Demographic and medical school characteristics associated with urban versus rural dermatology practice: A national cross-sectional study.

There are significant disparities in access to dermatologists in rural areas relative to urban areas. We examined the associations between demographic and medical school characteristics and entry into dermatology practice in urban versus rural counties. All dermatologists who graduated from U.S. allopathic or osteopathic medical schools in the 2020 Centers for Medicare & Medicaid Services Physician Compare Database were assessed. Dermatology practice locations were coded as metropolitan or non-metropolitan according to the Rural-Urban Continuum Codes. Of 10,076 dermatologists, 543 (5.4%) practiced in non-metropolitan counties. Male gender (odds ratio [OR] 1.48, 95% CI 1.23-1.77), public medical school attendance (OR 1.94, 95% CI 1.61-2.34), DO degree (OR 1.84, 95% CI 1.32-2.51), medical school location in a non-metropolitan county (OR 5.41, 95% CI 3.66-7.84), and medical school rural track program (OR 1.57, 95% CI 1.07-2.26) were associated with higher odds of non-metropolitan dermatology practice. Our findings highlight that male gender, graduation from a non-metropolitan or public medical school, DO degree, and rural tracks are associated with higher likelihood of non-metropolitan dermatology practice. These results can inform efforts within the field of dermatology to strengthen the rural dermatologist workforce and suggest that rural educational experiences during medical school may increase recruitment of rural dermatologists.

Evaluation of a Comprehensive Skin Toxicity Program for Patients Treated With Epidermal Growth Factor Receptor Inhibitors at a Cancer Treatment Center.

Importance: Up to 90% of patients treated with an epidermal growth factor receptor inhibitor (EGFRi) experience cutaneous toxic effects that are negatively associated with quality of life and lead to treatment interruptions. The Skin Toxicity Evaluation Protocol With Panitumumab trial found reduced incidence of skin toxicity and quality of life impairment with preemptive use of doxycycline hyclate, topical corticosteroids, moisturizers, and sunscreen, demonstrating the benefit of prophylactic treatment for skin toxicity. Objective: To evaluate the association of a comprehensive skin toxicity program with adherence to prophylaxis guidelines for the prevention of EGFRi-associated cutaneous toxic effects. Design, Setting, and Participants: A retrospective cohort study was conducted of all adult patients receiving at least 1 dose of cetuximab at the Dana-Farber Cancer Institute in the calendar year 2012 (2 years after publication of the Skin Toxicity Evaluation Protocol With Panitumumab) or the calendar year 2017 (2 years after full implementation of the Skin Toxicities from Anticancer Therapies program). Main Outcomes and Measures: Primary outcomes were rate of preemptive rash treatment and selection of preemptive agents. Secondary outcomes were incidence of rash, rates of rescue treatments, rates of cetuximab dose changes or interruptions, and overall survival at 2 years. Results: There were 118 patients (85 men; median age, 62.4 years [range, 23.5-91.7 years]) treated with cetuximab in 2012 and 90 patients (70 men; median age, 62.5 years [range, 30.7-90.5 years]) treated with cetuximab in 2017; 11 patients (9%) in 2012 and 31 patients (34%) in 2017 were treated at Dana-Farber Cancer Institute affiliate sites. At cetuximab treatment initiation, 29 patients (25%) in 2012 and 42 patients (47%) in 2017 were prophylactically treated for skin toxicity (P < .001). From 2012 to 2017, preemptive tetracycline use (13 of 29 [45%] to 30 of 42 [71%]; P = .02) and topical corticosteroid use (2 of 29 [7%] to 24 of 42 [57%]; P < .001) increased and topical antibiotic use (23 of 29 [79%] to 18 of 42 [43%]; P = .002) decreased. There was no significant difference in incidence of rash by prophylaxis status. Patients prescribed prophylactic treatment were 94% less likely to require a first rescue treatment for rash (adjusted odds ratio, 0.06; 95% CI, 0.02-0.16; P < .001), 74% less likely to require a second rescue treatment for rash (adjusted odds ratio, 0.26; 95% CI, 0.08-0.83; P = .02), and 79% less likely to experience a cetuximab dose change or interruption (adjusted odds ratio, 0.21; 95% CI, 0.06-0.81; P = .02) than patients not prescribed prophylactic treatment, adjusting for treatment site and year. Conclusions and Relevance: Dermatologists can add value to oncology care by raising awareness of appropriate treatment options and increasing adherence to evidence-based prophylaxis protocols for EGFRi-associated rash, which is associated with decreased interventions and toxicity-associated chemotherapy interruptions.

Natural language processing of Reddit data to evaluate dermatology patient experiences and therapeutics.

BACKGROUND: There is a lack of research studying patient-generated data on Reddit, one of the world's most popular forums with active users interested in dermatology. Techniques within natural language processing, a field of artificial intelligence, can analyze large amounts of text information and extract insights. OBJECTIVE: To apply natural language processing to Reddit comments about dermatology topics to assess for feasibility and potential for insights and engagement. METHODS: A software pipeline preprocessed Reddit comments from 2005 to 2017 from 7 popular dermatology-related subforums on Reddit, applied latent Dirichlet allocation, and used spectral clustering to establish cohesive themes and the frequency of word representation and grouped terms within these topics. RESULTS: We created a corpus of 176,000 comments and identified trends in patient engagement in spaces such as eczema and acne, among others, with a focus on homeopathic treatments and isotretinoin. LIMITATIONS: Latent Dirichlet allocation is an unsupervised model, meaning there is no ground truth to which the model output can be compared. However, because these forums are anonymous, there seems little incentive for patients to be dishonest. CONCLUSIONS: Reddit data has viability and utility for dermatologic research and engagement with the public, especially for common dermatology topics such as tanning, acne, and psoriasis.

Does Provider Specialty Matter?

OBJECTIVES: Multiple practice guidelines discourage indiscriminate use of broad panels of allergen-specific IgE (sIgE) tests due to increased risk of false positives and misinterpretation of results. We provide an analytical framework to identify specialty-specific differences in ordering patterns and effectiveness, which can be used to improve test utilization. METHODS: Test results from a tertiary pediatric hospital were analyzed by ordering specialty to evaluate size of allergen workups. Positivity rates were analyzed to determine effectiveness in selecting tests with high positive pretest probabilities. Laboratory test menu components were also evaluated. RESULTS: Our findings demonstrate 29% of sIgE tests are ordered as part of broad workups (>20 sIgE tests/date of service) contrary to the recommended testing approach. Detailed descriptions of ordering patterns and positivity rates are provided. CONCLUSIONS: This study provides a framework for using a cross-sectional analytical approach to assess test utilization patterns and evaluate components of laboratory testing menus.

Psoriasis in Israel: demographic, epidemiology, and healthcare services utilization.

BACKGROUND: Updated data regarding the epidemiology of psoriasis and related healthcare utilization are lacking. OBJECTIVE: To investigate the epidemiology, comorbidities, healthcare services utilization, and drug use in a large group of patients with psoriasis from Clalit Health Services (CHS) database. METHODS: A controlled cross-sectional study was performed. Case patients were defined when there was at least one documented diagnosis of psoriasis registered by a CHS dermatologist between the years 1998-2016. The extracted data included metabolic, cardiovascular and psychiatric comorbidities; community clinic visits; in- and outpatient services utilization profiles and drug use data, which included pharmacy claims of topical and systemic treatments, including phototherapy and climatotherapy. Comparative analysis was performed by a univariate and multivariate analysis, adjusting for age, gender, obesity, and smoking. RESULTS: The study included 118,680 patients with psoriasis (prevalence of 2.69%) and 118,680 age- and gender-matched controls. Patients with psoriasis had increased prevalence of metabolic, cardiovascular, and psychiatric illnesses. Psoriasis was significantly associated with an increased healthcare utilization. The mean (SD) number of annual dermatologist clinic visits and emergency room visits was 7.2 ± 12.4 and 2.9 ± 7.7 in psoriasis patients as compared to 2.9 ± 7.9 and 2.7 ± 7.4 in the control group (P < 0.001). Topical steroids were the most applied treatment in psoriasis patients (15.5%), and topical vitamin D analogs were second in use (14.6%). Traditional systemic treatment for psoriasis was used in 3.8% of the patients, and biologic treatments were used in 1.6% of the patients. CONCLUSIONS: Our study quantifies healthcare services utilization and drug use in patients with psoriasis.

The utilization of phototherapy in the department of dermatology, Hospital Kuala Lumpur: A 5-year audit.

INTRODUCTION: Ultraviolet phototherapies are important treatment modalities for a wide range of dermatological conditions. We aim to describe the utilization of phototherapy in the Department of Dermatology Hospital Kuala Lumpur. METHODS: This is a 5-year retrospective audit on patients who underwent phototherapy between 2011 and 2015. RESULTS: There were 892 patients, M:F=1.08:1, aged from 4- 88 years, with a median age of 38.8 years who underwent phototherapy. Majority (58.9%) had skin phototype IV, followed by type III (37.7%) and type II (0.7%). There were 697(78.1%) who underwent NBUVB, 136 (15.2%) had topical PUVA, 22(2.5%) had oral PUVA, 12(1.4%) had UVA1 and 23(2.6%) had NBUVB with topical or oral PUVA/UVA1 at different time periods. The indications were psoriasis (46.6%), vitiligo (26.7%), atopic eczema (9.8%), pityriasis lichenoides chronica (5.3%), mycosis fungoides (3.9%), lichen planus (2.5%), nodular prurigo (2.2%), scleroderma (1.2%), alopecia areata (0.7%) and others. The median number of session received were 27 (range 1-252) for NBUVB, 30 (range 1-330) for topical PUVA, 30 (range 3-190) for oral PUVA and 24.5 (range 2-161) for UVA1. The acute adverse effects experienced by patients were erythema (18%), pruritus (16.3%), warmth (3.3%), blister formation (3.1%), cutaneous pain (2.4%), and xerosis (0.8%), skin swelling (0.7%) and phototoxicity (0.2%). CONCLUSION: Narrow-band UVB was the most frequently prescribed phototherapy modality in our center. The most common indication for phototherapy in our setting was psoriasis. Acute adverse events occurred in a third of patients, although these side effects were mild.

Can long-term alopecia occur after appropriate pulsed-dye laser therapy in hair-bearing sites? Pediatric dermatologists weigh in.

BACKGROUND: The risk of long-term alopecia after pulsed-dye laser (PDL) therapy is unknown. To identify how many practitioners treat hair-bearing sites with PDL and how commonly long-term alopecia occurs, the authors queried pediatric dermatologists about their experiences using this modality. METHODS: A survey was designed to evaluate the frequency of and factors contributing to long-term alopecia after PDL treatment of port-wine stains (PWS). "Long-term" was defined as no sign of hair regrowth after several years of nontreatment. The survey was administered to attendees at the 2014 Society for Pediatric Dermatology biannual meeting. RESULTS: Sixty-four pediatric dermatologists completed the survey, 50 of whom had experience using PDL. Of these physicians, 86% have used PDL to treat PWS of the eyebrow and 80% have treated PWS of the scalp. Over one-quarter of respondents (25.5%) using PDL on hair-bearing areas had at least 1 of their patients develop long-term alopecia after PDL treatment. The incidence of long-term alopecia after PDL treatment in the surveyed population was 1.5% to 2.6%. CONCLUSION: The occurrence of long-term alopecia at hair-bearing sites after treatment with PDL may be greater than previously thought. Because the majority of physicians using PDL treat hair-bearing areas, prospective studies are needed to more accurately determine the risk of long-term alopecia and the factors that contribute to it.

Medical error analysis in dermatology according to the reports of the North Rhine Medical Association from 2004-2013.

BACKGROUND: Patient safety is a central issue of health care provision. There are various approaches geared towards improving health care provision and patient safety. By conducting a systematic retrospective error analysis, the present article aims to identify the most common complaints brought forth within the field of dermatology over a period of ten years. METHODS: The reports of the Expert Committee for Medical Malpractice Claims of the North Rhine Medical Association (from 2004 to 2013) on dermatological procedures were analyzed (n =  247 reports in the field of dermatology). RESULTS: Expert medical assessments in the field of dermatology are most frequently commissioned for nonsurgical therapies (e.g. laser therapy, phototherapy). While suspected diagnostic errors constitute the second most common reason for complaints, presumed dermatosurgery-related errors represent the least common reason for commissioning expert medical assessments. CONCLUSIONS: The most common and easily avoidable sources of medical errors include failure to take a biopsy despite suspicious clinical findings, or incorrect clinicopathological correlations resulting in deleterious effects for the patient. Furthermore, given the potential for incorrect indications and the inadequate selection of devices to be used as well as their parameter settings, laser and phototherapies harbor an increased risk in the treatment of dermatological patients. The fourth major source of error leading to complaints relates to incorrect indications as well as incorrect dosage and administration of drugs. Analysis of expert medical assessment reports on treatment errors in dermatology as well as other medical specialties is helpful and provides an opportunity to identify common sources of error and error-prone structures.

Complementary and alternative medicine use in dermatology in the United States.

BACKGROUND: Complementary and alternative medicine (CAM) has an increasing presence in dermatology. Complementary therapies have been studied in many skin diseases, including atopic dermatitis and psoriasis. OBJECTIVES: This study sought to assess oral CAM use in dermatology relative to medicine as a whole in the United States, using the National Ambulatory Medical Care Survey. DESIGN: Variables studied include patient demographic characteristics, diagnoses, and CAM documented at the visits. A brief literature review of the top 5 CAM treatments unique to dermatology visits was performed. RESULTS: Most CAM users in both dermatology and medicine as a whole were female and white and were insured with private insurance or Medicare. Fish oil, glucosamine, glucosamine chondroitin, and omega-3 were the most common complementary supplements used in both samples. CONCLUSIONS: CAM use in dermatology appears to be part of a larger trend in medicine. Knowledge of common complementary therapies can help dermatologists navigate this expanding field.

Phototherapy trends in dermatology.

BACKGROUND: Use of phototherapy in the United States declined during the 1990s, largely due to unfavorable economic incentives. The trends in phototherapy since then are not well characterized. METHODS: We analyzed the National Ambulatory Medical Care Survey (NAMCS) data on quantity of phototherapy visits and associated diagnoses and payment sources. Trends were assessed by linear regression. RESULTS: There were an estimated 230 000 outpatient phototherapy visits per year, with an increasing trend over time (p = 0.03). Dermatologists managed 87% of the visits. Leading diagnoses associated with phototherapy included psoriasis (25%), dermatitis NOS (6%), vitiligo (6%), other dyschromia (6%), and actinic keratosis (5%). CONCLUSIONS: Use of phototherapy for psoriasis has remained relatively low up to 2010. However, phototherapy may be becoming more frequent for conditions other than psoriasis.

Continuous primary care is central to comprehensive cancer care: are we ready to meet growing needs?

Primary care engagement is essential to meet the need for high-quality, comprehensive, long-term cancer care. Primary care currently serves an integral role as the point of care for preventive and surveillance cancer screenings. As cancer prevalence rises, primary care will increasingly serve a growing need for care continuity as patients transition between screening, active treatment, and continued follow-up care.

Can physician's self-estimates be used as a valid instrument to determine prescription frequencies of anti-psoriatic drugs? Comparison of the results of a cross-sectional study using self-estimates with actual prescription behavior documented in a cohort study.

PURPOSE: Physicians' self-estimates of their own prescription behavior can be used as a tool to gather information on prescription frequencies. Self-estimates as a tool for health-care research on prescription frequencies need to be validated as a suitable method before it can be used widely. METHODS: We performed a cross-sectional study inviting all dermatologists in Berlin and Brandenburg to give self-estimates of their own prescription behavior of anti-psoriatic drugs. The results were compared with the results from a consecutive 8-months cohort study with the same participants documenting their actual treatment choices during every visit of a psoriasis patient on a standardized documentation sheet. Differences between self-estimates and documented prescription patterns were analyzed with respect to systemic anti-psoriatic drugs and UV treatment. RESULTS: Fifty-one dermatologists participated. They documented an average of 91 patient visits each. Absolute differences between the self-estimates and the documented actual prescription behavior ranged from -2.5% to 1.4% for systemic treatments. For psoralen plus ultravioloet A (PUVA) treatment, the absolute difference was 3.3% and for ultraviolet B (UVB) 4.7%. CONCLUSIONS: Self-estimates were surprisingly exact. Self-estimates may be suggested as one tool to assess prescription frequencies, but further studies are needed to confirm their validity.

Evaluating practice patterns for managing moderate to severe plaque psoriasis: role of the family physician.

OBJECTIVE: To describe practice patterns for care of Canadian patients with moderate to severe plaque psoriasis. DESIGN: Online survey of a consumer panel. SETTING: Participants were drawn from a population-wide Canadian consumer database. PARTICIPANTS: To be eligible to participate, respondents had to have been diagnosed with plaque psoriasis within the past 5 years, and to have had body surface area involvement of 3% or greater in the past 5 years, or to have psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals), or to be currently receiving treatment with systemic agents or phototherapy for psoriasis. MAIN OUTCOME MEASURES: Proportion of respondents with psoriasis managed by FPs and other specialists, psoriasis therapies, comorbidities, and patient satisfaction. RESULTS: Invitations were sent to 3845 panelists with self-reported psoriasis, of which 514 qualified to complete the survey. Family physicians were reported to be the primary providers for diagnosis and ongoing care of psoriasis in all provinces except Quebec. Overall physician care was reported to be satisfactory by 62% of respondents. Most respondents receiving over-the-counter therapies (55%) or prescribed topical therapies (61%) reported that their psoriasis was managed by FPs. Respondents receiving prescription oral or injectable medications or phototherapy were mainly managed by dermatologists (42%, 74%, and 71% of respondents, respectively). Ongoing management of respondents with body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%). Of those respondents receiving medications for concomitant health conditions, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol and lipid levels (68%). CONCLUSION: Patient-reported practice patterns for the diagnosis and management of moderate to severe psoriasis vary among provinces and in primary and secondary care settings.

Psoriasis in African-Americans: a caregivers' survey.

BACKGROUND: Psoriasis is a common skin disease in Caucasians but less common in African-Americans. AIMS: Our aim is to evaluate caregiver opinions regarding the clinical presentations and treatment of psoriasis in African-Americans compared to Caucasians. PATIENTS/METHODS: A survey was sent to 29 dermatologists who are opinion leaders in the field of psoriasis. The survey included a number of questions regarding the characteristics of the patients seen in their practice. RESULTS: A total of 29 surveys were completed and returned. All of the dermatologists use the extent of disease as a criterion to determine the severity of the disease. Other criteria include scale, thickness, erythema, associated general symptoms, and dyspigmentation. About 66% of the respondents reported the different manifestations of disease, such as more dyspigmentation, thicker plaques, and less erythema in African-Americans. The most common first-line treatments for mild to moderate disease were highpotency topical steroids (68%) followed by topical vitamin D analogues (41%). For moderate to severe disease, the most commonly used first-line treatments were high-potency topical steroids (54%) and phototherapy (46%). CONCLUSIONS: The clinical manifestations of psoriasis in African-Americans are not exactly the same as in Caucasians. Physicians should be aware of the difference in clinical manifestations in African-Americans. Further research and large-scale studies are necessary to elucidate the differences in the clinical presentation, natural course of the disease, and the criteria used for the evaluation of severity among ethnic groups.

[Referrals to dermatology: proportion of banal disorders]. / Demanda derivada a Dermatología: peso de la patología banal.

BACKGROUND AND OBJECTIVE: Skin diseases account for a large number of consultations in primary care. The objective of this study was to determine the characteristics and cost of referrals from primary care to a dermatology clinic. MATERIAL AND METHODS: Descriptive cross-sectional study of referrals from a primary care health center to a dermatology clinic. The dermatology clinic was situated in the same health center and was attended by a dermatologist from Complejo Hospitalario Universitario in Albacete, Spain. The study was performed on 10 days selected at random between April 21, 2009, and June 26, 2009. The data gathered included age, sex, use of cryotherapy, and diagnostic group. Patients were divided into 4 diagnostic groups: A) benign degenerative disease or trivial disorders whose treatment may not merit involvement of the national health service, B) diseases resolved with a single dermatology consultation at the health center, C) diseases requiring evaluation in hospital-based dermatology outpatients, and D) diseases referred for surgical treatment. RESULTS: Data were gathered on 257 patients with a mean age was 41.18 years and there was a slight female predominance. The majority of patients were in diagnostic group B (53.7%), followed by groups A (19.1%), C (19.1%), and D (8.2%). The total estimated cost of these 257 visits was €29 750.32, of which €5672.24 was for trivial disorders. CONCLUSIONS: The current high prevalence of trivial disorders in the caseload of dermatology clinics by trivial disorders makes it necessary to control referrals from primary care more strictly.