Geospatial analysis of access to dermatology care in Los Angeles County: a cross sectional study.

Geographic maldistribution of dermatologists contributes to disparities in access to dermatologic care. We aimed to investigate the geographic distribution of, and differences in wait times for medical dermatology services in Los Angeles County (LAC). We placed phone calls to 251 dermatology practices in LAC to ask for a new patient appointment for a changing mole. We found West LAC (Service Planning Area [SPA] 5) had the highest number of dermatologists and South LAC (SPA 6) had the lowest (26.1 versus 0 per 100,000 residents, P=0.01). Service Planning Area 6 has a higher non-White, uninsured, and impoverished population than SPA 5. Dermatology appointment wait times and Medicaid acceptance varied between SPAs but was not statistically significant (P=0.37 and P=0.20, respectively). Medicaid-accepting practices had a significantly longer mean wait time for an appointment than practices that did not accept Medicaid (26.1 versus 15.1 days, P=0.003). Regions with predominantly non-White, Spanish-speaking, and medically underinsured residents were found to be disproportionately lacking in dermatologists across LAC, which may contribute to impaired access to dermatology services in LAC.

A Case of Atypical Lymphocytic Lobular Panniculitis.

Atypical lymphocytic lobular panniculitis (ALLP) is a rare T-cell dyscrasia of the subcutaneous fat. It typically presents with indurated erythematous nodules on the lower extremities and often will have a relapsing and remitting course. The cause is unknown, but clinically and histopathologically it shares similarities to lupus panniculitis (LP) and subcutaneous panniculitis-like T-cell lymphoma (SPTCL). It generally has an indolent course, and may best be treated like indolent versions of SPTCL with systemic steroids and immunosuppressive medications.

Teledermatology: Meeting the Need for Specialized Care in Rural Haiti.

BACKGROUND: In Haiti, rural populations lack access to specialized care, such as dermatology, yet dermatological conditions are common causes for primary care (PC) visits. Studies on teledermatology from resource-constrained settings demonstrate promising results. We assessed the feasibility of implementing teledermatology in rural Haiti. METHODS: Patients with dermatological problems were examined by a PC provider in Haiti. Photos and intake evaluations were reviewed by U.S.-based dermatologists. RESULTS: Among 101 patients with dermatological problems, atopic disease and fungal infections were most common. Average diagnostic concordance between Haitian providers and U.S. dermatologists was 68.9%. The average time from intake to "case-closed" was 1.67 days. DISCUSSION: Diagnostic concordance and turn-around time were comparable to similar studies, demonstrating that teledermatology is well-suited for rural Haiti and could increase access to specialized care. CONCLUSION: In Haiti and similar settings, telemedicine should be considered a viable option for meeting the health care needs of underserved populations.

Eccrine poromatosis following chemotherapy and radiation therapy.

Eccrine poroma presents as a single, symptomless erythematous papule in areas with a high density of eccrine sweat glands. Although rare, eccrine poromas can present as multiple lesions, otherwise known as eccrine poromatosis. The etiology of eccrine poromatosis is unclear. We present two cases of eccrine poromatosis in patients who had undergone chemotherapy, radiation therapy, and stem cell transplant. This case report serves to raise awareness of this condition and highlight its association with malignancies and their treatment.

Vaccine-induced toxic epidermal necrolysis: A case and systematic review.

BACKGROUND: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are cutaneous hypersensitivityreactions that develop in response to specific triggers such as medications and certain infections. Vaccines, which undergo rigorous safety testing prior to use in humans, are a rare cause of SJS/TEN and little is known about the frequency of such events and corresponding pathogenesis. OBJECTIVE: Herein, we discuss a case of suspected TEN in a 19-year-old woman who received the meningococcal B vaccine (the first report of such an association) and conduct a systematic review of the associated literature. We also discuss management of this patient with a single dose of etanercept. METHODS: Relevant literature was searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. RESULTS: A total of 29 articles reporting EM, SJS, or TEN following vaccination were included from >5 countries. Of the 29, 22 articles reported EM, 6/29 reported SJS, and 4/29 reported TEN (3 articlesreported cases of both EM and SJS/TEN). CONCLUSIONS: We suggest consideration of vaccines as an etiology for cases of SJS or TEN that begin with an EM-like presentation, and provide further evidence for the use of etanercept as a viable treatment for TEN.

Spotlight on brodalumab in the treatment of moderate-to-severe plaque psoriasis: design, development, and potential place in therapy.

Brodalumab is a novel fully human immunoglobulin G2 monoclonal antibody that antagonizes the interleukin (IL)-17 pathway by binding with high affinity to human IL-17RA. The role of IL-17A in the pathogenesis of psoriasis, as well as the remarkable effectiveness of IL-17 inhibitors in the treatment of moderate-to-severe plaque psoriasis, is well established. The mechanism of action of brodalumab is unique in that it inhibits the IL-17 receptor compared to the two other currently FDA-approved IL-17 inhibitors, secukinumab and ixekizumab, which inhibit the IL-17A molecule itself. The efficacy of brodalumab in the treatment of moderate-to-severe plaque psoriasis has been demonstrated in phase 2 and 3 trials, and subsequently the FDA approved this medication in February 2017. Brodalumab was approved in Japan in July 2016 and approval is pending in Europe. The safety and adverse effects of brodalumab were reviewed across several clinical trials, which, similar to other IL-17 inhibitors, demonstrated increased rates of neutropenia and Candida infections. Brodalumab treatment, similar to ixekizumab and secukinumab, showed no improvement in inflammatory bowel disease patients, and on the contrary, more exacerbations were encountered. Suicidal ideation and behavior events have been reported with brodalumab treatment and are of significant concern. Brodalumab provides another highly effective treatment option for moderate-to-severe plaque psoriasis.

Interobserver reliability of teledermatology across all Fitzpatrick skin types.

Introduction Demand for dermatologic services in safety net hospitals, which disproportionately serve patients with darker coloured skin, is growing. Teledermatology has the potential to increase access and improve outcomes, but studies have yet to demonstrate the reliability of teledermatology for all Fitzpatrick skin types. Methods We assessed the reliability of teledermatologists' diagnoses and management recommendations for store-and-forward teledermatology in patients with lightly pigmented (Fitzpatrick skin types I-III) versus darkly pigmented (Fitzpatrick skin types IV-VI) skin, when compared to in-person diagnosis and management decisions. This prospective study enrolled 232 adult patients, presenting with new, visible skin complaints in a Los Angeles county dermatology clinic. Forty-seven percent of patients were Fitzpatrick skin types I-III, and 53% were Fitzpatrick skin types IV-VI. Results Percent concordance for the identical primary diagnosis was 53.2% in lighter (Fitzpatrick I-III) skin types and 56.0% in darker (Fitzpatrick IV-VI) skin types. There was no statistically significant difference in concordance rates between lighter and darker skin types for primary diagnosis. Concordance rates for diagnostic testing, clinic-based therapy, and treatments were similar in both groups of Fitzpatrick skin types. Discussion These results suggest that teledermatology is reliable for the diagnosis and management of patients with all Fitzpatrick skin types.

Profile of secukinumab in the treatment of psoriasis: current perspectives.

Secukinumab (Cosentyx™) is a human monoclonal IgG1k antibody that has been developed to target and block the actions of IL-17A. It is known that this cytokine is elevated in lesions of psoriasis. Interleukins in the Th17 pathway play a pivotal role in the pathogenesis of psoriasis and have thus become targets for recent biologic drug development. As a monoclonal antibody immune modulator, secukinumab exhibits the expected pharmacokinetic properties of slow subcutaneous absorption, low clearance, and long half-life, although formal studies examining the impact of impaired hepatic or renal function on the overall pharmacokinetic profile have not been conducted. Both Phase II and III clinical trials have demonstrated the effectiveness of secukinumab in the treatment of moderate-to-severe plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis, and noninfectious uveitis. In June 2015, secukinumab was approved by the US Food and Drug Administration for the treatment of adults with moderate-to-severe plaque psoriasis, with a wealth of clinical trials showcasing its efficacy in improving psoriasis area and severity index scores, and it is superior to other comparable biologics on the market, including the TNF inhibitor etanercept. As such, this review focuses on the marquee clinical trials involving secukinumab treatment of plaque psoriasis, while also exploring this drug's efficacy in treating patients with psoriatic arthritis, a disease that has a well-documented comorbidity in patients diagnosed with moderate-to-severe plaque psoriasis. Finally, the safety and tolerability of this drug in a variety of clinical trials to date have also been reviewed, and will undoubtedly have a large impact on this drug's postmarketing surveillance and future studies regarding its long-term safety.

Association Between Mohs Surgery Wait Times and Surgical Defect Size in Patients With Squamous Cell or Basal Cell Carcinoma of the Skin.

BACKGROUND: Consequences of delays in treatment of nonmelanoma skin cancers (NMSCA) are largely unstudied. OBJECTIVE: To determine the relationship between Mohs micrographic surgery (MMS) delay time and final MMS defect size. METHODS: A retrospective chart review was performed to identify patients who underwent MMS for biopsy-proven basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) between 2004 and 2006. Time delay between date of biopsy and date of surgery and lesion diameter increase between biopsy and surgical defect were calculated. RESULTS: Two hundred eighty-three lesions qualified for inclusion in the study. No significant difference in mean change of major diameter between primary and recurrent tumors (1.0 vs 1.1 cm, p = .67), between BCCs and SCCs (both were 1.0 cm, p = .99), and between tumor size at presentation <1.0 versus ≥1.0 cm (1.1 vs 0.8 cm, p = .11) were found. However, the mean number of MMS layers taken was significantly different between BCCs and SCCs (1.9 vs 1.5, respectively; p = .0022). Linear regression analysis of major diameter change versus time delay to MMS showed no significant increasing trend over time. CONCLUSION: No evidence was found that time delays of up to 1 year from biopsy to MMS impact the growth of NMSCA.

UV-based therapy.

UV phototherapy has a long history of use for the treatment of select diseases in dermatology. Its use has evolved into more effective and targeted modalities, including psoralen + UV-A photochemotherapy, narrowband UV-B, excimer laser, and UV-A1 phototherapy. With its proven record of efficacy and safety, UV phototherapy is an excellent option in the treatment of an ever-growing number of skin conditions.

Psoriasis and comorbidities: links and risks.

Psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the population worldwide. In the past decade, many studies have drawn attention to comorbid conditions in psoriasis. This literature review examines the epidemiological evidence, pathophysiological commonalities, and therapeutic implications for different comorbidities of psoriasis. Cardiovascular disease, obesity, diabetes, hypertension, dyslipidemia, metabolic syndrome, nonalcoholic fatty liver disease, cancer, anxiety and depression, and inflammatory bowel disease have been found at a higher prevalence in psoriasis patients compared to the general population. Because of the wide range of comorbid conditions associated with psoriasis, comprehensive screening and treatment must be implemented to most effectively manage psoriasis patients.

Patient-reported frequency of acral surface inspection during skin examination in white and ethnic minority patients.

BACKGROUND: Acral lentiginous melanomas compose a higher proportion of melanomas and have a higher mortality in ethnic minorities than in whites. Early detection by acral surface inspection during skin examinations may lead to improved acral lentiginous melanoma outcomes. OBJECTIVE: This study compared patient-reported frequencies of acral skin examinations in ethnic and white populations. METHODS: Written surveys were collected from 1040 dermatology clinic patients. RESULTS: More whites reported performing self-skin examinations than ethnic minorities (P < .01), but there was no difference in the rates of hand (P = .7) or foot (P = .87) inspection during self-skin examination between whites and ethnic minorities. More whites (77.5%) than ethnic minorities (38.9%) reported having undergone a full-body skin examination (FBSE) from a health care provider (P < .01). During their most recent FBSE by a health care provider, more whites than ethnic minorities reported having their hands examined (P = .02), but there was no difference in reported hand inspection (P = .06) at any previous FBSE or foot inspection at any (P = .07) or the most recent (P = .59) FBSE between whites and ethnic minorities. LIMITATIONS: Single-center study using a new unvalidated survey is a limitation. CONCLUSION: Whites were found to more frequently report self-skin examination and FBSE than ethnic minorities, but significant differences in reported acral examinations were not detected.