Racial and ethnic disparities in clinical research and the dermatology workforce: Part 2.

Although racial and ethnic demographics are shifting in this country, it is not reflected in the diversity of clinical trial research participants; science, technology, engineering, and mathematics pipeline programs; or the workforce in the field of dermatology. Barriers to recruitment of minority patients for research studies also exist for numerous reasons including lack of education of prospective subjects, lack of awareness of ongoing trials, and mistrust within the health care system. Gaps in the science, technology, engineering, and mathematics pipeline for racial and ethnic minorities, particularly Black, Hispanic/Latinx, and American Indian or Alaska Native, are due in large part to structural racism. Lack of exposure as well as lack of educational, mentorship, and research opportunities contribute to gaps in the dermatology workforce. Having a representative population in the dermatology workforce and in clinical research trial patients is essential for optimum patient care, excellence in the specialty, and knowledge of appropriate treatments for minority populations. This article will discuss knowledge gaps for increasing minority subjects who participate in clinical research trials and discuss mechanisms to engage this community in trial recruitment. Additionally, this article addresses lack of racial and ethnic diversity of the dermatology workforce and performance gaps in the recruitment of racial/ethnic minorities into dermatology.

Gaps in medical education curricula on skin of color in medical school, residency, and beyond: Part 1.

Various studies have revealed a disproportionately low representation of skin of color (SOC) dermatology in the medical education system of the United States. This disparity contributes to adverse experiences, missed and/or delayed diagnoses, and overall health inequities for individuals of color. The lack of sufficient SOC education begins at the medical school level and continues throughout residency, fellowship, and beyond formal training. This lack of education can be seen in the dearth of images of common and uncommon skin conditions in darker skin in widely used textbooks and educational resources as well as in the lack of formal training in SOC in many residency programs. Thus far, there have been valuable strides to make dermatologic education more inclusive of all skin colors, but there remains significant work to be done. With the population of the United States expected to continue to diversify and with the expectation that SOC will be a trait of over half of the population of the United States by 2050, it is important to strive for health equity by ensuring that comprehensive and inclusive medical training incorporates SOC. This paper will explore the issue of gaps in medical education in SOC dermatology at all levels and offer a strategic call to action to aid in rectifying this situation.

Geospatial analysis of access to dermatology care in Los Angeles County: a cross sectional study.

Geographic maldistribution of dermatologists contributes to disparities in access to dermatologic care. We aimed to investigate the geographic distribution of, and differences in wait times for medical dermatology services in Los Angeles County (LAC). We placed phone calls to 251 dermatology practices in LAC to ask for a new patient appointment for a changing mole. We found West LAC (Service Planning Area [SPA] 5) had the highest number of dermatologists and South LAC (SPA 6) had the lowest (26.1 versus 0 per 100,000 residents, P=0.01). Service Planning Area 6 has a higher non-White, uninsured, and impoverished population than SPA 5. Dermatology appointment wait times and Medicaid acceptance varied between SPAs but was not statistically significant (P=0.37 and P=0.20, respectively). Medicaid-accepting practices had a significantly longer mean wait time for an appointment than practices that did not accept Medicaid (26.1 versus 15.1 days, P=0.003). Regions with predominantly non-White, Spanish-speaking, and medically underinsured residents were found to be disproportionately lacking in dermatologists across LAC, which may contribute to impaired access to dermatology services in LAC.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. Part II: Differences in clinical presentation and disparities in cutaneous disorders in skin of color.

Skin of color (SOC) patients are projected to comprise the majority of the population by 2044, yet knowledge gaps in the clinical presentation and treatment of both common and uncommon dermatologic conditions in skin of color persist. Improved awareness of disparities that disproportionately impact SOC patients is necessary to address health inequity in the field of dermatology. The first part of this CME discussed structural, genetic, and immunophenotypic differences in SOC in common inflammatory disorders as well as cutaneous malignancies. The second part of this CME highlights clinical differences in the phenotypic presentation of the inflammatory disorders of atopic dermatitis, psoriasis, and hidradenitis suppurativa as well as the cutaneous malignancies of melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma. Health disparities associated with each of these conditions are also discussed.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color - Part I: Genetic, biologic, and structural differences in skin of color.

Skin of color (SOC) populations include those who identify as Black/African, Hispanic/Latinx, Asian/Pacific Islander, American Indian/Native Alaskan, Indigenous Australian, Middle Eastern, biracial/multiracial, or non-White; this list is far from exhaustive and may vary between and within cultures. Recent genetic and immunological studies have suggested that cutaneous inflammatory disorders (atopic dermatitis, psoriasis, and hidradenitis suppurativa) and malignancies (melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma) may have variations in their immunophenotype among SOC. Additionally, there is growing recognition of the substantial role social determinants of health play in driving health inequalities in SOC communities. It is critically important to understand that social determinants of health often play a larger role than biologic or genetic factors attributed to "race" in health care outcomes. Herein, we describe the structural, genetic, and immunological variations and the potential implications of these variations in populations with SOC. This article underscores the importance of increasing the number of large, robust genetic studies of cutaneous disorders in SOC to create more targeted, effective therapies for this often underserved and understudied population. Part II of this CME will highlight the clinical differences in the phenotypic presentation of and the health disparities associated with the aforementioned cutaneous disorders in SOC.

Increased melanocytic nevi and lentigines in two patients with harlequin ichthyosis.

An increased number of melanocytic nevi and lentigines have been reported in patients with two types of autosomal recessive congenital ichthyosis (ARCI): lamellar ichthyosis and nonbullous congenital ichthyosiform erythroderma. These melanocytic lesions may have clinical and dermoscopic features of atypia, necessitating close surveillance. Here, we report two interesting cases of pediatric patients with harlequin ichthyosis (HI) who developed increased melanocytic nevi and lentigines. These cases are unique in that the patients presented at a younger age and one patient had a darker skin phototype than previously described in the literature.

Physical symptoms and psychosocial problems associated with hidradenitis suppurativa: correlation with Hurley stage.

BACKGROUND: Quality of life (QOL) in hidradenitis suppurativa (HS) patients is negatively impacted by physical and psychosocial problems. The aim of this study was to investigate the frequency and severity of HS-specific symptoms and to correlate these with disease severity. Methods We analyzed medical record data from 145 patients seen in an academic HS specialty clinic between August 2009 to March 2018. Results Hurley stage III patients had significantly higher mean Dermatology Life Quality Index (DLQI) scores (20.2) compared to patients with Hurley stage I (11.3) and II (13.9), (P<0.001 and P=0.001, respectively). More than 75% of patients reported physical symptoms of drainage, irritation, pain, itching, bleeding, and odor. There were associated psychosocial problems of embarrassment and self-consciousness. Symptom severity was most strongly correlated with disease severity for odor (correlation coefficient 0.4, P<0.001), difficulty moving arms (0.323, P<0.001), negative impact on job/school (0.303, P<0.001), and negative impact on relationships (0.298, P<0.001). Conclusion Our results highlight the significant burden of HS and the need for a more comprehensive, HS-specific evaluation tool to better assess the QOL of this patient population. Limitations A small cohort in a single academic center.

A neonatal pustule:Langerhans cell histiocytosis.

Langerhans cell histiocytosis (LCH) is a rare, clinically heterogeneous disease that most commonly occurs in pediatric populations. Congenital self-limited LCH is a benign variant of LCH. It most commonly presents as a diffuse eruption and reports of single lesion cases are infrequent in the literature. Even in the case of congenital self-limited LCH, there is potential for future multisystem relapse, making long-term follow-up important. We present a case of single lesion self-limited LCH in a full-term male infant with interesting morphology. Physical examination revealed a painless, 6 millimeter, well-demarcated, papule encircled by erythema with central hemorrhage. An infectious workup was negative and a punch biopsy was obtained, which showed a dermal infiltrate of histiocytes consistent with a diagnosis of LCH. The lesion healed without intervention within three weeks. Our case highlights the need for dermatologists to consider LCH in the differential diagnosis for lesions of varying morphology in children, as proper identification is necessary to monitor for multisystem recurrence.

Obese women experience multiple challenges with breastfeeding that are either unique or exacerbated by their obesity: discoveries from a longitudinal, qualitative study.

Obese women are at risk for shorter breastfeeding duration, but little is known about how obese women experience breastfeeding. The aim of this study was to understand obese women's breastfeeding experiences. We enrolled pregnant women in upstate New York, who were either obese [n = 13; body mass index (BMI) ≥30 kg/m2 ] or normal weight (n = 9; BMI 18.5-24.9 kg/m2 ) before conception and intended to breastfeed. A longitudinal, qualitative study was conducted from February 2013 through August 2014 with semi-structured interviews during pregnancy and at specific times post-partum through 3 months. Interviews were audio recorded, transcribed and analyzed using content analysis. Themes that emerged in analysis were compared between obese and normal-weight women. Differences were identified and described. Prenatally, obese women expressed less confidence about breastfeeding than normal-weight women. Post-partum, obese women and their infants had more health issues that affected breastfeeding, such as low infant blood glucose. Compared with normal-weight women, they also experienced more challenges with latching and positioning their infants. Breastfeeding required more time, props and pillows, which limited where obese women could breastfeed. Obese women also experienced more difficulty finding nursing bras and required more tangible social support than normal-weight women. In conclusion, obese women experienced more challenges than women of normal weight; some challenges were similar to those of normal-weight women but were experienced to a greater degree or a longer duration. Other challenges were unique. Obese women could benefit from targeted care prenatally and during the hospital stay as well as continued support post-partum to improve breastfeeding outcomes. © 2016 John Wiley & Sons Ltd.

Cosmetic injectables in skin of color: A review of uses, safety, and effectiveness of neuromodulators and dermal fillers.

BACKGROUND: Skin of color (SOC) individuals represent a growing market for cosmetic injectables and can have different aesthetic goals and responses to treatment. OBJECTIVE: A review of the uses, safety, and effectiveness of injectable neuromodulators and dermal fillers in SOC individuals. METHODS AND MATERIALS: A search of the PubMed/MEDLINE database was conducted from August 1960 to December 2020. Studies that were included either had a focus on SOC (>20% SOC study participants) or dedicated article content commenting on the safety and/or efficacy of injectables in SOC participants. RESULTS: Of the 503 publications identified, a total of 88 articles were selected for this review. Differences in aging and cultural factors can influence aesthetic goals amongst SOC populations. Available data suggests that botulinum toxin (BTX) and dermal fillers are safe and effective in SOC populations, with the largest amount of data existing for Asian populations. There remains a paucity of research on Black and Latinx populations. CONCLUSION: BTX and dermal fillers are generally effective and well tolerated in SOC populations, particularly Asian populations for which the greatest amount of data exists. More high quality, randomized controlled trials in Black and Latinx populations are warranted.

Isotretinoin in the treatment of hidradenitis suppurativa: a retrospective study.

OBJECTIVE: Isotretinoin has been used off-label in hidradenitis suppurativa (HS) patients with variable results, making it difficult to predict which patients with HS are likely to benefit. MATERIAL AND METHODS: We conducted a retrospective review of HS patients who presented to UCLA HS clinic between August 2009 and March 2018 and collected data on their demographics, reported history of isotretinoin treatment for HS, and treatment response. A number of patient variables were analyzed between the responders and non-responders to see if any were associated with a higher likelihood of a beneficial response. RESULTS: Of the 209 patients, 39 (18.7%) reported prior treatment with isotretinoin. A beneficial response to isotretinoin was reported by 14 (35.9%) patients, while 25 (64.1%) patients reported no response. When comparing responders to non-responders, responders were more likely to have a history of pilonidal cyst (p = .024). Having a concomitant history of regular or cystic acne did not appear to enhance HS treatment response to isotretinoin. CONCLUSIONS: Our data suggest that for HS patients, having a history of pilonidal cyst is associated with a beneficial response to isotretinoin.

Evaluation of Hidradenitis Suppurativa Disease Course During Pregnancy and Postpartum.

Importance: Hidradenitis suppurativa (HS) disproportionately affects women of childbearing potential. There is a paucity of data regarding the HS disease course during pregnancy and in the postpartum period. Objective: To explore the HS disease course during pregnancy and in the postpartum period. Design, Setting, and Participants: A retrospective cohort study was conducted on patients in the Henry Ford Health System, Detroit, Michigan-a large, academic, urban referral center. Women with a diagnosis of HS who became pregnant between January 1, 2008, and December 31, 2018, were included. International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, were used for identification of the diagnosis. Exposures: Pregnancy in patients with HS. Main Outcomes and Measures: Hidradenitis suppurativa disease status during pregnancy and the postpartum period. Results: A total of 127 women with HS were included in this study and accounted for 202 pregnancies. Of the 202 pregnancies, 171 were in black women, 25 in white women, 3 in women of other race/ethnicity, and 3 had unreported data. Mean (SD) age at HS onset was 19.3 (5.6) years; at time of HS diagnosis, 24.4 (5.3) years; and at time of pregnancy, 25.9 (5.0) years. The disease worsened during pregnancy in 70 pregnancies (61.9%), did not change in 34 pregnancies (30.1%), and improved in 9 pregnancies (8.0%). Hidradenitis suppurativa exacerbated in the postpartum period after 82 of 124 pregnancies (66.1%). Dermatologists were involved in managing HS in 28 pregnancies (14.4%) and for a higher proportion of patients with more severe Hurley stage as compared with cases of mild disease (stage 3: 7 of 18 [38.9%] vs stage 1: 10 of 100 [10.0%] or stage 2: 11 of 67 [16.4%]; P = .004). In addition, HS medical treatment was administered during 77 pregnancies (38.1%), while HS procedural treatment was administered during 34 pregnancies (16.8%). A significantly higher proportion of patients whose care was managed by dermatologists vs those without dermatologist involvement received any HS medication (22 [78.6%] vs 53 [31.7%], P < .001) or any HS procedure (14 [50%] vs 19 [11.4%], P < .001) during pregnancy. Conclusions and Relevance: Despite a high rate of HS exacerbation during pregnancy and postpartum, this cohort study found that most of the patients did not receive HS-directed medical treatment or care from a dermatologist during pregnancy. Close monitoring and improved collaborative care between dermatology and obstetrics-gynecology services is warranted.

Hidradenitis Suppurativa in a Patient with Smith-Magenis Syndrome: A Case Report.

Hidradenitis suppurativa (HS) is an inflammatory disorder characterized by recurrent painful nodules and draining sinus tracts with subsequent scarring. HS has been associated with several dermatologic syndromes including the follicular occlusion tetrad, PASH (pyoderma gangrenosum, acne, and suppurativa hidradenitis), PAPASH (pyogenic arthritis, pyoderma gangrenosum, acne, and suppurativa hidradenitis), and SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndromes. However, aside from the well-established association between HS and Down Syndrome, it has rarely been reported in association with other multisystem genetic diseases. We report a case of HS in a 22-year-old man with Smith-Magenis syndrome (SMS), a developmental disorder caused by a chromosomal 17 microdeletion. Obesity and a tendency toward follicular occlusion are features of SMS that may have contributed to the development of HS in our patient. Interestingly, the patient also had several other follicular-based skin diseases including erythromelanosis follicularis faciei, keratosis pilaris, and acne keloidalis nuchae. Dermatologic findings in SMS have been characterized in the literature in the past, but to our knowledge, this is the first case of HS reported in a patient with SMS. We also provide a brief literature review of cases of HS occurring in patients with other multisystem genetic diseases.

Rapidly growing lesions on the forehead.

Three distinct morphologies were visible. Biopsies revealed the diagnosis for each.

Experiences and Perspectives About Breastfeeding in "Public": A Qualitative Exploration Among Normal-Weight and Obese Mothers.

BACKGROUND: Women face societal and cultural barriers to breastfeeding. These challenges have been investigated in international studies and U.S. public opinion polls; however, mothers' experiences with breastfeeding in public in the United States remain unexplored. Research aim: The aim of this study was to describe the experiences of obese and normal-weight women with breastfeeding in public in central New York. METHODS: Pregnant women ( N = 26) in central New York who intended to breastfeed and were either normal weight or obese were enrolled during their third trimester. A longitudinal, qualitative study was conducted to obtain information about women's experiences from birth through 3 to 6 months postpartum. Interviews were audio recorded, transcribed, and verified for accuracy. Transcripts were analyzed iteratively using conventional content analysis. RESULTS: The concept of "public" was situational rather than a set of physical places; women experienced challenges while breastfeeding around others in private locations that were indistinguishable from those they encountered in places typically considered public. Women experienced social and physical awkwardness including perceived lack of acceptability, fear of confrontation, exposure, and positioning difficulties. They used strategies to reduce awkwardness, for example, being "discreet" and minimizing breastfeeding around other people. Obese women experienced similar challenges but to a greater degree than normal-weight women. CONCLUSION: "Breastfeeding around others" described mother's experiences more accurately than "breastfeeding in public" and was experienced as awkward both socially and physically, particularly by obese women. Strategies are needed to normalize breastfeeding in the United States and to prepare mothers for the challenges of breastfeeding around others.