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.

Prescribing Trends for Acne Vulgaris Visits in the United States.

Acne vulgaris is the most common reason for pediatric patients and third most common reason for adult patients to seek care from a dermatologist in the US. However, referring providers may be reluctant to initiate patients on acne treatment or certain prescriptions. We assessed over-the-counter (OTC) and prescription acne (antibiotic and non-antibiotic) treatment rates to characterize differences by patient demographics and provider specialty. The National Ambulatory Medical Care Survey (NAMCS) was analyzed for all acne therapies prescribed for at least 10 unweighted visits between 1993 and 2016 (most recent years available). Prescription rates varied by age, with younger patients more likely to receive a prescription; insurance status, with privately insured patients more likely to receive a prescription; and across and within specialties, with dermatologists more likely to recommend a prescription medication than family medicine and pediatric providers. Among all forms of antibiotics for acne vulgaris, oral minocycline was the most commonly prescribed antibiotic by dermatologists, followed by oral doxycycline. Oral minocycline was also the most common antibiotic prescribed by family physicians, followed by oral doxycycline and oral clindamycin, respectively. Pediatricians appeared to be less likely to prescribe oral antibiotics for acne. The OTC topical antimicrobial benzoyl peroxide was the most utilized drug for acne among pediatricians, and it was also the most commonly recommended OTC drug for acne among dermatologists, family physicians, and pediatricians.

Reasons for Visits to the Dermatologist Stratified by Race.

OBJECTIVES: The aim of this study was to examine, from the patient's perspective, the most common reasons for seeking medical attention for skin disease and how this varies among different races. METHODS: We conducted a cross-sectional analysis on the National Ambulatory Medical Care Survey between 2007 and 2018, the most recent years available. The frequency of each reason for visits was determined using the survey procedures of SAS version 9.4. RESULTS: Among White patients, skin cancer screening (8.2%) was the most common reason for visits followed by skin lesions (7.8%) and discoloration/abnormal pigmentation (7.4%). Among Blacks/African Americans, acne (9.2%), progress visit (8.2%), and skin rash (7.0%) were the top reasons for visits. Acne (12%), skin rash (7.5%), and discoloration/abnormal pigmentation (7.3%) were the most common reasons for patient visits in the "other" race category. CONCLUSIONS: Reasons for visits to the dermatologist vary with race. White patients appear to be aware of their increased risk of skin cancer, visiting frequently for skin cancer screenings and skin lesions, whereas Blacks/African Americans are more affected by conditions associated with chronic pruritus. To train dermatologists and nondermatologists to provide equitable care for cutaneous conditions to all races and skin types, especially for those groups experiencing barriers to receiving dermatologic care, it is important that we characterize the reasons why patients visit the dermatologist.

Trends in Office Visits for the Five Most Common Skin Diseases in the United States.

Objective: We sought to determine the outpatient visit rates for the five most common skin conditions among dermatologists and non-dermatologists. Methods: We conducted a population-based, cross-sectional analysis using the National Ambulatory Medical Care Survey between 2007 and 2016, the most recent years available. Results: The five most common skin diagnoses among all medical specialties were contact dermatitis, acne vulgaris, actinic keratosis, benign neoplasm of the skin, and epidermoid cyst, respectively. Actinic keratosis followed by acne vulgaris and benign neoplasm of skin were the three most common visit diagnoses among dermatologists, whereas contact dermatitis, acne vulgaris, and epidermoid cyst were the most common among non-dermatologists. Overall, visits for the five most common skin conditions seen by dermatologists and non-dermatologists remained constant over the study interval. Limitations: Misclassification bias could be impacting the results of this study. Additionally, the NAMCS samples only non-hospital based outpatient clinicians, and thus cannot describe hospital-based outpatient visits or inpatient hospital care. Conclusion: Visits for contact dermatitis, acne, actinic keratosis, benign neoplasm of the skin, and epidermoid cysts have remained constant over the last ten years. These conditions represent the most common diagnoses of the skin at both dermatologists and non-dermatologists outpatient visits. Non-dermatologists continue to see almost half of visits for the five most common skin diagnoses. Patients are often referred from the primary care setting for growths of skin and skin lesions; thus, it is not surprising that actinic keratosis has remained the most common diagnosis among dermatologist and benign neoplasm the third most common dermatologic diagnosis.

Workforce Requirements for Skin Cancer and Related Skin Tumors Continue to Increase: Clinicians Expend an Average of 1,740 Full-Time Effort Years Annually.

BACKGROUND: With an aging population, estimating workforce requirements for management of common conditions such as skin cancer will be necessary to meet the health care needs of the American people. OBJECTIVE: The authors aimed to estimate the workforce requirements for managing skin cancer and other skin tumors. MATERIALS AND METHODS: The authors conducted a population-based, cross-sectional analysis using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between the years 2007 and 2016, the most recent years available. The significance threshold was set at a p-value <.05. RESULTS: The full-time effort of 1,740 (95% confidence interval: 1,340-2,220) clinicians is required to care for skin cancer and other skin tumors each year. The full-time effort years necessary for management of melanoma (p = .006), keratinocytic carcinoma (p < .0001), actinic keratosis (p < .0001), and all skin cancers and tumors (p < .0001) were significantly increasing from 2007 to 2016. CONCLUSION: Clinicians expend a significant amount of time managing skin cancer and other skin tumors, and the time required for management increased over the study period. These workforce requirement trends can likely be attributed to increased prevalence and incidence rates of cutaneous malignancy secondary to an aging population and increased whole-body skin examinations.

Why Do Patients in the United States Seek Care from Dermatologists?

INTRODUCTION: While the diagnoses made at visits to the dermatologist are well characterized, the reasons patients visit the dermatologists are not well described. Understanding why patients present to dermatologists could be helpful in identifying patients' unmet needs and developing outreach programs to improve patients' access to care. The purpose of this study is to characterize the reasons why US patients sought medical attention from dermatologists. METHODS: We evaluated the National Ambulatory Medical Care Survey (NAMCS) between 2007 and 2018, the most recent years available, to characterize the most common reasons patients visit the dermatologist. RESULTS: Sixty-four thousand records were identified in the NAMCS estimating 1.55 billion visits to the dermatologist in the US during the study period. The most common reasons for visits were skin examination (7.8%), skin lesion (7.5%), and discoloration/abnormal pigmentation (7.3%). For patients ≤ 18 years, the most common reasons for visits were acne (28%), warts (7.7%), and skin rash (6.4%). For patients 19-65 years and ≥ 66 years, skin examinations (7.7%) and skin lesions (10%) were the most common reasons for visits to dermatologists, respectively. CONCLUSION: By identifying the most common reasons for visits to the dermatologist, we can improve our understanding of a patient's needs and appropriate health outreach resources to improve patients' access to care.

Skin conditions affect 1.9 billion people globally. While we understand the most common diagnoses made at a dermatology visit, the reasons why patients visit the dermatologist have not been evaluated. We utilized an annual survey conducted by the Centers for Disease Control and Prevention (CDC), the National Ambulatory Medical Care Survey (NAMCS), to identify the most common reasons patients visited the dermatologist between the years 2007 and 2018, the most recent years of the survey available. The most common reasons for visits were skin examination, skin lesion, and discoloration/abnormal pigmentation. For patients ≤ 18 years, the most common reasons for visits were acne, warts, and skin rash. For patients 19­65 years and ≥ 66 years, skin examinations and skin lesions were the most common reasons for visits to dermatologists, respectively. By identifying the most common reasons for visit to the dermatologist, we can better understand a patient's needs and improve a patient's ability to access care for skin conditions.

Epidermolytic ichthyosis complicated by staphylococcal scalded skin syndrome in the newborn.

Epidermolytic ichthyosis is characterized by erythema and blistering at birth. We present a neonate with epidermolytic ichthyosis who had a subtle change in clinical findings while hospitalized, including increased fussiness, erythema, and a change in her skin odor, which represented superimposed staphylococcal scalded skin syndrome. This case highlights the unique challenge of recognizing cutaneous infections in neonates with blistering skin disorders and emphasizes the importance of having a high suspicion for superinfection in this population.

Dermatologists are increasing their use of non-opioid pain medications faster than opioids.

INTRODUCTION: There is a lack of consensus in the literature on how and when dermatologists should prescribe pain medications. As there is an ongoing opioid abuse epidemic driven by prescription opioids, it is important for all fields to investigate their own prescribing patterns. METHODS: We analyzed the National Ambulatory Medical Care Survey from 2007 to 2016 to assess the usage of systemic pain medications amongst dermatologists. RESULTS: There were 16,777 total visits with dermatologists which represents 368 (95% confidence interval 363, 373) million estimated visits. Opioids were used at 1.4% (1.3, 1.6) of visits. As relative proportions, opioids were 35.6 (31.7, 39.6) of all systemic pain medication and non-opioids were 64.4% (53.8, 74.9). The use of opioid (p=.01 [odds ratio 1.08 (1.02, 1.14)]) and non-opioid (p<.001 [odds ratio 1.12 (1.07, 1.17)]) medications increased over the study interval. CONCLUSION: Pain medications were used at a relatively small proportion of visits with dermatologists. Opioids were nearly half of all pain medications used. The use of opioids and non-opioids rose over the study interval, however, non-opioids rose at a faster rate. The faster rise of non-opioids may indicate that dermatologists are making an effort to use medications with less potential for abuse.

Adverse events associated with weekly short course isoniazid and rifapentine therapy in pediatric patients with latent tuberculosis: A chart and literature review.

BACKGROUND: Effective yet safe treatment of latent tuberculosis is important for preventing the spread of tuberculosis and the progression to active disease in pediatric patients. As of 2017, the short course combination regimen of weekly isoniazid and rifapentine (3HP) administered by directly observed therapy (DOT) has replaced 9 months of isoniazid as the standard of treatment for latent tuberculosis in pediatric patients. The literature, limited in size, has established the 3HP regimen's superior safety and adherence. METHODS: We completed a retrospective chart review (n = 22) of pediatric patients at our institution receiving the 3HP regimen via DOT between 2017 and 2019. Frequencies of selected outcomes were compared to previously published data collected in a literature review. RESULTS: In this retrospective chart review, pediatric patients ages 2-20 years receiving 3HP with DOT for latent tuberculosis experienced frequent adverse events, more severe adverse events such as anaphylaxis, and higher treatment discontinuation than that which has been previously reported in the literature. Of note, our cohort's race/ethnicity differed from the cohorts described in the literature. CONCLUSIONS: Our data suggests that the short course combination regimen for pediatric latent tuberculosis patients may have a higher adverse event rate than previously established. Although this sample size is small, this study urges further investigation of more diverse cohorts to better establish the 3HP regimen's safety and tolerability.

Global Epidemiology of Urticaria: Increasing Burden among Children, Females and Low-income Regions.

Urticaria has a high socioeconomic burden worldwide. However, the global epidemiology of urticaria and its geographical and temporal trends are not well studied. Using the Global Burden of Disease dataset, the aim of this study was to analyse the age-standardized prevalence, incidence, years lived with disability, and mean duration of urticaria in 195 countries from 1990 to 2017. In addition, the relationship between socioeconomic development and urticaria was evaluat-ed. The global prevalence of urticaria in 2017 was 86 million people. Females and children aged 1-4 years were more commonly affected than males and adults, respectively: these differences were outside the 95% uncertainty intervals. Regression analyses show-ed that a lower gross domestic product per capita was associated with a higher prevalence and incidence of urticaria (p < 0.001). The global prevalence of urticaria, incidence, and years lived with disability have remained stable from 1990 to 2017.

Burning behaviour of rainscreen façades.

Four reduced-height (5 m) BS 8414-1 façade flammability tests were conducted, three having mineral-filled aluminium composite material (ACM-A2) with polyisocyanurate (PIR) and phenolic (PF) foam and stone wool (SW) insulation, the fourth having polyethylene-filled ACM (ACM-PE) with PIR insulation. Each façade was constructed from a commercial façade engineer's design, and built by practising façade installers. The ACM-PE/PIR façade burnt so ferociously it was extinguished after 13.5 min, for safety. The three ACM-A2 cladding panels lost their structural integrity, and melted away from the test wall, whereupon around 40% of both the combustible PIR and PF insulation burnt and contributed to the fire spread. This demonstrates why all façade products must be non-combustible, not just the outer panels. For the three ACM-A2 tests, while the temperature in front of the cavity was independent of the insulation, the temperatures within it varied greatly, depending on the insulation. The system using PF/A2 allowed fire to break through to the cavity first, as seen by a sharp increase in temperature after 17 min. For PIR/A2, the temperature increased sharply at 22 minutes, as the panel started to fall away from the wall. For SW/A2, no rapid temperature rise was observed.

Smoke toxicity of rainscreen façades.

The toxic smoke production of four rainscreen façade systems were compared during large-scale fire performance testing on a reduced height BS 8414 test wall. Systems comprising 'non-combustible' aluminium composite material (ACM) with polyisocyanurate (PIR), phenolic foam (PF) and stone wool (SW) insulation, and polyethylene-filled ACM with PIR insulation were tested. Smoke toxicity was measured by sampling gases at two points - the exhaust duct of the main test room and an additional 'kitchen vent', which connects the rainscreen cavity to an occupied area. Although the toxicity of the smoke was similar for the three insulation products with non-combustible ACM, the toxicity of the smoke flowing from the burning cavity through the kitchen vent was greater by factors of 40 and 17 for PIR and PF insulation respectively, when compared to SW. Occupants sheltering in a room connected to the vent are predicted to collapse, and then inhale a lethal concentration of asphyxiant gases. This is the first report quantifying fire conditions within the cavity and assessing smoke toxicity within a rainscreen façade cavity.

Fire behaviour of modern façade materials - Understanding the Grenfell Tower fire.

The 2017 Grenfell Tower fire spread rapidly around the combustible façade system on the outside of the building, killing 72 people. We used a range of micro- and bench-scale methods to understand the fire behaviour of different types of façade product, including those used on the Tower, in order to explain the speed, ferocity and lethality of the fire. Compared to the least flammable panels, polyethylene-aluminium composites showed 55x greater peak heat release rates (pHRR) and 70x greater total heat release (THR), while widely-used high-pressure laminate panels showed 25x greater pHRR and 115x greater THR. Compared to the least combustible insulation products, polyisocyanurate foam showed 16x greater pHRR and 35x greater THR, while phenolic foam showed 9x greater pHRR and 48x greater THR. A few burning drips of polyethylene from the panelling are enough to ignite the foam insulation, providing a novel explanation for rapid flame-spread within the facade. Smoke from polyisocyanurates was 15x, and phenolics 5x more toxic than from mineral wool insulation. 1 kg of burning polyisocyanurate insulation is sufficient to fill a 50m3 room with an incapacitating and ultimately lethal effluent. Simple, additive models are proposed, which provide the same rank order as BS8414 large-scale regulatory tests.