Perceived Barriers to Career Advancement: Medical Students and Resident Physicians.

BACKGROUND: The path to becoming a physician is challenging, with various barriers influencing medical student and resident physician residency and fellowship training career decisions. Studies comparing perceived obstacles at disparate training levels are limited and given these obstacles are dynamic, studies are frequently needed to evaluate perceived barriers to pursuing residency specialty or fellowship of interest for physician trainees. OBJECTIVE: To evaluate and compare perceived barriers to obtaining residency specialty or fellowship of choice for medical students and resident physicians, respectively. METHODS: A Likert scale survey assessing perceived barriers was administered via the listservs of medical schools and organizations in 2021. Differences in the Likert scale score mean between medical students and resident physicians were measured with student t-tests (2-sided). RESULTS: A total of 404 medical trainees participated (301 medical students and 103 resident physicians). Medical students indicated lack of opportunity to obtain alpha omega alpha membership as the most crucial perceived barrier (mean Likert scale score ± standard deviation, 4.01±1.97), followed by USMLE Step 1 score (3.92±1.89) and lack of home program in specialty/fellowship of interest (3.62±1.85). Similarly, resident physicians implicated the lack of a home program in a specialty/fellowship of interest as the most prominent barrier (3.48±1.78), followed by lack of connections/networking (3.17±1.50) and probability of matching (3.14±1.44). CONCLUSIONS: The lack of a home program was an important barrier to pursuing a specialty or fellowship of choice for both medical students and resident physicians, respectively, and may have been heightened during the COVID-19 pandemic. J Drugs Dermatol. 2023;22(11):e17-e20    doi:10.36849/JDD.7005e.

Emerging Intralesional Treatments for Plantar Warts: A Systematic Review.

BACKGROUND: Therapies for plantar warts remain subjective and unclear, which has led to continual pursuit of an optimal treatment. As a consequence, many intralesional therapies have emerged over the last decade. This warrants a systematic review from a clinical lens which provides updates on intralesional treatment options for plantar warts from the last decade. METHODS: A PubMed/MEDLINE literature search was performed, in accordance with PRISMA reporting guidelines for systematic reviews. Original peer-reviewed articles on safety/efficacy of intralesional plantar wart treatments, published from January 2012 to January 2021, were considered for inclusion. RESULTS: Twenty-6 studies were included and the following intralesional modalities were identified (median cure rates): vitamin D3 (80%), bleomycin (74%), 5-fluorouracil (59%), Candida antigen (66%), zinc sulfate (70%), and purified protein derivative (67%). CONCLUSION: Intralesional vitamin D3, in particular, demonstrated promising results as a potential second- or even first-line agent although not accessible in the United States. Candida antigen and bleomycin are less effective than intralesional vitamin D3, but given their greater accessibility and superiority to cryotherapy, should continue to be considered for treating recalcitrant plantar warts. Moreover, the quadrivalent human papillomavirus (HPV) vaccine, showing success in case reports, warrants further attention for both the treatment and prevention of plantar warts. J Drugs Dermatol. 2022;21(12):1322-1329. doi:10.36849/JDD.6735.

Systemic Medications Associated With Hair Texture Changes.

BACKGROUND: In addition to hair loss, alterations in hair texture can be a worrisome side effect of certain medications yet are seldom reported and poorly characterized. OBJECTIVE: To systematically analyze the scientific literature to characterize medication-associated hair texture changes. METHODS: Relevant primary literature within PubMed and Cochrane was reviewed from 1985-2021 including 31 articles (1 randomized controlled trial with texture changes incidentally noted, 6 cohort, 1 cross-sectional, 23 case studies), comprising 2594 patients. RESULTS: Texture changes were associated primarily with antineoplastic agents (n = 97), antiepileptics (n = 56), retinoids (n = 15), immunomodulators (n = 3), and antiretroviral therapy (n = 1). Average age was 48.4 years old (41.2% female). De novo or exaggerated curling patterns were most commonly reported. Average time to texture change varied from 4.5 months (immunomodulators) to 17 months (antiretrovirals). Prognosis was seldom discussed with reversibility noted across all medication classes (n = 17/21; 3 weeks to 5 years post therapy). Irreversible changes were linked with antiretrovirals, retinoids, and antineoplastics. LIMITATIONS: Inability to define true incidence rates, ethnicity, and severity of texture changes due to the nature of available literature. CONCLUSIONS: Hair texture changes are potential side effects of antineoplastics, antiepileptics, retinoids, immunomodulators, and antiretroviral therapy. As these can have associated psychosocial impact, awareness among prescribing physicians is important.J Drugs Dermatol. 2022;21(9):989-996 doi:10.36849/JDD.6852.

Hair Follicle Melanogenesis Reflected in Hair Pigmentation as a Developmental Factor in Alopecia Areata.

The mechanism of alopecia areata (AA) is not well-elucidated, and hair follicle melanogenesis pathways are implicated as possible sources for autoantigens. After a retrospective medical record review at a single tertiary medical center, the hair color of 112 AA patients were identified and compared to a control group of 104 androgenetic alopecia patients. There were no statistically significant differences in the natural hair color prevalence between the 2 groups (p = 0.164), and hair color was not a predictor of the alopecia type. Our results suggest hair pigmentation, determined by the eumelanin-to-pheomelanin ratio, is not a positive risk factor for AA development. We hope that our study will encourage multiple large-scale, collaborative, retrospective medical reviews to determine if our results are reproducible in diverse patient populations.

Safety Profile for Microneedling: A Systematic Review.

BACKGROUND: Microneedling is a minimally invasive procedure that stimulates collagen and elastin proliferation. It is used in the treatment of various skin pathologies, that is, scarring, photodamage, and hair loss; however, its safety profile has yet to be comprehensively reviewed. OBJECTIVE: This review will discuss the reported side effects of microneedling in the current literature and delineate factors that increase the risk of complications. MATERIALS AND METHODS: A literature search in August 2019 was conducted using the PubMed database to identify studies reporting adverse events (AEs) after microneedling therapy. RESULTS: Eighty-five articles were included in this systematic review. The most common reported AEs are transient procedural events that are expected postprocedure lasting up to 7 days, such as transient erythema/edema and pain, postinflammatory hyperpigmentation (PIH), dry skin/exfoliation, lymphadenopathy, and irritant contact dermatitis. Persistent serious adverse effects included PIH, tram-track scarring, and granulomatous reactions. Factors that increase the risk of events are active infections, darker skin, and metal allergies. CONCLUSION: Microneedling is a relatively safe therapy. Most reported AEs are minimal, resolving quickly and spontaneously. Caution should be taken in patients with active infection, darker skin types, metal allergies, and when used in conjunction with products not approved for intradermal use.

The Impact of Color Fidelity on Evaluation of Patients in the Outpatient Dermatologic Setting.

BACKGROUND AND OBJECTIVES: To demonstrate that high color fidelity light-emitting diode (LED) sources are preferred by dermatologists for the evaluation of patients during standard-of-care, outpatient visits when compared to low color fidelity LED sources similar to fluorescent lighting. STUDY DESIGN/MATERIALS AND METHODS: Three different LED sources were installed in exam rooms at a single, academic, medical institution (low color fidelity [82 color rendering index (CRI)] similar to fluorescent lighting, and high color fidelity [97 CRI and 96+red CRI]). A cross-sectional survey study was conducted in three parts. Naturalness (i.e. ability to reproduce natural, daylight conditions), effectiveness, color contrast, comfort, and overall performance of each LED source were rated on a 5-point scale from 0 to 4 with 0 being the worse, and 4 being the best. The first part included a survey of board-certified dermatologists (n = 3) assessing their visual experience while clinically evaluating a subset of patients during standard-of-care outpatient visits. The second survey was completed by dermatologic medical providers (n = 55) at three separate monthly departmental Grand Rounds sessions in which standardized patients were evaluated with the LED sources. Lastly, patients (n = 75) finished a survey assessing the comfort level of the LED sources. RESULTS: In the first part of the study, all dermatologists significantly preferred the high color fidelity sources over low color fidelity sources based on all five evaluation criteria, with two preferring the 97 CRI LED source overall, while the third dermatologist favored 96+red CRI. Assessments provided by the 55 participants at Grand Rounds demonstrated that the 97 CRI was most "liked." Patients also preferred the high color fidelity LED source, reporting the 96+red CRI source was the "most comfortable." CONCLUSION: Dermatologists, dermatologists-in-training and mid-level providers significantly prefer high color fidelity LED sources for outpatient evaluation of dermatologist patients in enclosed spaces, rating them the more natural, effective, comfortable, and providing superior color contrast than low color sources. Patients also favor high color fidelity LED sources as being the most comfortable in the clinic room. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Mohs surgery for the treatment of lentigo maligna and lentigo maligna melanoma - a systematic review.

BACKGROUND: The role of Mohs micrographic surgery (MMS) in the treatment of lentigo maligna (LM), and lentigo maligna melanoma (LMM) has been controversial. The use of frozen sections is commonly cited as a suboptimal way to distinguish atypical melanocytes, resulting in traditional wide-local excision techniques as the mainstay of therapy. OBJECTIVE: To compare the success of MMS as a treatment option for LM and LMM with that of traditional surgical and nonsurgical therapies by analyzing the published recurrence rates of these lesions after MMS procedures. METHODS AND MATERIALS: PubMed database was used to find relevant articles with search terms related to MMS, LM, and LMM. RESULTS: The search strategy resulted in 27 articles that fulfilled the inclusion criteria. All studies considered; MMS provided a 1.35% recurrence rate with follow-up times ranging from 1 month to 5 years. Specifically, studies employing classical MMS and MMS with rush sections provided recurrence rates of 1.17% and 2.4%, respectively. CONCLUSION: MMS is one of the most successful treatment options for LM and LMM, with published evidence of improved recurrence rates when compared to other forms of therapy. Additional clinical trials are needed to further delineate the role of MMS in the treatment algorithm for these conditions.

Catamenial Hyperpigmentation: A Review.

BACKGROUND: Changes in skin pigmentation patterns related to the fluctuation of estrogen receptors and progesterone receptors during menstruation, also known as catamenial hyperpigmentation, have been reported in several studies. OBJECTIVE: We sought to summarize the literature on catamenial skin hyperpigmentation and menses-induced exacerbations of skin pigmentation disorders. METHODS: We searched PubMed/MEDLINE and the Cochrane Skin database with the search terms menses and pigment, estrogen and pigment, progesterone and pigment, and hyperpigmentation and menses, then assessed the relevant literature on skin diseases related to nonpathological menstruation. RESULTS: The most commonly reported primary catamenial hyperpigmentation disorders are postinflammatory hyperpigmentation (PIH) after laser therapy and ultraviolet sensitivity (UV). The most reported chronic skin pigmentation exacerbated by menses is melasma. The literature detailing catamenial hyperpigmentation is limited to cross-sectional studies, experimental studies, surveys, review articles, case reports, and small trials, leading to a lower level of evidence. CONCLUSION: Our review of the literature revealed that the most common catamenial hyperpigmentation is melasma. We also found a reported higher risk of PIH after laser therapies and UV sensitivity. Estrogen and progesterone are two of the major factors responsible for catamenial hyperpigmentation of the skin. Generally, the changes happen in the luteal phase of the menstrual cycle when the serum levels of sex hormones are at their peak. Although the exact balance of influence is controversial, most recent studies indicate that estrogen has a more prominent role than progesterone in inducing hyperpigmentation.

Low-dose oral minoxidil as treatment for non-scarring alopecia: a systematic review.

BACKGROUND: Topical minoxidil has been used for almost 40 years to treat alopecia. There is growing evidence supporting off-label use of low-dose oral minoxidil. OBJECTIVE: To conduct a systematic review evaluating the use of oral minoxidil for all types of alopecia. METHODS: A primary literature search was conducted using PubMed in May 2019, utilizing the search term "oral minoxidil AND (hair loss OR alopecia OR baldness)". Reviews, non-English studies, and articles concerning only topical minoxidil were excluded. RESULTS: Ten articles were included for review comprising a total 19,218 patients (215 women and 19,003 men). Oral minoxidil dose ranged from 0.25 to 5 mg daily to twice daily. The strongest evidence existed for androgenetic alopecia and alopecia areata (AA), with 61-100% and 18-82.4% of patients demonstrating objective clinical improvement. Successful treatment of female pattern hair loss, chronic telogen effluvium, monilethrix, and permanent chemotherapy-induced alopecia was also reported. The most common adverse effects with oral minoxidil included hypertrichosis and postural hypotension. CONCLUSION: Oral minoxidil is a safe and successful treatment of androgenic alopecia and AA. In addition to its therapeutic benefits, practical advantages over topical minoxidil stem from improved patient compliance.

The expression of opsins in the human skin and its implications for photobiomodulation: A Systematic Review.

BACKGROUND: Skin is the organ most extensively exposed to light of a broad range of wavelengths. Several studies have reported that skin expresses photoreceptive molecules called opsins. However, the identity and functional role of opsins in the human skin remain elusive. We aim to summarize current scientific evidence on the types of opsins expressed in the skin and their biological functions. METHODS: A primary literature search was conducted using PubMed to identify articles on dermal opsins found in nonhuman animals and humans. RESULTS: Twenty-two articles, representing, however, a non-exhaustive selection of the scientific papers published in this specific field, met the inclusion criteria. In nonhuman animals, opsins and opsin-like structures have been detected in the skin of fruit fly, zebrafish, frog, octopus, sea urchin, hogfish, and mouse, and they mediate skin color change, light avoidance, shadow reflex, and circadian photoentrainment. In humans, opsins are present in various skin cell types, including keratinocytes, melanocytes, dermal fibroblasts, and hair follicle cells. They have been shown to mediate wound healing, melanogenesis, hair growth, and skin photoaging. CONCLUSION: Dermal opsins have been identified across many nonhuman animals and humans. Current evidence suggests that opsins have biological significance beyond light reception. In nonhuman animals, opsins are involved in behaviors that are critical for survival. In humans, opsins are involved in various functions of the skin although the underlying molecular mechanisms remain unclear. Future investigation on elucidating the mechanism of dermal opsins will be crucial to expand the therapeutic benefits of photobiomodulation for various skin disorders.

Medication-Induced Repigmentation of Gray Hair: A Systematic Review.

Hair graying is a common sign of aging resulting from complex regulation of melanogenesis. Currently, there is no medical treatment available for hair repigmentation. In this article we review the literature on medication-induced hair repigmentation, discuss the potential mechanisms of action, and review the quality of the literary data. To date, there have been 27 studies discussing medication-induced gray hair repigmentation, including 6 articles on gray hair repigmentation as a primary objective, notably with psoralen treatment or vitamin supplementation, and 21 reports on medication-induced gray hair repigmentation as an incidental finding. Medications noted in the literature include anti-inflammatory medications (thalidomide, lenalidomide, adalimumab, acitretin, etretinate, prednisone, cyclosporin, cisplatinum, interferon-α, and psoralen), stimulators of melanogenesis (latanoprost, erlotinib, imatinib, tamoxifen, and levodopa), vitamins (calcium pantothenate and para-amino benzoic acid), a medication that accumulates in tissues (clofazimine), and a medication with an undetermined mechanism (captopril). Diffuse repigmentation of gray hair can be induced by certain medications that inhibit inflammation or stimulate melanogenesis. There is also low-quality evidence that some vitamin B complex supplementation can promote gray hair darkening. While these compounds are not currently indicated for the treatment of gray hair, their mechanisms shed light on targets for future medications for hair repigmentation.

The use of phosphodiesterase inhibitors for the treatment of alopecia.

Background: Hair loss encompasses a group of scarring and nonscarring diseases with limited treatment options. Understanding the pathogenesis of alopecias has led to the experimental use of phosphodiesterase inhibitors (PDEi).Objective: To perform a systematic review of literature surrounding the use of PDEi for alopecia.Materials and methods: A search was conducted using PubMed in February 2019 on PDEi and alopecia. Inclusion criteria were clinical trials, prospective or retrospective studies, case series and case reports written in English, using PDEi in human subjects for the treatment of alopecia.Results: Fifteen articles were included for review - eight discussing the use of topical caffeine 0.2%-2.5% for the treatment of androgenetic alopecia (AGA) and telogen effluvium (TE), one using injectable caffeine for AGA, one using topical sildenafil for pediatric alopecia areata (AA), and five using oral apremilast for adult AA.Conclusions: Preliminary results using topical caffeine for AGA or TE are promising with minimal adverse events. However, these studies are primarily single-center trials with few patients. Studies using topical or systemic PDEi for AA demonstrate limited success. Current research using PDEi for alopecia is limited, however new clinical trials are being conducted.