Acitretin for Secondary Prevention of Keratinocyte Cancers in a Veteran Population: A Retrospective Cohort Study.

Acitretin, a vitamin A derivative used for psoriasis, can prevent keratinocyte carcinoma (KC). It induced regression of keratoacanthomas (KA) in animal models, presumably by activating retinoic acid and retinoid X receptors that regulate gene expression for growth and proliferation.1,2.

Teledermatology Outcomes in the Providence Veterans Health Administration.

Background: As technology evolves, so does the integration of technology into health care delivery. Telemedicine, the use of information technology to provide remote health care, aims to improve patient access to quality care across a wide range of barriers. Introduction: Our objective was to determine whether teleconsultation leverages specialist expertise at one site within the United States' largest integrated health system. We evaluated the Providence Veterans Affairs Medical Center (PVAMC) teledermatology store-and-forward program. Materials and Methods: We evaluated 460 completed teleconsultations using retrospective chart review at the PVAMC in June-August 2016 for 12 postimaging outcomes, with no exclusion criteria. We determined outcomes using Computerized Patient Record System chart reviews. Results: Dermatologists completed 84-99% of all teleconsultations within 1 week after referral. Fifty one percent (51%) of patients required no dermatology clinic visit. Six percent (6%) of all teleconsultations were ultimately diagnosed with a biopsy-proven skin cancer. Sixty nine percent (69%) of referring providers prescribed recommended medications within 7 days. Discussion: We conclude that the PVAMC teledermatology program enables rapid access to dermatologic expertise while avoiding unnecessary clinic appointments. Conclusion: By detecting both weak links, and steps in the chain of care that successful teledermatology requires, our findings can help teledermatology systems within and outside the Veterans Affairs maximize their effectiveness.

Mortality burden and prognosis of thin melanomas overall and by subcategory of thickness, SEER registry data, 1992-2013.

BACKGROUND: Thin melanomas cause a high death toll despite excellent prognosis. OBJECTIVE: We examined melanoma mortality burden and prognosis by categories of thickness within Surveillance, Epidemiology, and End Results (SEER) 13 Registry 1992-2013. METHODS: We divided 49,319 stage I and II melanoma cases diagnosed between 1992 and 2003 into T1 through T4 and then subdivided T1 into 0.01-0.25 mm, 0.26-0.50 mm, 0.51-0.75 mm, and 0.76-1.00 mm categories. We determined the number and proportion of deaths due to melanoma within 10 years of diagnosis for each thickness category and proportions within T1 subcategories with ulceration. RESULTS: We confirmed prognosis worsened as melanoma thickened from T1 to T4; however, most deaths resulted from melanomas that were diagnosed at the T1 stage. The smallest number of deaths within T1 resulted from 0.01-0.25 mm-thick melanomas; however, the risk for death within 10 years was greater for those diagnosed with melanoma when tumor depth was 0.01-0.25 mm than for those diagnosed when tumor depth was 0.26-0.50 mm. Prognosis worsened with depths starting at 0.51 mm. The pattern within T1 was not explained by ulceration. LIMITATIONS: We did not evaluate melanoma subtype, mitotic rate, or other associated features. CONCLUSION: Thin melanomas are a substantial public health burden. Efforts should be made to diagnose melanoma at the in situ stage.

Four Diseases, Two Associations, One Patient: A Case of Frontal Fibrosing Alopecia, Lichen Planus Pigmentosus, Acne Rosacea, and Morbihan Disease.

A 77-year-old woman born in the Dominican Republic presented with fullness of the glabella and medial eyebrows for 1 year followed by alopecia of the lateral eyebrows and frontal hairline. She stated that although she had a high hairline at baseline, it had receded in the past year. She had also noted central scalp hair thinning that started 6 years earlier. She denied all styling practices that used traction or chemical processes, although she admitted to hair dye and blow dryer use. She reported "acne" in the central face for decades and darkening of the skin on the lateral face for several years. Her medical history included hypertension, hyperlipidemia, hypothyroidism, benign paroxysmal positional vertigo, and treated breast ductal hyperplasia. Her medications were metoprolol, amlodipine, aspirin, levothyroxine, omeprazole, pravastatin, and meclizine; she denied starting any new medications within the past 2 years. Her family history was notable for androgenic pattern alopecia in a brother and a high hairline in her father. Review of systems was negative except for knee arthralgias and seasonal allergic rhinitis.

Teledermatology Within the Veterans Health Administration, 2002-2014.

BACKGROUND: In order to increase veterans' access to dermatologic care, the Veterans Health Administration (VHA) has developed one of the largest teledermatology programs in the United States. This article describes the recent expansion of the VHA's teledermatology program after local and national initiatives and resource allocation. MATERIALS AND METHODS: This report describes routinely collected VHA data. RESULTS: For the first half of fiscal year 2014, the VHA recorded 31,926 teledermatology encounters, which represents 14% of all recorded teledermatology visits. Although every region in the VHA used teledermatology in the past year, four regions created 51% of the encounters. The use of store-and-forward telehealth (SFT), in which physicians view patient images after the patients were photographed, is increasing, whereas live video use is decreasing. Starting in 2012, encounters for patients in urban areas exceeded those in rural areas. The majority of patients were male veterans 60-79 years of age. Seventy-one percent of SFT consultations for the first half of 2014 were completed within 1 week. CONCLUSIONS: Although errors in and the evolution of coding encounters may distort results, the data show rapid growth of a telemedicine system that increases access to dermatology services for veterans. Most likely this growth reflects institutional commitment to telehealth via policy and resources.

Teledermatology: key factors associated with reducing face-to-face dermatology visits.

Teledermatology makes 3 promises: better, cheaper, and faster dermatologic care. It is "better" because, although it cannot offer as much to the patient as a traditional visit, it extends the dermatologist's reach to places and in ways not previously possible as a result of time and place limitations; it is "cheaper and faster" because it has the potential to reduce costs and increase efficiency for both patients and providers. For teledermatology to fulfill these promises, it must enable dermatologists to improve access by increasing the number of patients evaluated and treated. Increased patient access depends on maximizing a scarce resource-dermatologists' time-in part by avoiding unnecessary and time-consuming face-to-face appointments. We examined the literature to date to determine which teledermatology programs have greater or lesser success in reducing face-to-face visits. Our review highlights 4 factors that are associated with a higher number of face-to-face appointments avoided by teledermatology programs: (1) effective preselection of patients for teleconsultation, (2) high-quality photographic images, (3) dermoscopy if pigmented lesions are evaluated, and (4) effective infrastructure and culture in place to implement teleconsultation recommendations.

Developing an interactive web-based learning program on skin cancer: the learning experiences of clinical educators.

Web-based learning in medical education is rapidly growing. However, there are few firsthand accounts on the rationale for and development of web-based learning programs. We present the experience of clinical educators who developed an interactive online skin cancer detection and management course in a time-efficient and cost-efficient manner without any prior skills in computer programming or technical construction of web-based learning programs. We review the current state of web-based learning including its general advantages and disadvantages as well as its specific utility in dermatology. We then detail our experience in developing an interactive online skin cancer curriculum for primary care clinicians. Finally, we describe the main challenges faced and lessons learned during the process. This report may serve medical educators who possess minimal computer programming and web design skills but want to employ the many strengths of web-based learning without the huge costs associated with hiring a professional development team.

Group clinic for chemoprevention of squamous cell carcinoma: a pilot study.

Topical 5-fluorouracil (5-FU) is a valuable treatment of actinic keratosis (AK), but its use is limited by bothersome side effects. To evaluate patient satisfaction with a regimen of 5-FU for AK in group clinics, we offered participation in shared medical appointments (SMAs) to dermatology clinic patients diagnosed with AK at the Providence VA Medical Center in Rhode Island. Approximately 3 to 4 patients attended each pair of sessions spaced 2 weeks apart. At each visit, photographs and feedback were obtained; at the second visit, clinicians graded the patients' reactions to 5-FU according to a validated numeric scale. Of the 14 study patients who attended the second SMA, 10 stated that they completed 2 weeks of 5-FU therapy, and the other 4 stated that they completed at least 11 days. The validated scale used during the second visit to grade the patients' 5-FU reactions confirmed that all 14 patients demonstrated at least 1 expected adverse skin reaction. Feedback about the group setting was uniformly positive, with specific appreciation for the educational aspects, normalization of the treatment process, and opportunities to ask questions. The group clinic setting for 5-FU was well received and is a promising model for delivering this important treatment.

Bullous Pemphigoid Complicated by MRSA Cellulitis and Bacteremia.

Unrecognized skin conditions are highly prevalent among the elderly population.[10] Bullous pemphigoid (BP), an autoimmune dermatologic disease with greater incidence in the elderly, typically features pruritus, tense bullae formation, and negative Nikolsky's sign.[1,2] We describe a case of BP in an elderly Veteran that developed insidiously for months before it presented with a life-threatening secondary infection due to Methicillin Resistant Staphylococcus Aureus (MRSA).

Compared efficacy and safety of tretinoin 0.1% microsphere gel alone and in combination with benzoyl peroxide 6% cleanser for the treatment of acne vulgaris.

Our purpose was to evaluate the efficacy and safety of a combination of benzoyl peroxide 6% cleanser and tretinoin 0.1% microsphere gel versus monotherapy with tretinoin 0.1% microsphere gel. Eighty-seven healthy males and nonpregnant nonlactating females between the ages of 12 and 30 years with moderate inflammatory acne vulgaris were enrolled in this randomized controlled, investigator-blind, parallel group clinical trial. Subjects were evaluated over 12 weeks for a total of 4 visits. The investigators and subjects completed questionnaires about the test medications. Data from the 56 subjects completing the protocol were considered in the analyses of efficacy and tolerability. The reduction in inflammatory lesions from baseline was significant for both treatment groups at the end of the study. However, there was a significantly greater reduction in the group receiving the combination regimen. Both treatment groups had significant reductions from baseline in noninflammatory lesions at week 12, but no differences were observed between treatment groups. With the exception of skin tightness, which was significantly greater at week 12 in the subjects who received the monotherapy, there were no significant differences between the 2 treatment groups with respect to localized irritation. Adverse events were rare in all subjects. Not only did the combination regimen result in a greater reduction of inflammatory acne lesions than use of the monotherapy but also it did not result in an increase in local irritation.