Comparison of Work Relative Value Units for Outpatient Pediatric and Adult Dermatology Encounters.

Importance: Dermatologists with specialty training in pediatric dermatology are scarce, which can mean extended wait times and reduced access to care for patients. Lower compensation for pediatric dermatology visits compared with adult visits may affect physician career choice and contribute to workforce shortages. Objective: To evaluate differences in work relative value units (wRVUs) generated by pediatric and adult outpatient dermatology encounters. Design, Setting, and Participants: This cross-sectional study used data from outpatient dermatology encounters at a single-site academic center in Atlanta, Georgia, from September 1, 2016, to March 31, 2020. Encounters with patients younger than 18 years were classified as pediatric, and encounters with those 18 years or older were classified as adult. Encounters with missing data were excluded as were those generating 0 wRVUs, inpatient visits, nursing visits, postoperative encounters, cosmetic procedures, phototherapy visits, and Mohs surgery encounters. Main Outcomes and Measures: Work relative value units generated per encounter type were assessed through multivariable linear regression models adjusted for the potential confounder of sex. Results: The study included 12 989 pediatric dermatology encounters (mean [SD] age, 7.3 [5.2] years; 7586 [58.4%] girls) and 78 057 adult dermatology encounters (mean [SD] age, 54.9 [18.9] years; 45 724 [58.6%] women). Pediatric encounters were associated with 0.23 (95% CI, 0.21-0.25; P < .001) fewer wRVUs than adult encounters after adjusting for sex. In a mediation analysis, biopsies and destruction of premalignant lesions explained 74.1% (95% CI, 69.6%-77.9%; P < .001) of the wRVU difference between pediatric and adult encounters. Conclusions and Relevance: This cross-sectional study found significant differences in wRVUs generated between adult and pediatric dermatology encounters that were largely attributable to biopsies and destruction of premalignant lesions. Policies that increase the value of cognitive services to be on par with procedural care may mitigate wRVU differences and improve reimbursement for pediatric dermatologists.

Clearance of atypical cutaneous manifestations of hyper-IgE syndrome with dupilumab.

Hyper-IgE syndromes (HIES) are a heterogeneous group of rare primary immunodeficiency diseases classically characterized by the triad of atopic dermatitis, and recurrent cutaneous and pulmonary infections. Autosomal dominant, loss-of-function STAT3 pathogenic variants are the most common genetic cause, which lead to deficiency of Th17 lymphocytes, impaired interferon gamma production, and IL-10 signal transduction, and an unbalanced IL-4 state. Dupilumab, a monoclonal antibody to the IL-4a receptor, inhibits both IL-4 and IL-13, and has been shown to improve atopic dermatitis and other manifestations of HIES including asthma and allergic bronchopulmonary aspergillosis. We present a pediatric patient with HIES who presented predominantly with eosinophilic folliculitis, recurrent cutaneous infections, and other non-eczematous findings and achieved sustained clearance with dupilumab.

Natural Is Not Always Better: The Prevalence of Allergenic Ingredients in "Clean" Beauty Products.

BACKGROUND: Consumers seek "clean" and "natural" products based on their perception of safety. However, there is no standard, scientific basis, or regulatory oversight in the marketing or ingredient use for "clean" products. OBJECTIVE: The aim of this study was to determine the prevalence of allergenic ingredients in "clean" products. METHODS: Target and Walgreens Web sites were queried for "clean" products with inclusion of 1470 products. Ingredient lists were analyzed for potential allergens. Analysis included descriptive statistics and χ2 test. RESULTS: The most common allergens were fragrances/botanicals (1218/1470, 82.9%), phenoxyethanol (591/1470, 40.2%), tocopherol (545/1470, 40.2%), benzoic acid and benzoates (434/1470, 29.5%), propylene glycol (369/1470, 25.1%), alkyl glucosides (305/1470, 20.7%), ethylhexylglycerin (304/1470, 20.7%), cetyl alcohol (282/1470, 19.2%), cocamidopropyl betaine (258/1470, 17.6%), and benzyl alcohol (232/1470, 15.8%). Among fragrances/botanicals, the most common ingredients found were fragrance/perfume/aroma (911/1470, 68.2%), citrus derivatives (375/1470, 25.5%), linalool (305/1470, 20.7%), limonene (279/1470, 19.0%), and benzyl alcohol (231/1470, 15.7%). A total of 93.8% of the products (1379/1470) contained at least 1 potential allergen. CONCLUSIONS: Most "clean" products contain a potential allergen, predominately fragrances and botanicals.

Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: A nationwide needs assessment survey.

BACKGROUND: Many patients with inflammatory vulvovaginal skin diseases, such as lichen planus and lichen sclerosus, experience a delay in diagnosis and lack of appropriate treatment. Unfortunately, patients experience significant morbidity with these conditions. OBJECTIVE: The aim of this study was to assess the adequacy of training in vulvar dermatoses for dermatology and obstetrics-gynecology residents (in the United States), with a secondary goal of identifying the most ideal modality to broadly reach these residents with high quality instruction. METHODS: We created a survey with questions relating to attitudes about training in vulvovaginal disease, quantity of current education on the subject, and opinions on ways to improve training. The survey was distributed to obstetrics-gynecology and dermatology residents and program directors nationwide. RESULTS: Most respondents reported that training was not adequate in this area and that additional education was needed. CONCLUSION: We propose that online, interactive, case-based learning modules, created by vulvovaginal experts, could help improve graduate medical education and lead to better patient outcomes.

Lipoatrophic panniculitis in an adolescent.

Lipoatrophic panniculitis (LP) is a rare childhood panniculitis characterized by sclerotic, atrophic plaques on the extremities. We present a case of LP diagnosed during the inflammatory phase that was difficult to distinguish clinically from eosinophilic fasciitis. This report adds to the limited phenotypic spectrum of LP by differentiating the clinical features of disease activity from disease damage and highlighting the importance of biopsy in establishing a diagnosis.

Accuracy of Product Ingredient Labeling: Comparing Drugstore Products With Online Databases and Online Retailers.

BACKGROUND: Patients with allergic contact dermatitis rely on ingredient lists published in databases and by online retailers to find safe skincare products. OBJECTIVE: The aim of this study was to determine the accuracy of product ingredient labeling by comparing drugstore product labels to ingredient lists published online. METHODS: Amazon was queried for best-selling items in several categories of skincare, generating a list of 93 products. These products were then found at a local Target and Walgreens and online on Contact Allergen Management Program, SkinSAFE, and Consumer Product Information Database. Drugstore product labels were compared with online ingredient lists and analyzed for discrepancies. RESULTS: There were 31 occurrences in which an allergen listed in the 2017 American Contact Dermatitis Society Core Allergen Series was omitted (present on the in-store label but missing from an online list.) Seven omissions occurred on Contact Allergen Management Program, 11 occurred on SkinSAFE, 5 occurred on Consumer Product Information Database, and 8 occurred on Amazon. CONCLUSIONS: Definitive treatment of allergic contact dermatitis is avoidance of allergens found on patch testing. These data suggest that patients may be at risk of inadvertent exposure to allergens from products, which are supposedly deemed safe according to online ingredient lists.

Characterization of 6S RNA in the Lyme disease spirochete.

6S RNA binds to RNA polymerase and regulates gene expression, contributing to bacterial adaptation to environmental stresses. In this study, we examined the role of 6S RNA in murine infectivity and tick persistence of the Lyme disease spirochete Borrelia (Borreliella) burgdorferi. B. burgdorferi 6S RNA (Bb6S RNA) binds to RNA polymerase, is expressed independent of growth phase or nutrient stress in culture, and is processed by RNase Y. We found that rny (bb0504), the gene encoding RNase Y, is essential for B. burgdorferi growth, while ssrS, the gene encoding 6S RNA, is not essential, indicating a broader role for RNase Y activity in the spirochete. Bb6S RNA regulates expression of the ospC and dbpA genes encoding outer surface protein C and decorin binding protein A, respectively, which are lipoproteins important for host infection. The highest levels of Bb6S RNA are found when the spirochete resides in unfed nymphs. ssrS mutants lacking Bb6S RNA were compromised for infectivity by needle inoculation, but injected mice seroconverted, indicating an ability to activate the adaptive immune response. ssrS mutants were successfully acquired by larval ticks and persisted through fed nymphs. Bb6S RNA is one of the first regulatory RNAs identified in B. burgdorferi that controls the expression of lipoproteins involved in host infectivity.