Psoriasis - The Life Course Approach.

Over the last decades, Life Course Research (LCR), predominantly the domain of sociology, has been increasingly applied in health research, as Life Course Epidemiology (LCE). The latter is concerned with disease patterns over time, accumulation of exposures over time, critical time periods and patterns of risk. We argue that concepts from LCR and LCE could be widely applied in dermatology, in general, and, more precisely, in the study of chronic inflammatory skin diseases, e.g. atopic eczema and psoriasis. The life course approach can generally be applied in two different ways. It may be used in the more traditional manner, in which the disease and its patterns over time are examined as the outcome vari-able. Conversely, it can examine life course as the outcome variable, which is dependent on the disease course, the treatments administered, and other physical or psychosocial environmental exposures. In dermatology, this second application of the LCR concepts is both promising and relevant because of the notable impact of chronic skin diseases on the patients' quality of life. In particular, we argue how LCR may be conducive to a better understanding of the concept of 'Cumulative Life Course Impairment', which is increasingly gaining acceptance. This approach helps identifying not only individuals at risk and particularly vulnerable patients but also critical periods for optimising interventions in order to avoid life course impairment. It also may facilitate more appropriate treatment decisions in clinical practice.

Effect of Age at Diagnosis on Chronic Quality of Life and Long-Term Outcomes of Individuals with Psoriasis.

Psoriasis is a skin disorder that frequently begins in the pediatric and young adult population but imposes physical and psychosocial burdens over a lifetime. The objective of this retrospective cohort study was to evaluate the effect of age at diagnosis on the lifetime outcomes of psoriasis patients. Individuals with psoriasis (N = 114) completed a questionnaire regarding disabilities, relationships, education, finances, and medical outcomes. Responses were compared among quartiles of age at diagnosis and regression analyses were performed. Those diagnosed at a younger age were more likely to have a greater lifetime Dermatology Life Quality Index (LT DLQI) (p < 0.001), have felt depressed (p = 0.003), believe that psoriasis had caused their depression (p < 0.001), experience lifetime sleep problems (p = 0.004), use recreational drugs (p < 0.001), hide their psoriasis over their lifetime (p < 0.001), and experience more severe lifetime discrimination in social settings (p = 0.002). Early onset psoriasis is associated with depression, social discrimination, and greater LT DLQI.

Patient-clinician concordance, face-time and access.

PURPOSE: People in socially disadvantageous positions may receive less time with their clinicians and consequently reduced access to healthcare resources, potentially magnifying health disparities. Socio-cultural characteristics of clinicians and patients may influence the time spent together. The purpose of this paper is to explore the relationship between clinician/patient time and clinician and patient characteristics using real-time location systems (RTLS). DESIGN/METHODOLOGY/APPROACH: In the MGH/MGPO Outpatient RFID (radio-frequency identification) project clinicians and patients wore RTLS tags during the workday to measure face-time (FT), the duration patients and clinicians are co-located, wait time (WT); i.e. from registration to clinical encounter and flow time (FLT) from registration to discharge. Demographic data were derived from the health system's electronic medical record (EMR). The RTLS and EMR data were synthesized and analyzed using standard structured-query language and statistical analytic methods. FINDINGS: From January 1, 2009 to January 1, 2011, 1,593 clinical encounters were associated with RTLS measured FTs, which differed with socioeconomic status and gender: women and lower income people received greater FT. WT was significantly longer for lower socioeconomic patients and for patients seeing trainee clinicians, women or majority ethnic group clinicians (Caucasian). FLT was shortest for men, higher socioeconomic status and for attending physician patients. Demographic concordance between patient and clinician did not significantly affect process times. RESEARCH LIMITATIONS/IMPLICATIONS: The study demonstrates the feasibility of using RTLS to capture clinically relevant process measures and suggests that the clinical delivery system surrounding a clinical encounter may more significantly influence access to clinician time than individual patient and clinician characteristics. ORIGINALITY/VALUE: Applying RTLS to healthcare is coming. We can now successfully install and run these systems in healthcare settings and extract useful information from them. Interactions with the clinical delivery system are at least as important as interactions with clinicians for providing access to care: measure FT, WT and FLT with RTLS; link clinical behavior, e.g. FT, with patient characteristics; explore how individual characteristics interact with system behavior.

A survey assessment of the recognition and treatment of psychocutaneous disorders in the outpatient dermatology setting: how prepared are we?

BACKGROUND: Dermatologists provide the bulk of psychocutaneous care; however, recent studies suggest that dermatologists believe they are largely underprepared to treat most psychocutaneous conditions. OBJECTIVE: We sought to identify gaps in psychodermatologic knowledge among practicing dermatologists in two academic institutions. METHODS: An online survey was sent to 59 dermatologists at the Massachusetts General Hospital (Boston, MA) and Brigham and Women's Hospital (Boston, MA) from July 2010 through October 2011. RESULTS: The response rate was 40 of 59 (68%). More than 50% of dermatologists were comfortable making diagnoses for 8 of 10 psychocutaneous disorders. In all, 57% were comfortable making a diagnosis of depression. A total of 11% were comfortable starting antidepressants; 3%, antipsychotics; and 66%, medications for neuropathic pain. In all, 72%, 68%, and 21% of dermatologists never prescribe antidepressants, antipsychotics, or medications for neuropathic pain, respectively. Only 38% believed they were successful treating compulsive skin picking; 15%, body dysmorphic disorder; 27%, delusions of parasitosis; and 24%, depression. LIMITATIONS: Limitations include small sample size, data extraction from an academic setting, self-reporting of outcome measures, and response bias. CONCLUSION: Although the majority of the physicians surveyed believed they were capable of diagnosing psychocutaneous disease, very few were comfortable starting psychotropics or thought they were successful treating such conditions.

Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting.

Treatment with tumor necrosis factor-alfa inhibitors and other systemic medications increases the risk of reactivating a latent tuberculosis (TB) infection. Therefore, screening for latent TB infection is important in dermatology patients eligible for treatment with these medications. Although the tuberculin skin test (TST) has its limitations, it has been the standard choice for diagnosis of latent TB infection. Since the development of interferon gamma release assays (IGRAs), the role of the TST has been re-evaluated and IGRAs have increasingly been incorporated into national guidelines. Although there are situations when either test may be performed, in individuals who have received a BCG vaccination and in those who are unlikely to return for a TST reading, IGRAs may be particularly helpful in distinguishing patients at risk for TB. This article discusses the advantages and disadvantages of both the TST and the IGRA and presents a summary of the Centers for Disease Control and Prevention 2010 guidelines for using IGRAs.

The effects of adalimumab treatment and psoriasis severity on self-reported work productivity and activity impairment for patients with moderate to severe psoriasis.

BACKGROUND: Psoriasis significantly impairs work productivity and daily activities. OBJECTIVES: We sought to examine the effects of adalimumab on psoriasis-related work productivity and activity impairment and associations between the impairment and psoriasis severity in patients with moderate to severe psoriasis. METHODS: Data were from the first 16 weeks of the Randomized controlled EValuation of adalimumab Every other week dosing in moderate to severe psoriasis TriAL (REVEAL). Outcomes as measured by the Work Productivity and Activity Impairment Questionnaire for Psoriasis (WPAI-Psoriasis) included employment status, total work productivity impairment, and total activity impairment. Logistic regression and analyses of covariance were used to assess the effects of adalimumab and treatment response (≥ 75% improvement in Psoriasis Area and Severity Index responders) on WPAI-Psoriasis outcomes. Longitudinal generalized estimating equations and Pearson correlation coefficients were used to assess associations between WPAI outcomes and psoriasis severity. RESULTS: Greater improvements in total work productivity impairment and total activity impairment were observed with adalimumab treatment versus placebo (15.5 and 11.1 percentage points, respectively; P < .001). Unemployment rate, total work productivity impairment, and total activity impairment were significantly associated with greater baseline psoriasis severity. Changes in WPAI outcomes were significantly correlated with greater psoriasis severity. The Dermatology Life Quality Index had stronger associations with changes in WPAI outcomes compared with clinical severity measures (Psoriasis Area and Severity Index and Physician Global Assessment). LIMITATIONS: REVEAL only included WPAI data for 16 weeks. Therefore, long-term impact of adalimumab treatment on productivity outcomes could not be assessed. In addition, information on occupational job title or industry was not collected and data were not adjusted for psoriatic arthritis. CONCLUSIONS: Adalimumab reduced psoriasis-related work productivity and activity impairment in patients with moderate to severe psoriasis.

Review of treatment options for psoriasis in pregnant or lactating women: from the Medical Board of the National Psoriasis Foundation.

BACKGROUND: Treating psoriasis in pregnant and lactating women presents a special challenge. For ethical reasons, prospective randomized control trials have not been conducted in this patient population although these patients do encounter new-onset psoriasis in addition to flares and may require treatment throughout their pregnancies. OBJECTIVE: Our aim was to arrive at consensus recommendations on treatment options for psoriasis in pregnant and lactating women. METHODS: The literature was reviewed regarding all psoriasis therapies in pregnant and lactating women. RESULTS: Topical therapies including emollients and low- to moderate-potency topical steroids are first-line therapy for patients with limited psoriasis who are pregnant or breast-feeding. The consensus was that second-line treatment for pregnant women is narrowband ultraviolet B phototherapy or broadband ultraviolet B, if narrowband ultraviolet B is not available. Lastly, tumor necrosis factor-α inhibitors including adalimumab, etanercept, and infliximab may be used with caution as may cyclosporine and systemic steroids (in second and third trimesters). Some specific strategies may be used to minimize risk and exposure. LIMITATIONS: There are few evidence-based studies on treating psoriasis in pregnant and lactating women. CONCLUSIONS: Because there will always be a question of ethical concerns placing pregnant and lactating women in prospective clinical trials, investigation of both conventional and biologic agents are unlikely to ever be performed. Some of these medications used to treat psoriasis are known abortifacients, mutagens, or teratogens and must be clearly avoided but others can be used with relative confidence in select patients with appropriate counseling of risks and benefits.

Career trajectory and job satisfaction trends in Mohs micrographic surgeons.

BACKGROUND: Although many residents and fellows in Mohs surgery express an interest in academics, departure from academics occurs for many trainees or junior faculty. OBJECTIVE: We designed a survey, issued to all American College of Mohs Surgeons (ACMS) members in 2009, to assess reasons for practice selection. RESULTS: A response rate of 65.0% (n=455) was obtained. Of all ACMS members, 33.9% started in academic positions, and 66.1% started in private practice. Retention rates in private practice (61.2%) were significantly higher than in academics (28.0%) (p<.001). The rationale for selection of an academic career included referral base and teaching and research opportunities. Reasons for selection of a private practice career were higher salary, autonomy over resources, and geographic flexibility. There were high rates of departure from academics early on; reasons for departure included lack of support from the academic chair and lack of autonomy over resources. Surgeons leaving academia were able to perform Mohs surgery and continue interests in research and teaching with benefits of greater autonomy over resources in private practice. CONCLUSIONS: Novel efforts to retain academic Mohs surgeons are needed to ensure continued success and evolution of the specialty.

Practice models and roles of physician extenders in dermatologic surgery.

BACKGROUND: The prevalence of physician extenders (PEs) has increased significantly in dermatologic surgery over the last decade. METHODS: An analysis was performed of the staff in dermatologic surgery practices, roles of PEs, and level of supervision. RESULTS: Mohs fellowship-trained (MMSFT) dermatologic surgeons were more likely to employ registered nurses (n=85, 73.9%) than non-fellowship-trained (NMMSFT) surgeons (n=65, 50.0%, p<.05) (dermatologists who reported performing Mohs without having completed a Mohs College fellowship). NMMSFT surgeons (n=46, 35.4%) were 33% more likely to employ physician assistants than MMSFT surgeons (n=30, 26.1%, p=.05). Both surgeon types reported that their physician assistants and nurse practitioners spent the majority of their time treating medical dermatology patients, but NMMSFT surgeons were twice as likely as MMSFT surgeons to have their PEs involved in performing or assisting with cosmetic procedures. MMSFT surgeons (38.5%) were twice as likely to have direct supervision of their PEs as NMMSFT surgeons (16.1%, p=.01). CONCLUSIONS: PEs are highly prevalent in dermatologic surgery practices and are playing direct roles in the delivery of dermatologic care. Promoting patient safety through appropriate extender supervision and reporting of patient outcomes are highly needed as this sector of the dermatologic surgery workforce continues to expand.

Conditioned pharmacotherapeutic effects: a preliminary study.

OBJECTIVE: To test the hypothesize that psoriasis patients treated under a partial schedule of pharmacologic (corticosteroid) reinforcement would show less severe symptoms and relapse than those given the same amount of drug under standard conditions. Behavioral conditioning as an inherent component of many pharmacotherapeutic protocols has never been examined. METHODS: A double-blind, simple randomization intervention was conducted with 46 patients from California and New York. Initially, lesions were treated with 0.1% acetonide triamcinolone under standard treatment conditions. Thereafter, a Standard Therapy group continued on continuous reinforcement (active drug every treatment) with 100% of the initial dose; Partial Reinforcement patients received a full dose 25% to 50% of the time and placebo medication other times; Dose Control patients received continuous reinforcement with 25% to 50% of the initial dose. RESULTS: Severity of disease scores in California neither supported nor refuted the hypothesis. In New York, where there was no difference between Partial Reinforcement and Dose Control groups at baseline, partial reinforcement effected a greater reduction in lesion severity than Dose Control conditions and did not differ from Standard Therapy patients receiving two to four times more drug. For the entire population, the frequency of relapse under partial reinforcement (26.7%) was lower than in Dose Control patients (61.5%) and did not differ from full-dose treatment (22.2%). CONCLUSIONS: A partial schedule of pharmacotherapeutic reinforcement could maintain psoriasis patients with a cumulative amount of corticosteroid that was relatively ineffective when administered under standard treatment conditions. Conceivably, corticosteroid administration only one quarter or half as frequently as currently prescribed is sufficient to treat psoriasis. We posit, however, that these preliminary observations implicate conditioning processes in-and for the design of-regimens of pharmacotherapy.

Recent changes in the workforce and practice of dermatologic surgery.

BACKGROUND: The increasing number of American College of Mohs Surgery (ACMS) fellowship positions over the last decade has resulted in a greater number of fellowship-trained surgeons in dermatologic surgery. METHODS: Mohs micrographic fellowship-trained surgeons (MMFTSs) and non-Mohs fellowship-trained surgeons performing Mohs micrographic surgery (NMMFTSs) were compared using the American Academy of Dermatology Practice Profile Survey (2002/05). An analysis of recent Mohs fellowship classes was also performed. RESULTS: In 2005, there was an equivalent proportion of MMFTSs and NMMFTSs in the workforce (ratio MMFTS:NMMFTS=0.9) but, in 2005, there was a shift in the youngest age cohort (29-39) to a greater proportion of MMFTSs (MMFTS:NMMFTS=1.55). In 2005, the youngest MMFTSs (29-39) were more likely to be female (47.1%) than of MMFTSs overall (24%). MMFTSs were 5 times as likely to be in full-time academic positions and performed 2 to 3 times as many Mohs cases per week as NMMFTSs. CONCLUSIONS: Consistent with demographic shifts in dermatology, differences have emerged in the demographics, surgical volumes, and settings of MMFTSs and NMMFTSs. Recent increases in the ACMS fellowship positions have resulted in a greater proportion of MMFTSs among younger dermatologic surgeons. It will be important to follow how this increase in fellowship trainees affects the dermatologic surgery workforce.

Academic productivity and affiliation of dermatologic surgeons.

BACKGROUND: Because Mohs fellowship training typically incorporates a research component, as required by the Mohs College for fellowship certification, we evaluated whether Mohs microscopic surgery fellowship-trained (MMSFT) dermatologic surgeons were more likely to join academic institutions and demonstrate greater activity in teaching, research, and scientific writing than non-fellowship-trained surgeons (NMMSFT). METHODS: Responses to the 2002 and 2005 American Academy of Dermatology Practice Profile survey comparing practice settings, proportion of time spent in various practice settings, and professional roles were compared between the two groups. RESULTS: MMSFT dermatologic surgeons were 5 times as likely to be in full-time academic practice and 3 times as likely to be in part-time academia as NMMSFT dermatologic surgeons. Consistent with their greater presence in academia, in 2004, 47% of MMSFT dermatologist surgeons participated in teaching, compared with 19% of NMMSFT surgeons (p=.001) and 16% of all dermatologists (p=.001). Twenty-two percent of MMSFT dermatologic surgeons were involved in research, compared with only 4% of NMMSFT dermatologic surgeons (p=.001) and 8% of all dermatologists (p<.05). CONCLUSIONS: Academic productivity of dermatologic surgeons appears to be associated with Mohs fellowship training. The level of teaching and research was significant even in MMSFT surgeons who were not in full- or part-time academic faculty positions. This suggests a strong tradition of academic productivity for dermatologic surgeons outside traditional academic institutions.

The US dermatology workforce: a specialty remains in shortage.

INTRODUCTION: Since 1999, multiple surveys have documented a stable undersupply of dermatologic services in the United States. Factors contributing to the imbalance include changes in the demographics of the physician workforce, increased demand for services, and a limited number of training positions for new physicians. In response to the demand, there has also been a substantial influx of nonphysician clinicians into dermatology offices. METHODS: We sought to follow up the large data set collected by the American Academy of Dermatology in 2002; the survey was repeated in 2005 and 2007. Response rates ranged from 30% to 35% and included more than 1200 respondents each year. RESULTS: Few changes were noted in the metrics used to assess the balance of supply and demand in the US dermatology workforce between 2002 and 2007. Mean wait times for new patient appointments decreased slightly from 36 to 33 days. One third of practices continue to seek additional dermatologists. In 2007, 23% of practices reported employing a physician assistant and 10% a nurse practitioner (up from 15% and 8% in 2002). In 2007, typical dermatologists continued to spend the bulk of their direct patient care time in medical dermatology (23.9 hours, 63%), followed by surgery (10.2 hours, 27%), and then cosmetic dermatology (3.8 hours, 10%). A substantial subset of dermatologists (29%) spent half or more of their time in surgical and cosmetic dermatology combined. Although female dermatologists worked fewer total hours, they spent equal time caring for patients with medical dermatologic conditions, less time in surgical dermatology, and more time in cosmetic dermatology. LIMITATIONS: The survey is potentially subject to inaccurate self-report and response bias. Although the results shed light on patient access and the dermatology workforce, they do not establish or quantify any impact on patients' health. CONCLUSIONS: Between 2002 and 2007, despite continued increases in the number of nonphysician clinicians in US dermatology offices, there were only small changes in the overall metrics commonly used to assess workforce balance. These findings suggest persistent unmet demand, but, given divergent trends of ongoing increases in surgical and cosmetic dermatology, growth in the use of physician assistants and nurse practitioners, and an aging and expanding US population, the future balance of supply and demand remains difficult to predict. Nevertheless, careful workforce planning and deliberative consideration of the risks and benefits of rapidly emerging changes in the delivery of dermatologic care are essential to ensure access to high-quality care for patients with skin disease.

Clobetasol propionate emulsion formulation foam 0.05%: review of phase II open-label and phase III randomized controlled trials in steroid-responsive dermatoses in adults and adolescents.

BACKGROUND: Clobetasol propionate 0.05% emulsion foam was recently developed for use on multiple body sites. OBJECTIVE: We sought to evaluate safety and efficacy of clobetasol emulsion foam 0.05% to treat steroid-responsive dermatoses in multiple age groups. METHODS: A phase II open-label study evaluated the effect of clobetasol foam on the hypothalamic-pituitary-adrenal axis in 52 participants aged 6 years or older with mild-to-severe atopic dermatitis (AD). Cosyntropin stimulation test was used to determine the effect of clobetasol foam on hypothalamic-pituitary-adrenal axis, with a normal response considered to be a postinjection serum cortisol level greater than 18 mug/dL. Another phase II open-label pharmacokinetic safety study was conducted in 32 participants aged 12 years or older with mild-to-moderate plaque-type psoriasis. Pharmacokinetic parameters evaluated included maximal plasma concentration of clobetasol propionate, time to achieve maximum concentration, and area under the curve. Two phase III, randomized controlled studies assessed treatment success in participants aged 12 years or older with moderate-to-severe AD (N = 377) or mild-to-moderate plaque-type psoriasis (N = 497). In all studies, participants received study drug for 2 weeks. In the AD study, treatment success was determined using a composite end point requiring an Investigator's Static Global Assessment (ISGA) score of 0 or 1, erythema score of 0 or 1, induration/papulation score of 0 or 1, and improvement in the ISGA score of at least two grades from baseline. Likewise, the study in plaque-type psoriasis used a composite end point requiring an ISGA score of 0 or 1, erythema score of 0 or 1, scaling score of 0 or 1, plaque thickness score of 0, and improvement in the ISGA score of at least two grades from baseline. RESULTS: Significantly more participants achieved treatment success on clobetasol foam than vehicle foam (P < .0001 and P = .0005 for each study). Reversible hypothalamic-pituitary-adrenal axis suppression was observed in 27% of participants aged 18 years or older and 47% in participants aged between 6 and younger than 12 years, but 0% in participants aged between 12 and younger than 18 years. LIMITATIONS: The studies evaluated short-term use only. CONCLUSION: Clobetasol emulsion formulation foam is safe and effective for treatment of moderate-to-severe AD and mild-to-moderate plaque-type psoriasis in patients aged 12 years or older.

From the Medical Board of the National Psoriasis Foundation: monitoring and vaccinations in patients treated with biologics for psoriasis.

BACKGROUND: Biologics are widely used in the treatment of psoriasis and psoriatic arthritis. OBJECTIVE: Our aim was to arrive at a consensus on the kind of monitoring and the vaccinations that should be performed before and during biologic therapy. METHODS: Medical literature and data presented at meetings were reviewed and a consensus conference was held by members of the Medical Board of the National Psoriasis Foundation. RESULTS: Consensus was established on monitoring and vaccination practices that included discussion and recognition of variations in those practices. History, physical examination, chemistry screen with liver function tests, complete blood cell count, and platelet count and tuberculosis testing are widely obtained at baseline and with variable frequencies thereafter. Patients treated with efalizumab have platelet counts checked more often; liver function tests are repeated more frequently in patients treated with infliximab; patients taking tumor necrosis factor blockers undergo tuberculosis testing more often; and patients treated with alefacept have CD4 counts checked approximately every 2 weeks. Avoidance of live vaccines during biologic therapy and administration of essential vaccines before biologic therapy were discussed, although vaccination is performed only to a variable degree. There was no consistency in the measurement of antinuclear antibodies among the experts. LIMITATIONS: There are few evidence-based studies on monitoring practices for patients with psoriasis taking biologic therapies. CONCLUSIONS: In patients taking biologic therapies for psoriasis, monitoring of blood chemistries, blood counts, CD4 counts, antinuclear antibodies, tuberculin skin tests, history, and physical examination may be warranted depending on the particular therapy and the particular patient. Vaccination practices are also addressed.

Alefacept for erosive lichen planus: a case series.

INTRODUCTION: Erosive mucosal lichen planus is thought to be an autoimmune disease mediated by increased T-cell activation and proliferation. Alefacept is a biologic agent that selectively targets memory T cells. OBJECTIVE: To evaluate the preliminary efficacy and safety of alefacept in the treatment of moderate to severe mucosal LP. METHODS: Seven subjects were randomly selected to receive either alefacept 15 mg or placebo every week for 12 weeks. Endpoints of the case series were the Physician Global Assessment (PGA) of disease severity, mucosal pain (MP) severity, and itch severity (IS). Both subjects and investigators were blinded. RESULTS: Two of the subjects receiving alefacept achieved significant improvement during the study. There were no serious adverse events during the course of the study period. CONCLUSIONS: In this small case series, alefacept may have conferred a modest therapeutic response in erosive lichen planus (LP). Larger multicenter prospective studies will be needed to determine whether alefacept can improve erosive LP in a statistically significant way.

Reductions in healthcare resource utilization in psoriatic arthritis patients receiving etanercept therapy: results from the educate trial.

The Experience Diagnosing, Understanding Care, and Treatment with Enbrel (EDUCATE) trial is a phase IV, 24-week, multicenter, open-label study of etanercept 50 mg weekly in the treatment of psoriatic arthritis (PsA) in community dermatology clinics. In this study, patients with active PsA and moderate to severe plaque psoriasis have measurable uses of healthcare resources at baseline, reflecting a burden of illness. Etanercept significantly reduced healthcare resource utilization, absenteeism, and caregiver assistance in PsA patients after 24 weeks of treatment. These results could translate into savings on both direct and indirect costs and improvements in health-related quality of life for patients with PsA.

Median dermatology base incomes in senior academia and practice are comparable, but a significant income gap exists at junior levels.

BACKGROUND: The perception that dermatologists in practice have substantially higher incomes than in academics is often cited as the primary reason people choose to practice outside academic institutions. OBJECTIVE: We sought to compare the incomes of dermatologists in academics versus various practice settings. METHODS: Data from various surveys of dermatologists from 2002 to 2004 were adjusted for annual inflation to the year 2004 and compared. Benefits and bonuses were not included. The income level of clinical instructors, who are 7.0% of all academic dermatology faculty, were not available for inclusion. RESULTS: Median dermatology faculty income (combined average of assistant, associate, and professor levels) was 192,267 dollars, 12.0% less than the median practice income of 215,303 dollars. There was substantial variation across regions, institutions, and types of nonacademic practice. Median starting incomes for dermatology residency graduates were comparable in practice across multiple data sources (182,116 dollars-200,000 dollars) and private universities (189,336 dollars); however, both were significantly higher than median starting incomes in public universities (83,349 dollars). LIMITATIONS: This study relied on self-reported data. Although all attempts were made to use comparable information, variances in how data were collected and classified may exist. CONCLUSIONS: Initial income for those entering practice is equivalent to those entering academia in private universities; however, incomes for both of these groups are 2- to 3-fold higher than those entering academia in public universities. This discrepancy may discourage some recent trainees, some of whom have high debt and high expenses, from entering the field of academic dermatology. Because incomes in academia increase predictably with increasing rank, overall self-reported incomes for established dermatologists in practice and senior academia are comparable.