Applications of nitric oxide-releasing nanomaterials in dermatology: Skin infections and wound healing.

Nitric oxide (NO) is produced in most cells in the skin and is an important regulator of essential cutaneous functions, including responses to UV irradiation, microbial defense, wound healing, melanogenesis and epidermal permeability barrier homeostasis. Harnessing the physiological activities of NO for therapeutic use is difficult because the molecule is highly reactive and unstable. A variety of exogenous NO delivery platforms have been developed and evaluated; however, they have limited clinical applications in dermatology due to instability and poor cutaneous penetration. NO-releasing nanomaterials overcome these limitations, providing targeted tissue delivery, and sustained and controlled NO release. This review provides a comprehensive and up-to-date evaluation of the use of NO-releasing nanomaterials in dermatology for the treatment of skin and soft tissue infections and wound healing.

Perceptions, Utilization, and Cost Assessment of Sebaceous Hyperplasia Treatment Modalities: A Pilot Survey.

BACKGROUND: Sebaceous hyperplasia (SH) is a common, benign but cosmetically bothersome skin condition preferentially affecting older adults. Despite multiple treatment options, there is no universally accepted first-line treatment for SH nor standard pricing for said approaches.  Methods: A survey aimed at evaluating treatment approaches and their respective costs was disseminated on the Orlando Dermatology Aesthetic and Clinical Conference email listserv.  Results: Out of 224 dermatologists who participated in the survey (response rate 9.2%), most treated patients with SH (95.98%). In-office procedures were used more than pharmacologic treatments (P=<0.05). Treatments most used by respondents included electrodesiccation (ED; 83.9%), cryosurgery (35.3%), oral isotretinoin (32.6%), and carbon dioxide (CO2) laser (19.2%). Cryosurgery and ED priced between <$200 to $400. Most reported 1 to 2 sessions to achieve lesion clearance for ED, CO2 laser, and cryosurgery. Twenty-one percent reported 3-4 sessions with cryosurgery. Chemical peels, diode lasers, and photodynamic therapy required between 2-4 sessions. Respondents indicated lesions were most unlikely to recur with ED and CO2 laser. Most dermatologists (86.39%) agreed or strongly agreed that they were exposed to new treatments methods for SH through this survey and 86.49% of dermatologists were interested in learning about treatments employed by others. CONCLUSION: SH is a common issue that presents in the dermatologist's office. These data highlight the perception that ED is the most common approach employed, associated with lower costs, and requiring fewer sessions to achieve resolution. More data is needed and wanted to better determine best practices for the management of SH.J Drugs Dermatol. 2024;23(2):29-37.  doi:10.36849/JDD.7734.

Curcumin nanoparticles as a photoprotective adjuvant.

With rising skin cancer rates and interest in preventing photoaging, adjuvants for sunscreens are in high demand. The potential of curcumin has been posited due to its anti-inflammatory, antioxidant and wound healing properties. In prior studies, curcumin decreased UV-induced inflammation, apoptotic changes in human keratinocytes and dermal fibroblasts, and the expression of matrix metalloproteinases. However, curcumin's utility has been hindered by poor aqueous solubility and rapid degradation in vivo. To overcome these limitations, we synthesized curcumin nanoparticles (curc-np), which offer sustained topical delivery and enhanced bioavailability. Curc-np and controls were applied to the skin of BALB/c mice prior to UVB irradiation. Twenty-four hours later, mice pretreated with curc-np showed less erythema, induration and scale compared to controls. Histopathology showed fewer sunburn cells, and TUNEL assay indicated decreased apoptosis in curc-np treated mice. Immunohistochemistry illustrated less p53 expression in skin pretreated with curc-np. Furthermore, cytokine analysis revealed significantly less IL-6 and significantly greater anti-inflammatory IL-10 in skin of curc-np-treated mice as compared to controls. Taken together, our results reinforce curcumin's established anti-inflammatory effects in the skin and highlight its potential as a photoprotective adjuvant when delivered through nanoparticles. Further investigation alongside sunscreens against UV-induced damage is warranted.

Treating Cutaneous Immune-Related Adverse Events from Immune Checkpoint Blockade.

Immune checkpoint inhibitors (ICPis) have revolutionized outcomes in various advanced malignancies. Therapeutic restoration of a robust T-cell response against malignant cells is also at the root of distinct cutaneous immune-related adverse events (cirAEs). As approved indications for ICPis increase and interdisciplinary collaboration with oncology grows, identifying the most common skin toxicities from ICPis, particularly on melanin-rich skin,1 and understanding treatment strategies are increasingly crucial for dermatologists. This brief review highlights common cirAEs and summarizes the latest evidence for interventions.

Leveraging Virtual Boot Camp to Alleviate First Year Dermatology Resident Anxiety.

The coronavirus disease 2019 pandemic has quickly and abruptly altered workflow and education across medical specialties. As the health crisis persists in the United States, change will be the norm for the foreseeable future. Dermatology residents report high levels of anxiety, with concerns ranging from redeployment to career prospects.1.

Pyoderma Gangrenosum Occurring in the Setting of Hypercortisolism Associated With Adrenocortical Adenoma: A Pathophysiological Paradox.

Pyoderma gangrenosum (PG) is a challenging, rare, ulcerating skin disease characterized by neutrophilic abundance and absence of infection, often associated with systemic diseases. We present a 25-year old previously healthy female with a 1.5-year history of treatment refractory PG. Features of Cushing’s syndrome such as facial plethora, striae, and lipodystrophy were noted on exam, which prompted several studies that ultimately revealed an adrenal adenoma. Following surgical excision of the adenoma, symptoms rapidly resolved and systemic immunosuppressants were discontinued. This rare case highlights the importance that adrenal adenoma and resultant Cushing’s syndrome may be a driver of PG despite the pathophysiologic paradox. J Drugs Dermatol. 2021;20(1):95-97. doi:10.36849/JDD.5566.

Patient Perceptions and Satisfaction With Teledermatology During the COVID-19 Pandemic: A Survey-Based Study.

BACKGROUND: The COVID-19 pandemic has drastically changed the practice of dermatology as social distancing guidelines have led to a shift from in-office care to virtual telehealth (teledermatology). We aimed to determine patient satisfaction, perceived barriers, as well as indications for teledermatology appointments during the COVID-19 pandemic. METHODS: A survey was sent out via SurveyMonkey's online platform to patients of the George Washington Medical Faculty Associates' Dermatology department who attended telehealth appointments during the COVID-19 pandemic. RESULTS: Out of 894 invitations sent, 168 patients completed our survey.The most common reasons for making a telehealth appointment were for a new rash (11.6%), eczema (9.8%), and psoriasis (9.1%). The most common reasons respondents liked telehealth were because of time efficiency (81.1%), not requiring transportation (74.2%), and maintaining social distancing (73.6%). The most common reasons respondents did not like telehealth were due to lack of physical touch (26.8%) and feeling they received an inadequate assessment (15.7%). Very few patients reported that they were unlikely to undertake another telehealth visit (9.94%) or recommend a telehealth visit to others (6.92%). CONCLUSION: Dermatology patients likely perceive telehealth visits as a convenient and safe method for quality care during the COVID-19 pandemic. The lack of physical touch, inability to provide close inspection and/or procedural intervention can be frustrating for patients and therefore meaningful selection of appropriate cases for telehealth visits can optimize the patient experience. Overall, telemedicine represents an effective and safe vehicle for delivering care especially during a global pandemic. J Drugs Dermatol. 2021;20(2):178-183. doi:10.36849/JDD.5714.

Supporting Underrepresented in Medicine (UIM) and non-UIM Trainees Applying into Dermatology: A Qualitative Analysis.

BACKGROUND: Recently, there have been calls to improve diversity among the dermatology workforce, with emphasis placed on the resident selection process and trainee pipeline. However, there is limited data on the perspectives of dermatology applicants, especially among UIM trainees, and the support that they need and want to successfully apply in dermatology. METHODS: To assess trainee perspectives, we disseminated a survey to medical students, interns (matched into dermatology), and dermatology residents asking how dermatology residency programs can best support trainees through the dermatology application process. We developed a codebook drawing upon grounded theory methodology, and consensus coded all qualitative responses. RESULTS: We received 224 qualitative responses from underrepresented in medicine (UIM) (65, 29.0%) and non-UIM trainees (159, 70.9%). UIM trainees were more likely to mention diversity and inclusion initiatives (46.2% vs 3.8%, P<0.001), transparency in program information (40.0% vs 24.5%, P=0.021), holistic review (30.8% vs 6.3%, P<0.001), UIM student outreach/pipeline programs (23.1% vs 0.6%, P<0.001), and mentorship (21.5% vs 8.2%, P=0.009). CONCLUSION: Improving programmatic efforts to address unique challenges UIM trainees face when applying into dermatology is instrumental to mitigating barriers. We highlight opportunities for dermatology residency programs to create a more fair and equitable dermatology application process and support a more diverse pipeline of future dermatologists. J Drugs Dermatol. 2021;20(7):795-797. doi:10.36849/JDD.6043.

Evaluating provider knowledge, perception, and concerns about cannabinoid use in pediatric dermatology.

As the use of medical cannabinoids expands, the value and acceptance in pediatric dermatology is poorly characterized. To better assess the current climate, this survey evaluated pediatric dermatologists' familiarity and knowledge about medical cannabis and their interest to research and use cannabinoids. While the fund of knowledge and acceptance was high, providers voiced concerns about psychoactive effects of cannabis and substance abuse among their pediatric patients.

Harnessing nitric oxide for preventing, limiting and treating the severe pulmonary consequences of COVID-19.

The ongoing outbreak of COVID-19 has quickly become a daunting challenge to global health. In the absence of targeted therapy and a reported 5.5% case fatality rate in the United States, treatments preventing rapid cardiopulmonary failure are urgently needed. Clinical features, pathology and homology to better understood pathogens suggest that uncontrolled inflammation and a cytokine storm likely drive COVID-19's unrelenting disease process. Interventions that are protective against acute lung injury and ARDS can play a critical role for patients and health systems during this pandemic. Nitric oxide is an antimicrobial and anti-inflammatory molecule with key roles in pulmonary vascular function in the context of viral infections and other pulmonary disease states. This article reviews the rationale for exogenous nitric oxide use for the pathogenesis of COVID-19 and highlights its potential for contributing to better clinical outcomes and alleviating the rapidly rising strain on healthcare capacity.

Spironolactone use does not increase the risk of female breast cancer recurrence: A retrospective analysis.

BACKGROUND: Spironolactone is used off-label for androgenic alopecia because of its ability to arrest hair loss progression and long-term safety profile. However, little is known about the safety of spironolactone in breast cancer (BC) survivors. Because spironolactone has estrogenic effects, there is a theoretical risk for BC recurrence. Given that spironolactone is an important tool in the treatment of alopecia, we investigated whether spironolactone increased risk for BC recurrence. OBJECTIVE: To determine whether spironolactone is associated with increased BC recurrence. METHODS: A retrospective analysis was conducted using the Humana Insurance database. Patients with a history of BC were identified using International Classification of Diseases codes, stratified by spironolactone prescription, and also matched 1:1 using propensity score analysis. Patient characteristics and cancer recurrence rates between both cohorts were compared and analyzed. RESULTS: BC recurrence developed in 123 patients (16.5%) who were prescribed spironolactone compared with 3649 patients (12.8%) who developed BC recurrence without spironolactone prescribed (P = .004). After propensity matching, adjusted Cox regression analysis showed no association between spironolactone and increased BC recurrence (adjusted hazard ratio, 0.966; 95% confidence interval, 0.807-1.156; P = .953). LIMITATIONS: Retrospective study. CONCLUSION: Spironolactone was not independently associated with increased BC recurrence and may be considered for the treatment of alopecia in BC survivors.

Disparities in the Utilization of Dermatologists for Primary Cicatricial Alopecias.

Early intervention in cicatricial alopecias is critical to prevent permanent damage to the hair follicles. Previous literature, however, has suggested that individuals who are black are less likely to visit dermatologists than individuals who are white.1.

Is TNF-α Inhibitor-Induced Psoriasiform Dermatitis Always Psoriasiform?

Tumor necrosis factor-α inhibitors (TNFIs) have significantly improved the quality of life for patients with psoriasis and psoriatic arthritis. Despite their beneficial effects, TNFIs have been reported to cause paradoxical 'psoriasiform' eruptions.1 Although this nomenclature has become pervasive in the dermatology lexicon, there is a growing body of literature highlighting the protean clinical presentation of this eruption (Figure 1), which could ultimately lead to a delayed diagnosis.2-5 The diversity of the morphology highlights the importance of identifying key histopathologic characteristics, which to date have not been well-characterized.2

The Influence of Dermatologists' Use of Social Media on Attracting Patients.

BACKGROUND: Many dermatologists consider social media to be a useful tool for building their practices and personal brands. However, limited data exists on patients’ perceptions of the value of social media in dermatology. OBJECTIVE: To examine how social media influences patients when choosing a dermatologist and which aspects of dermatologists’ sites offer the most benefit to patients. METHODS: A cross-sectional study was completed by sampling a diverse online population using a 10-question survey. RESULTS: The survey was sent to 1,481 individuals; of the 57.5% who qualified, 98.5% completed the survey (N=715). Of the qualified respondents, 58% were female and 42% were male. Twenty five percent were 18-29 years, 24% were 30-44 years, 33% were 45-60 years, and 19% were over 60 years. Fifty-seven percent reported that social media is only slightly important or not at all important when selecting a dermatologist. According to respondents, patient reviews (68%), years of experience (61%), and medical information written by the dermatologist (59%) were the most important aspects of dermatologists’ social media sites. Cosmetic patients (P<0.0001), younger patients (P<0.0001), and participants with fewer years of education (P=0.0006) valued social media significantly more when selecting a dermatologist compared to their counterpart populations. LIMITATIONS: Selection bias is possible given the survey was distributed only to SurveyMonkey® users. CONCLUSION: Given the majority of patients reported that social media is not important or only slightly important, dermatologists should consider means other than social media to attract new patients to their practices. For dermatologists who use social media, they should highlight patient reviews, experience level, and original medical content. J Drugs Dermatol. 2020;19(5):   doi:10.36849/JDD.2020.4849.

The Influence of Supportive Oncodermatology Interventions on Patient Quality of Life: A Cross-Sectional Survey.

BACKGROUND: Dermatologic adverse events (dAEs) secondary to anticancer treatments reduce patients’ quality of life (QOL) and result in interruptions in anticancer therapy. OBJECTIVE: Determine if a comprehensive supportive oncodermatology program improves patients’ QOL scoring. METHODS: This was a cross-sectional survey of adult cancer patients enrolled in the George Washington University Supportive Oncodermatology Clinic. All patients were above age 18 years and received dermatologic care between May 1, 2017 and November 1, 2019. Fifty-five patents meeting inclusion criteria were invited to complete an online survey with questions adapted from the Dermatology Life Quality Index (DLQI) and Patient Satisfaction Questionnaire (PSQ-18). RESULTS: Survey initiation rate was 61.8% (34/55) and completion rate 88.2% (30/34). Average QOL score prior to treatment was 6.5 (moderate effect on QOL) and 3.8 (small effect) afterwards (P=0.0005; 95% CI -3.9 to -1.). Average satisfaction score was 4.15 ± 0.7 (satisfied). Impact on treatment adherence earned the lowest score (3.67, neutral to satisfied). LIMITATIONS: Recall bias Conclusion: Enrollment was significantly associated with improved QOL. Dermatologic care also resulted in overall satisfied patient outcomes, although many patients were unsure if these dermatologic interventions aided in anticancer treatment adherence, highlighting the need for evidence-based management strategies for dAEs. J Drugs Dermatol. 2020;19(5):  doi:10.36849/JDD.2020.5040.

A Survey of Dermatologists' Preparedness for Natural and Manmade Disasters

Natural and manmade disasters cause a range of dermatologic manifestations, including secondary infections after a flood,1 irritation from blistering agents used in chemical warfare,2 or acute and chronic effects of cutaneous radiation syndrome.3 Recognizing and managing these disaster sequelae require diagnostic acumen, knowledge on reporting, and short- and long-term management strategies. However, a 2003 survey revealed that 88% of dermatologists felt unprepared to respond to a biological attack.4

Hydrogen Peroxide Topical Solution, 40% (w/w) for the Treatment of Seborrheic Keratoses: A Review

HP40 (Eskata™) is a stabilized, topical solution of 40% hydrogen peroxide (H2O2) packaged in an applicator pen that is US FDA-approved to treat seborrheic keratoses (SKs). By harnessing the oxidative capabilities of H2O2 , 1-2 treatments with HP40 produced a higher rate of clearance of four SKs per patient compared to vehicle in two phase 3 trials. The clearance rate was higher for the face than the trunk and extremities. Similarly, the risks of pigmentary changes and scarring from HP40 were lower for the face than other locations. Further, based on an ex vivo study, HP40 may be less cytotoxic to melanocytes than cryotherapy, but clinical trials comparing these therapies are needed. Limitations of HP40 are its low efficacy and requirement of multiple treatments, which can result in elevated costs. The application can also be time-consuming, though extenders or even staff members can apply it. Therefore, HP40 may be better reserved for the treatment of facial SKs.

Hydrogen peroxide and cutaneous biology: Translational applications, benefits, and risks.

Hydrogen peroxide (H2O2) is an endogenous reactive oxygen species that contributes to oxidative stress directly as a molecular oxidant and indirectly through free radical generation. Topically applied 1% to 45% H2O2 can be used for a range of clinical purposes, which will be reviewed here in addition to its safety. In concentrations from 1% to 6%, H2O2 has antimicrobial properties and can act as a debriding agent through its effervescence, making low-concentration H2O2 useful for wound care. H2O2 has also been shown to promote venous insufficiency ulcer healing, but studies in other wound types are needed. In 1% formulations, H2O2 is used outside the United States to treat acne and has shown efficacy similar to or greater than benzoyl peroxide, with reduced side effects. In a concentration of 40%, H2O2 is US Food and Drug Administration-approved to treat seborrheic keratoses and may cause fewer pigmentary changes than cryotherapy, although elimination often requires 2 to 4 treatments. However, H2O2 should be used with caution, as exposure can cause adverse effects through its oxidant capabilities. Low H2O2 concentrations cause only transient symptoms (blanching and blistering), but exposure to 9% to 45% H2O2 can cause more severe skin damage, including epidermal necrosis leading to erythema and bullae. Overall, H2O2 has numerous therapeutic uses, and novel indications, such as treating actinic keratoses and skin cancers, continue to be explored.

A systematic review of evidence-based treatments for prurigo nodularis.

Prurigo nodularis is a chronic dermatologic condition involving the development of multiple cutaneous nodules in the setting of intractable pruritus. Given emerging treatment options for this difficult-to-treat condition, a current review of therapeutics is needed. A systematic review was performed for clinical studies investigating prurigo nodularis treatment published from 1990 to present including ≥5 subjects. A total of 35 articles were assigned a level of evidence according to the Oxford Center for Evidence-based Medicine. All 5 studies investigating topical agents, including corticosteroids, calcineurin inhibitors, calcipotriol, and capsaicin, conveyed some beneficial effect with level of evidence 2b or higher. Six of 8 reports investigating photo- and photochemotherapy achieved levels of evidence 2b or greater and showed good partial response rates. Thalidomide was studied by 6 reports providing evidence of good symptom response, only 2 of which were rated level 2b or greater. Cyclosporine and methotrexate have demonstrated benefit in 4 combined studies, albeit with level 4 evidence. Pregabalin, amitriptyline, paroxetine, fluvoxamine, and neurokinin-1 receptor antagonists have demonstrated promising evidence in 5 level 2b studies. Higher-powered studies and additional randomized controlled trials are needed for the evaluation of safe and efficacious systemic treatment options for prurigo nodularis.

Use of In-Office Preparations by Dermatologists for the Diagnosis of Cutaneous Fungal Infections

Cutaneous fungal infections account for millions of office visits per year, yet their varied presentations often lead to misdiagnosis. If dermatology clinics are Clinical Laboratory Improvement Amendment (CLIA) certified, direct microscopy with potassium hydroxide or other stains can be used to inexpensively and rapidly diagnose fungal infections. In this survey, we examined dermatologists' perceptions of fungal preparations and CLIA certification to identify barriers that prevent the use of these bedside diagnostics. The response rate was 13% (n=308, based on the number of emails opened). When a cutaneous fungal infection is suspected, 20.94% rarely/never and 19.86% sometimes perform fungal preparations, often because they think clinical diagnosis is adequate or that preparations take too long. 21.32% reported not having CLIA certification, most frequently because the process requires too much work, or they do not know how to apply. Of providers with CLIA certification, over 25% thought it was difficult to obtain. Our results demonstrate that numerous barriers prevent the common use of fungal preparations, including the perception that clinical diagnosis is sufficient and the lack of required CLIA certification. These barriers emphasize the need for additional education about cutaneous fungal infections and use of bedside diagnostics. Additionally, policy-based interventions are necessary to ease the process of CLIA certification.