South Dakota Dermatology: Urban vs Rural Wait Times and Dermatologist Density.

BACKGROUND: As of 2019, South Dakota had only 32 registered dermatologists, one per 27,569 people. Wait times for dermatologic care are affected by factors such as socioeconomic status, provider distribution, and patient to provider ratios. This inaccessibility to care or prolonged wait times may lead to diagnosis and treatment delays as well as disease progression. We hypothesized wait times to see a dermatologist would be longer in rural areas than urban areas in South Dakota. METHODS: Dermatology clinics throughout South Dakota were contacted to obtain wait times. An internet search was conducted to develop a list of dermatology providers. A population of 50,000 or greater defined an urban area and a ratio of four dermatologists per 100,000 people was used as an ideal patient to provider ratio. RESULTS: Overall, 75% of South Dakota's dermatology clinics participated with an equal rural to urban distribution. There was no difference in wait times for new (p=0.787) or established patients (p=0.461) comparing rural and urban clinics. All South Dakota cities with clinics met the goal patient to dermatologist ratio except for Dakota Dunes (included as part of the Sioux City, Iowa, metro population). CONCLUSIONS: The data does not support the hypothesis that wait times for dermatologists would be longer in rural locations than urban locations. Despite adequate dermatologist to patient ratios throughout most of South Dakota, wait times of over six weeks were found at both urban and rural locations, indicating the need for future studies to assess potential solutions for improving timely access to dermatologic care.

A Rare Case of Axillary Extramammary Paget's Disease with an Underlying Adenocarcinoma.

Extramammary Paget's disease (EMPD) is an uncommon cutaneous neoplasm almost exclusively located in the vulvar, perianal, and male genitalia regions. Evaluation and management are complicated given the average delay in diagnosis is two years and approximately 30% of cases are associated with underlying malignancies. The axilla is a unique location for EMPD. We report a rare case of a 78-year-old male with axillary EMPD associated with an underlying adenocarcinoma. A 1-cm tender and pruritic erythematous plaque with surrounding erythema appeared in the patient's axilla. An irritated seborrheic keratosis secondarily impetiginized along with irritant contact dermatitis was suspected. Treatment of cefdinir and topical hydrocortisone failed and a biopsy was taken. Microscopic and immunohistochemical examination showed ulceration with an underlying proliferation of atypical glands (Figure 2A) and a nested intraepidermal proliferation with pagetoid spread (Figure 2B). The atypical cells were positive for gross cystic disease fluid protein 15 (Figure 2C), epithelial membrane antigen (Figure 2D), cytokeratin 5/6, and cytokeratin 7. These findings were supportive of an apocrine adenocarcinoma arising in association with EMPD. Wide location excision was performed. Screening for associated malignancies or lymphatic spread is the primary goal during evaluation. Outcomes are favorable when the primary neoplasm is of limited distribution. The accepted treatment for primary lesions is wide local excision, although anatomic tissue constraints necessitate further research into other treatment modalities. To our knowledge, this is the 14th reported case of axillary EMPD with an underlying adenocarcinoma which may help with identification and management of future cases.