Implementation of Teledermatology in Alberta, Canada: A Report of One Thousand Cases.

BACKGROUND: Teledermatology utilizes photoimaging and background information to allow dermatologists to remotely provide a diagnosis to practitioners. ConsultDerm is an asynchronous, web-based teledermatology software that allows practitioners to submit their electronic referrals for assessment by board-certified dermatologists. OBJECTIVE: Our study aimed to retrospectively analyze teledermatology's utilization in Canada by using the teledermatology platform ConsultDerm. METHODS: After implementing inclusion criteria, 1000 patients were selected, and relevant demographic and clinical information were extracted for data analysis. In addition, an online survey with pre-formulated questions was distributed to 7 dermatologists currently using the ConsultDerm platform to determine their experience in utilizing teledermatology. RESULTS: Of the 1000 patients, 66.5% had not received treatment prior to their teledermatology referral, and on average, patients experienced symptoms for 489.5 days prior to their referral. Diagnoses made were categorized by conditions, most common being dermatitis (37.1%), followed by acneiform conditions (10.6%), benign lesions/neoplasms (12.1%), infections (9.4%), and dyspigmentation (3.1%). Most consults originated from small population centers, and the referring practitioners were predominantly family physicians. Dermatologists utilizing the platform expressed ease of use, however, areas of improvement were identified such as increasing the quality of imaging and more detailed patient history. CONCLUSION: Through our analysis of 1000 cases, we identified how a teledermatology consultation could be used to assess a wide variety of cutaneous conditions, improving access for patients who may face barriers to seeing a dermatologist.

Real-World Moderate-to-Severe Hidradenitis Suppurativa: Decrease in Disease Burden With Adalimumab.

BACKGROUND: Real-world knowledge of the burden of hidradenitis suppurativa (HS) on patients remains limited. OBJECTIVES: To measure the impact of adalimumab on moderate-to-severe HS patients' health-related quality of life (HRQoL) and work productivity. METHODS: In 23 Canadian centres, 138 adults with moderate-to-severe HS requiring a change in ongoing therapy were treated with adalimumab for up to 52 weeks as per the physician's practice. Patient-reported outcome measures (PROMs) were obtained at baseline, weeks 24 and 52 to measure overall HRQoL, HS severity, levels of anxiety and depression, impact and symptoms of HS, work productivity and activity impairment. A post-hoc analysis further explored the PROMs by abscess and inflammatory nodule (AN) count at baseline (≤5, low; 6-10, medium; ≥11, high). RESULTS: From baseline to weeks 24 and 52, all PRO overall scores improved significantly (P ≤ .0023). The number of patients reporting "good disease control" and "complete disease control" increased from 9.7% to 66.4% over 52 weeks. The score in Health Utility Index Mark 3 (HUI3) pain attribute meaningfully decreased over 52 weeks (mean difference ≥.05). The HS symptoms skin "tenderness" and "itchiness" improved the most. Work productivity loss and activity impairment improved by approximately 20% over 52 weeks. Disease burden improved more in 24 week responders with low and medium AN counts at baseline than in those with high AN count or in 24 week nonresponders. CONCLUSION: At week 24 and maintained at week 52 in a real-world setting, adalimumab meaningfully improved HRQoL, work productivity, and activity impairment in moderate-to-severe HS patients.

Multidisciplinary Real-World Experience With Bilastine, a Second Generation Antihistamine

Introduction: Allergic conditions frequently require treatment with antihistamines. First-generation antihistamines can potentially interfere with restful sleep, cause "morning after" effects, impair learning and memory, and reduce work efficiency. Second-generation antihistamines, such as bilastine, have been demonstrated to decrease allergy symptoms effectively without causing night-time sleep disturbances and related adverse events. Method: A real-world case project was developed to help optimize patient care by recognizing the role bilastine can play for allergic conditions where antihistamine treatment is needed. The presented real-world patient cases conducted by the panel members are supported with evidence from the literature, where available. Any discussion concerning off-label use should be considered an expert opinion only. Results: The real-world cases presented here used bilastine in conditions such as perennial and seasonal allergic rhinitis, chronic urticaria, as well as urticarial vasculitis and pruritus associated with inflammatory skin conditions. The treated patients were between 9 and 76-years old providing information on a full spectrum of patients that require treatment with antihistamines. Conclusions: The presented real-world cases using the second-generation antihistamine, bilastine, demonstrated favorable outcomes for the treated patients. While effectively relieving symptoms, the antihistamine was reported to be safe and well-tolerated. J Drugs Dermatol. 2020;19(2)145-154. doi:10.36849/JDD.2020.4835

Skin Surface pH

The role of skin surface pH, also referred to as "acid mantle," was described more than 90 years ago and due to developing insights has now returned into focus.1

Clinical Insights About the Role of pH in Acne

Acne vulgaris is the most common dermatological disorder globally.1,2 Psychological and emotional distress due to acne, including poor self-esteem, social anxiety, depression, and suicidal ideation have been reported in various studies.3,4, Acne is a complex multifactorial disease with its pathophysiology incompletely elucidated.

Canadian Patients' Preferences in Topical Psoriasis Care: Insights From the PROPEL Surveys.

BACKGROUND: Patients with psoriasis of all severities employ topical treatment, either alone or in combination. Promoting Patient Engagement at the Leading Edge of Topical Psoriasis Treatment (PROPEL) surveyed Canadian dermatologists and their patients about their attitudes toward topical care. OBJECTIVES: To identify gaps between patients and dermatologists regarding the burden of psoriasis, the burden of treatment, and priorities for topical care to Canadian patients with psoriasis. METHODS: Two parallel surveys explored patient attitudes toward psoriasis and their experience with topical care, as expressed by patients or as perceived by their dermatologists. A third survey, addressed to patients, included additional questions regarding treatment adherence to current topical treatment regimens. RESULTS: PROPEL dermatologists underestimated the burden associated with psoriatic itch. Otherwise, they were well aligned with patients' views, including their preference for maintaining topical care of their psoriasis over other treatment modalities, the nature of good psoriasis control, and desirable features of topical medications. Despite holding generally positive views of topical therapy, many patients self-identified as poorly adherent. CONCLUSIONS: Long-term adherence to psoriasis topical care remains a challenge. Formulations with improved acceptability might help patients maintain good adherence.

Application of intense pulsed light in the treatment of dermatologic disease: a systematic review.

BACKGROUND: The Food and Drug Administration (FDA) has approved intense pulsed light (IPL) devices for the treatment of a variety of benign pigmentary and vascular lesions, but the range of disease amenable to IPL treatment continues to expand, and there are no evidence-based clinical guidelines for its use in FDA-approved and off-label indications. OBJECTIVE: To provide evidence-based recommendations to guide physicians in the application of IPL for the treatment of dermatologic disease. EVIDENCE REVIEW: A literature search of the CENTRAL (1991 to May 6, 2013), EMBASE (1974 to May 6, 2013), and MEDLINE in-process and nonindexed citations and MEDLINE (1964 to present) databases was conducted. Studies that examined the role of IPL in primary dermatologic disease were identified, and multiple independent investigators extracted and synthesized data. Recommendations were based on the highest level of evidence available. FINDINGS: Level 1 evidence was found for the use of IPL for the treatment of melasma, acne vulgaris, and telangiectasia. Level 2 evidence was found for the treatment of lentiginous disease, rosacea, capillary malformations, actinic keratoses, and sebaceous gland hyperplasia. Level 3 or lower evidence was found for the treatment of poikiloderma of Civatte, venous malformations, infantile hemangioma, hypertrophic scars, superficial basal cell carcinoma, and Bowen's disease. CONCLUSIONS: IPL is an effective treatment modality for a growing range of dermatologic disease and in some cases may represent a treatment of choice. It is typically well tolerated. Further high-quality studies are required.

Mobile teledermatology: a promising future in clinical practice.

BACKGROUND: As a product of electronic health, teledermatology is a cost-effective means of improving access to care, facilitating specialist consultations, and supporting patient self-management. Even so, use of traditional teledermatology services is limited by infrastructure and costs in the form of digital cameras, computers, and Internet access. METHODS: Considering the significant improvement in smartphone camera resolution and the rapidly increasing number of physicians using smartphones, we explored the use of smartphones as reliable, effective clinical tools in store-and-forward teledermatology. We describe the technical specifications of modern smartphone cameras, the widespread use of smartphones by physicians, and the advantages of smartphones over traditional camera and Internet teledermatology, and we propose recommendations as to how mobile teledermatology may be more effectively used in modern dermatologic practice.

Prospective, randomized, open-label trial comparing the safety, efficacy, and tolerability of an acne treatment regimen with and without a probiotic supplement and minocycline in subjects with mild to moderate acne.

BACKGROUND: Systemic antibiotics are an effective treatment for acne vulgaris. However, intolerable side effects may invariably occur. OBJECTIVE: To determine whether probiotics reduce the side effects imparted by systemic antibiotics while working synergistically with the latter in treating inflammatory acne. METHODS: Forty-five 18- to 35-year-old females were randomly assigned to one of three arms in this prospective, open-label study. Group A received probiotic supplementation, whereas group B received only minocycline. Group C was treated with both probiotic and minocycline. Clinical and subjective assessments were completed at baseline and during the 2-, 4-, 8-, and 12-week follow-up visits. RESULTS: All patients demonstrated a significant improvement in total lesion count 4 weeks after treatment initiation (p < .001), with continued improvement seen with each subsequent follow-up visit (p < .01). At the 8- and 12-week follow-up visits, group C had a significant decrease in total lesion count versus groups A (p < .001) and B (p < .01). Two patients (13%) from group B failed to complete the study secondary to vaginal candidiasis. CONCLUSION: Probiotics may be considered a therapeutic option or adjunct for acne vulgaris by providing a synergistic antiinflammatory effect with systemic antibiotics while also reducing potential adverse events secondary to chronic antibiotic use.

Laser management of acne scarring.

Acne scarring is often challenging to manage. Various laser treatments are helpful in addressing abnormal color and texture in order to improve the appearance of an acne scar. This paper will review the appropriate use and side-effects of these laser treatments.

Vascular lesions.

Advances in laser and light-based technology have increased their potential applications, safety and efficacy for the management of vascular lesions in dermatology. Light devices for vascular lesions include the variable-pulse 532 nm potassium titanyl phosphate laser, 577 to 595 nm pulsed dye laser, intense pulsed light devices, and 800 to 940 nm diode, long-pulse 755 nm alexandrite and 1,064 nm Nd:YAG lasers. This review will discuss the various different laser and light-based devices, and provide a focused treatment approach for the management of common congenital and acquired vascular lesions.

Treatment of acne scarring.

Acne scarring is a common and expected result of moderate to severe acne vulgaris. Given the clinical variety of acne scars and the plethora of treatment options available, management of cutaneous scarring from acne can be challenging and confusing. This article discusses the pathophysiology of acne and acne scarring to better understand its biologic and structural nature. A simple, yet practical classification schema is presented, allowing caregivers to better organize their assessment of acne scarring and develop useful management strategies from this model. This article highlights the various useful laser options that are available for the treatment of acne scarring.

Evaluation of a telehealth clinic as a means to facilitate dermatologic consultation: pilot project to assess the efficiency and experience of teledermatology used in a primary care network.

BACKGROUND: Primary care offices spend considerable time coordinating the specialist referral process. Patients experience long wait times for consultation and intervention. OBJECTIVE: To determine if telehealth combined with interdisciplinary team-based care can reduce wait times for dermatologic consultation while making the consultation process easier for physicians. METHODS: Retrospective chart reviews as well as patient, referring physician, nonreferring physician, clinic physician, nurse, and teledermatologist interviews were used to evaluate the clinic. A comparative immersion approach generated themes from field notes. Wait times, appointment times, and encounter durations were measured. RESULTS: Twenty-eight patients were seen (23 had previous specialist referral experience) within 1 week of referral compared to a wait period of 104 days for conventional referral. Patients requiring intervention were treated within 1 week of their initial appointment. Referring practitioners were concerned that they would lose control of patients' care. An easier referral process and faster intakes met physician expectations. CONCLUSIONS: Teledermatology improves the timeliness of appointments. Patients forgo face-to-face appointments if alternatives are available sooner. Physicians are concerned about their own liability if dermatologists do not assess the patient in person but will refer through teledermatology when patients are seen faster and they remain in control of the care process.

A double-blind, comparative study of nonanimal-stabilized hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands.

BACKGROUND AND OBJECTIVE: Cosmetic surgery to counteract the aging process is an evolving field. Most procedures have concentrated on the face; however, the hands are an often-neglected area. Current methods of hand rejuvenation include autologous fat injection, sclerotherapy, intense pulsed light, chemical peel, and microdermabrasion. Only autologous fat injection restores dermal thinning. We compare the use of hyaluronic acid (Restylane, Medicis Aesthetics Inc.) versus collagen (Cosmoplast, INAMED Aesthetics) for soft tissue augmentation of the dorsal hands. MATERIALS AND METHODS: Ten female patients who demonstrated dermal thinning of the dorsal hands were randomized to receive 1.4 mL of hyaluronic acid or 2.0 cm(3) collagen to alternate interphalangeal spaces of dorsal hands. Patients returned at 1 week, 1 month, 3 months, and 6 months for digital photography and completion of a patient/physician questionnaire. RESULTS: Hands were scored by two separate blinded physicians on scales of 1 to 5 for clearance of veins. Patients scored both tolerability and satisfaction on a scale of 1 to 5. Analysis showed a mean difference of 0.95 (0.004), median difference of 0.9 (0.008) for clearance, and a mean difference of 0.90 (0.010) with a median difference of 1.0 (0.031). The satisfaction difference was not significant with a mean difference of 0.80 (0.070) and median difference of 1.0 (0.117). CONCLUSION: Aging of the hands is a common problem that is often overlooked. The use of soft tissue fillers is a viable tool in hand rejuvenation. In this study hyaluronic acid proved to be superior in efficacy to collagen.

Violaceous papules on the palms and soles.

BACKGROUND: Lichen planus (LP) is a condition with many clinical variants that can be quite varied in their presentation. OBJECTIVE: We report a case of a 60-year-old woman who presented with a very unusual palmoplantar eruption characterized by violaceous pustule-like papules that was subsequently diagnosed as LP. METHODS: The above case is reported, along with biopsy results. The patient was subsequently treated with a combination of topical corticosteroids and oral acitretin, and her clinical course was followed. RESULTS: The eruption responded dramatically to our combination treatment and resolved by the 2-month follow-up. CONCLUSION: Palmoplantar LP is a rare variant of LP that bears little resemblance to its classic LP. This condition responds well to a combination of potent topical corticosteroids and oral acitretin.

Treatment of wrinkles and elastosis using vacuum-assisted bipolar radiofrequency heating of the dermis.

BACKGROUND: Reduction of wrinkles is increasingly becoming one of the most sought after aesthetic procedures. A variety of treatment modalities are available for this application, including radiofrequency energy in various modes of action. OBJECTIVE: The goal of the reported study was to evaluate the safety and efficacy of a new device, which implements an innovative combination of bipolar radiofrequency and vacuum. METHODS: Forty-six healthy adults at two clinics underwent eight facial treatments every 1 to 2 weeks. For 6 months after treatment, patients were assessed directly by two evaluators at each clinic (the treating physician and an additional reviewer) using standard evaluation tools-the Fitzpatrick-Goldman Classification of Wrinkling and Degree of Elastosis and a visual analog scale. RESULTS: Significant improvement in the skin's appearance and texture was observed during the treatment course and continued to increase during the follow-up period. The mean elastosis score on the wrinkling and elastosis scale before treatment was 4.5 and was reduced to less than 2.5 by 6 months after treatment, representing a drop of an entire wrinkle class (from II to I) on this scale. The reported pain levels were low, and the subjects expressed their satisfaction with the treatment and its outcome. The adverse responses consisted mainly of transient erythema and burn/blistering; there were also a few occurrences of edema, purpura, and crusting and one transient hyperpigmentation. No permanent complications had occurred. CONCLUSIONS: Our results demonstrate the safety and efficacy associated with use of this radiofrequency and vacuum device, employing Functional Aspiration Controlled Electrothermal Stimulation (FACES) technology, for reduction of facial wrinkles and elastosis.

Photodynamic therapy for actinic keratoses.

Actinic keratoses (AKs) are one of the most common conditions that are treated by dermatologists and they have the potential to progress to squamous cell carcinoma if left untreated. Photodynamic therapy (PDT) has emerged as a novel and versatile method of treating those lesions. Topical preparations of aminolevulinic acid and methyl aminolevulinate are commercially available photosensitizers, and numerous light sources may be used for photoactivation. This article focuses on practical aspects of PDT in the treatment of AKs, outcomes of relevant clinical trials, and special applications of PDT in transplant recipients and other who are predisposed to AK formation. Step-by-step descriptions of PDT sessions are presented.