with photosensitization using 5-aminolevulinic acid (ALA) [including a nanoemulsion (BF-200 ALA)] is approved in the USA for the treatment of actinic keratoses (AKs); another derivative, methyl aminolevulinate, is not approved in the USA but is used in Europe. For AK treatment, the photosensitizer may be applied to individual AK lesions or, depending on treatment regimen, to broader areas of sun-damaged skin to manage field cancerization, although not all products are approved for field treatment. ALA-PDT and photosensitizers have also been used off-label for the treatment of nonmelanoma skin cancers, primarily basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCC). Advantages of PDT include potentially improved cosmesis and patient satisfaction; disadvantages include pain and duration of treatment. Alternative illumination approaches, including intense pulsed light as well as pulsed-dye lasers, have also been used successfully. Pretreating the affected tissue or warming during incubation can help to increase photosensitizer absorption and improve therapeutic efficacy. Combinations of multiple treatments are also under exploration. Reducing incubation time between photosensitizer application and illumination may significantly reduce pain scores without affecting treatment efficacy. Substituting daylight PDT for a conventional illumination source can also reduce pain without compromising efficacy. The objective of this narrative review is to describe current and ongoing research in the use of topical photosensitizers and modified light delivery regimens to achieve improved therapeutic outcomes with less toxicity in patients with AK, cSCC, BCC, and field cancerization.

Knowledge Gaps Among Dermatologists Regarding Immunotherapy for Non-melanoma Skin Cancer.

Background: Advanced nonmelanoma skin cancer (NMSC) is a sometimes unrecognized public health burden. The development of immune checkpoint inhibitors (ICIs), such as those affecting programmed cell death protein-1 (PD-1), have dramatically changed the management of advanced NMSC. Dermatologists need to be knowledgeable about these therapies given their key role in diagnosing, treating, and comanaging NMSC. The purpose of this study was to assess the knowledge base and identify knowledge gaps that dermatologists may have regarding ICIs and assess advanced NMSC referral patterns. Methods: A 10-question survey was emailed to United States-based dermatologists in July 2021 assessing knowledge of ICI therapy and referral patterns for metastatic cutaneous squamous cell carcinoma (mcSCC) or locally advanced basal cell carcinoma (laBCC) management. Results: At their current knowledge level, respondents averaged 40.6 out of 100 (95% CI [35.1, 46.0]) when asked how comfortable they feel counseling a patient on the risks and benefits of an ICI. Seventy-one percent reported that having more information about treatment for mcSCC or laBCC would be helpful in their practice. Being in practice for less than 10 years was not significantly associated with desiring more information about treatment. The respondents reported that the highest number of annual average referrals out for mcSCC or laBCC were made to Mohs surgeons. Fifty-four percent of respondents received referrals for mcSCC or laBCC, and of the providers receiving referrals, 40 percent of them came from general dermatology. Conclusion: These results demonstrate that a knowledge gap exists for dermatologists in treating mcSCC and laBCC with immunotherapy. There is a need among all dermatologists, regardless of years in practice, to receive this information.

Variance from published guidelines and changes in temporal trends in the management of cutaneous malignant melanoma: a 5-year update.

This study aimed to assess the current management of melanoma from relative to present guidelines and determine changes 5 years ago. An eight-question survey was sent to practicing US dermatologists using the same methodology and questions from our JAAD study. Overall, saucerization/scoop biopsy (48%) was the most commonly used method. The most commonly chosen margin for melanoma in-situ (MMIS) removal was 6-10 mm (51% of respondents). For CMM with a depth greater than 1 mm, the most commonly chosen margins were in the 1.1-1.9 cm range (55% of respondents). More respondents referred cases of MMIS and CMM out for treatment as compared to 2016. Academic dermatologists in 2021 were 8% less likely to treat MMIS as compared to all other practice types in 2021, whereas 7% more likely to treat CMM greater than 1 mm. Academic dermatologists in 2016, as compared to 2021, were 4% more likely to treat MMIS and 19% more likely to treat CMM greater than 1 mm. A total of 91% of respondents reported having some change in their management of CMM. Our study findings suggest that a knowledge gap still exists representing a continued educational opportunity to more effectively distribute and implement CMM management guidelines.

Expert Consensus on the Use of Prognostic Gene Expression Profiling Tests for the Management of Cutaneous Melanoma: Consensus from the Skin Cancer Prevention Working Group.

BACKGROUND: Prognostic assessment of cutaneous melanoma relies on historical, clinicopathological, and phenotypic risk factors according to American Joint Committee on Cancer(AJCC) and National Comprehensive Cancer Network (NCCN) guidelines but may not account for a patient's individual additional genetic risk factors. OBJECTIVE: To review the available literature regarding commercially available gene expression profile (GEP) tests and their use in the management of cutaneous melanoma. METHODS: A literature search was conducted for original, English-language studies or meta-analyses published between 2010 and 2021 on commercially available GEP tests in cutaneous melanoma prognosis, clinical decision-making regarding sentinel lymph node biopsy, and real-world efficacy. After the literature review, the Skin Cancer Prevention Working Group, an expert panel of dermatologists with specialized training in melanoma and non-melanoma skin cancer diagnosis and management, utilized a modified Delphi technique to develop consensus statements regarding prognostic gene expression profile tests. Statements were only adopted with a supermajority vote of > 80%. RESULTS: The initial search identified 1064 studies/meta-analyses that met the search criteria. Of these, we included 21 original articles and meta-analyses that studied the 31-GEP test (DecisionDx-Melanoma; Castle Biosciences, Inc.), five original articles that studied the 11-GEP test (Melagenix; NeraCare GmbH), and four original articles that studied the 8-GEP test with clinicopathological factors (Merlin; 8-GEP + CP; SkylineDx B.V.) in this review. Six statements received supermajority approval and were adopted by the panel. CONCLUSION: GEP tests provide additional, reproducible information for dermatologists to consider within the larger framework of the eighth edition of the AJCC and NCCN cutaneous melanoma guidelines when counseling regarding prognosis and when considering a sentinel lymph node biopsy.

Improved cutaneous melanoma survival stratification through integration of 31-gene expression profile testing with the American Joint Committee on Cancer 8th Edition Staging.

Cutaneous melanoma (CM) survival is assessed using averaged data from the American Joint Committee on Cancer 8th edition (AJCC8). However, subsets of AJCC8 stages I-III have better or worse survival than the predicted average value. The objective of this study was to determine if the 31-gene expression profile (31-GEP) test for CM can further risk-stratify melanoma-specific mortality within each AJCC8 stage. This retrospective multicenter study of 901 archival CM samples obtained from patients with stages I-III CM assessed 31-GEP test predictions of 5-year melanoma-specific survival (MSS) using Kaplan-Meier and Cox proportional hazards. In stage I-III CM population, patients with a Class 2B result had a lower 5-year MSS (77.8%) than patients with a Class 1A result (98.7%) and log-rank testing demonstrated significant stratification of MSS [χ2 (2df, n = 901) = 99.7, P < 0.001). Within each stage, 31-GEP data provided additional risk stratification, including in stage I [χ2 (2df, n = 415) = 11.3, P = 0.004]. Cox regression multivariable analysis showed that the 31-GEP test was a significant predictor of melanoma-specific mortality (MSM) in patients with stage I-III CM [hazard ratio: 6.44 (95% confidence interval: 2.61-15.85), P < 0.001]. This retrospective study focuses on Class 1A versus Class 2B results. Intermediate results (Class 1B/2A) comprised 21.6% of cases with survival rates between Class 1A and 2B, and similar to 5-year MSS AJCC stage values. Data from the 31-GEP test significantly differentiates MSM into lower (Class 1A) and higher risk (Class 2B) groups within each AJCC8 stage. Incorporating 31-GEP results into AJCC8 survival calculations has the potential to more precisely assess survival and enhance management guidance.

Newer Therapies in Psoriasis.

Psoriasis is a systemic inflammatory condition that negatively affects the quality of life and medical health of 125 million individuals globally. Although psoriasis has historically been viewed as a skin-limited disease and managed with topical agents (eg, coal tar, corticosteroids, and vitamin D analogues), the recontextualization of psoriasis as a systemic condition involving multiple organ systems has prompted the development of numerous immunomodulating, systemic agents with more targeted mechanisms of action. This article briefly discusses the indications and nuances of new and developing therapeutic agents for psoriasis management.

Dumbbells for Dummies: A Simplified Approach to Managing Dumbbell-shaped Keloids of the Earlobe.

BACKGROUND: Keloids are dense, fibrous tumors that arise from the dysregulation of normal wound healing, ultimately outgrowing the initial traumatic lesion. OBJECTIVE: We present a modified technique for the excision of dumbbell-shaped keloids on the earlobe using tools common to every dermatologist's office. METHODS: This was an observational report on the outcomes of dumbbell keloid excision using a #15 blade and punch biopsy. Eligible individuals were those with dumbbell-shaped keloids located on the earlobe. All procedures were conducted at an urban dermatology clinic. RESULTS: When combining the technique with continual compression earrings and intralesional corticosteroids, excellent cosmetic outcomes and minimal recurrence were achieved. CONCLUSION: The pairing of a #15 blade and punch biopsy has been demonstrated to produce a more user-friendly method for dumbbell keloid excision by dermatologists and clinicians without advanced surgical training.

The creatine kinase conundrum: a reappraisal of the association of isotretinoin, creatine kinase, and rhabdomyolysis.

BACKGROUND: Isotretinoin has been reported to elevate creatine kinase, which may lead to fatal rhabdomyolysis. OBJECTIVE: To review the literature and propose practice guidelines for management of elevated creatine kinase during isotretinoin therapy. FINDINGS: Patients have intrinsic and extrinsic qualities that may synergistically work with isotretinoin to elevate serum creatine kinase. Darker skin types and males on isotretinoin are more likely to have elevated creatine kinase. Isotretinoin may induce oxidative stress within muscle tissue, thereby leading to elevations in serum creatine kinase. CONCLUSION: Evidence supports a tenuous correlation between isotretinoin, elevated creatine kinase, and exercise. Physicians should consider obtaining baseline creatine kinase on elite athletes and counseling patients on risk factors that may elevate creatine kinase. However, the potential for elevated CK is not a contraindication for isotretinoin therapy.

Rosacea: a wholistic review and update from pathogenesis to diagnosis and therapy.

Rosacea is a chronic inflammatory disorder of the central face with multiple overlapping presentations. Recent advancements are reshaping our understanding of rosacea from both a pathophysiologic perspective and clinical approach to therapy, introducing novel agents that have improved patient outcomes and reduced morbidity. In this article, we aim to outline the advancements in understanding, diagnosing, and managing rosacea and to familiarize physicians with the literature, thereby allowing us to better practice safe and effective medicine.