Understanding patient perspectives on vaccine decision making in adults with autoimmune bullous diseases: a qualitative study.

Patients with autoimmune bullous diseases are at an increased risk of infection, both from the underlying skin disease and from immunosuppressive treatments. Limited information is available on vaccine beliefs and behaviors in dermatology patients and adults with autoimmune bullous diseases in particular. To understand vaccine decision making, identify perceived risks and benefits of vaccinations, and discuss individual experiences in patients with autoimmune bullous diseases in the United States. A qualitative study was performed utilizing semi-structured interviews, and analysis was conducted on NVivo. Patterns were identified in the coded data, and representative quotations were recorded for each major theme. Interviews were conducted between February 15, 2022 and September 15, 2022. Twenty patients with a diagnosis of bullous pemphigoid, mucous membrane pemphigoid, pemphigus vulgaris, or pemphigus foliaceous were interviewed. Of the 20 participants, 14 (70%) were female, with a mean (SD, range) age of 64.8 (13.2, 34-83) years. Key themes that emerged from qualitative analysis of the interviews included patient concerns regarding their increased susceptibility to infection, potential exacerbation of skin disease following vaccination, and the effect of immunosuppressive medications on humoral response to vaccines. Lack of appointment availability, difficulty accessing vaccines, and cost were commonly identified barriers to vaccination. These findings provide valuable knowledge for dermatologists in regard to providing counseling specific to patient concerns and to improve communication surrounding vaccination in the dermatology setting.

Identifying Core Outcome Domains in Chronic Skin Disease Using the Best-Worst Scaling Method.

Importance: The use of patient-reported outcome measures (PROMs) potentially holds promise as an opportunity to improve outcomes and quality of care for patients with skin disease, but the routine use of PROMs remains limited. While the Patient-Reported Outcomes Measurement Information System (PROMIS) has several strengths and domains relevant to those with chronic skin disease, it is not clear which are most useful. Objective: To determine which PROMIS domains are most meaningful to those with chronic skin disease to develop a PROMIS profile that effectively captures the experience of living with these skin diseases. Design, Setting, and Participants: This cross-sectional study was based on data gathered from an internet survey that was administered to a sample of adult respondents in the US on the Prolific Platform and ResearchMatch and through the National Psoriasis Foundation. A list of PROMIS domains relevant to chronic skin disease was developed through literature review. These domains were included in a best-worst scaling exercise, in which participants were shown 12 sets of 4 domains and asked to choose which domain in each set was the most important and least important to their experience. Participants completed the survey between December 2022 and June 2023. Data were analyzed in June 2023. Main Outcomes and Measures: Ratio-scaled preference score for each of the domains. Results: Of 939 total participants, 559 (59.5%) were female, 20 (2.1%) gender nonconforming, 7 (0.7%) transgender men, and 1 (0.1%) transgender women; there were 4 American Indian/Alaska Native (0.4%), 50 Asian (5.3%), 63 Black (6.7%), 66 Hispanic or Latino/a/x (7.0%), 2 Native Hawaiian/Pacific Islander (0.2%), 749 White (79.8%), and 42 multiracial individuals (4.5%). The survey was completed by 200 participants with acne, 316 with psoriasis, 199 with atopic dermatitis, and 224 with various chronic skin diseases. For those with acne, the highest-scored domains were body image (15.66), appearance (14.96), life satisfaction (11.29), depression (9.25), and anxiety (9.18). For those with psoriasis, the highest-scored domains were life satisfaction (11.31), appearance (11.05), itch (10.98), pain (9.97), and body image (8.75). For those with atopic dermatitis, the highest-scored domains were itch (12.60), life satisfaction (11.65), appearance (11.40), body image (11.25), and pain (10.03). Conclusion and Relevance: The results of this study suggest that body image, appearance, life satisfaction, itch, pain, anxiety, and depression were highly rated across the surveys. By identifying the PROMIS domains most important to individuals with chronic skin disease, clinicians can choose the domains that are most relevant to patients. In addition, this may guide the construction of a PROMIS profile that effectively captures the experience of living with these skin diseases and can serve as a patient-reported measure of disease severity and treatment effectiveness.

Guidelines of care for the management of acne vulgaris.

BACKGROUND: Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older. OBJECTIVE: The objective of this study was to provide evidence-based recommendations for the management of acne. METHODS: A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations. RESULTS: This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements. LIMITATIONS: Analysis is based on the best available evidence at the time of the systematic review. CONCLUSIONS: These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Psoriasis: A Systematic Review.

Importance: Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQL) exist for patients with psoriasis. Evidence for the content validity and other measurement properties of these PROMs is critical to determine which HRQL PROMs could be recommended for use. Objective: To systematically review the validity of HRQL-focused PROMs used in patients with psoriasis. Evidence Review: Using PubMed and Embase, full-text articles published in English or Spanish on development or validation studies for psoriasis-specific, dermatology-specific, or generic HRQL PROMs were included. Development studies included original development studies, even if not studied in psoriasis patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included multiple diagnoses, more than 50% of patients had to have psoriasis or psoriasis-specific subgroup analyses available. Data extraction and analysis followed the COSMIN guidelines. Two independent reviewers extracted and analyzed the data, including PROM characteristics, quality of measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness), and level of evidence. PROMs were classified into 3 levels of recommendations: (1) PROM recommended for use; (2) PROM requires further validation; and (3) PROM not recommended for use. Findings: Overall, 97 articles were identified for extraction. This included 19 psoriasis-specific, 8 skin-specific, and 6 generic PROMs. According to COSMIN standards, most measures identified received a B recommendation for use, indicating their potential but requiring further validation. Only the Rasch reduced version of the Impact of Psoriasis Questionnaire (IPSO-11 Rasch) received an A recommendation for use given that it had sufficient content validity, structural validity, and internal consistency. Conclusions and Relevance: This study identified a significant lack of information concerning the quality of HRQL measures in psoriasis. This gap in knowledge can be attributed to the fact that traditional measures were developed using validation criteria that differ from the current standards in use. Consequently, additional validation studies in accordance with contemporary standards will be useful in aiding researchers and clinicians in determining the most suitable measure for assessing HRQL in patients with psoriasis.

Comorbid psychiatric disease significantly mediates increased rates of alcohol use disorder among patients with inflammatory and pigmentary skin disorders: a case-control study in the All of Us Research Program.

Dermatologic diseases have a well-documented association with depression and anxiety, which are in turn often comorbid with alcohol use disorder (AUD). Nonethleess, the relationship between dermatologic disease and AUD, and the relative contribution of depression and anxiety, are poorly understood. Here, we utilize the National Insittutes of Health All of Us Research Program to investigate the association between inflammatory and pigmentary dermatologic diseases with AUD. Furthermore, we investigate whether comorbid depression and anxiety mediates this relationship. We employed a matched case-control model with multivariable logistic regression. We also employed a mediation analysis. We found an increased odds of AUD among patients with atopic dermatitis, acne/rosacea, hidradenitis suppurativa, psoriasis, and pigmentary disorders (vitiligo, melasma, and post-inflammatory hyperpigmentation). This was partially mediated by anxiety and depression, especially for diseases with a significant cosmetic component. Overall, these findings highlight the profound psychological and physical health effects that inflammatory and pigmentary disease can have on patients, both independently and in combination with comorbid psychiatric disease.

Evaluation of Stigma Toward Individuals With Acne.

Importance: Little is known about the prevalence and magnitude of stigmatizing attitudes of the general public toward individuals with acne. Objective: To explore the degree of stigma toward individuals with acne and whether these attitudes vary based on characteristics of the individuals with acne or of the survey participants. Design, Setting, and Participants: In this cross-sectional internet survey study, 4 stock portraits of adults that varied in sex (male/female) and skin tone (light/dark) were digitally enhanced to have acne (mild/severe). One of these 12 images was randomly presented to survey participants, who subsequently answered questions regarding stigmatizing attitudes with respect to the pictured individual, such as desire for social distance and stereotype endorsement. The survey was administered to a convenience sample of adult respondents in the US who were volunteers on the ResearchMatch platform. Main Outcomes and Measures: Prevalence and magnitude of stigma toward individuals with acne. Results: The survey was completed by 1357 respondents (65.7% completion rate) (mean [SD] age, 42.4 [14.3] years; 918 [67.7%] female, 439 [32.4%] male). Compared to those with no acne, for those with severe acne, participants reported less comfort being friends (adjusted coefficient [95% CI], -0.28 [-0.47 to -0.10]; P = .003), hiring (-0.33 [-0.51 to -0.15]; P < .001), having physical contact (-0.26 [-0.45 to -0.08]; P = .006), dating (-0.44 [-0.74 to -0.14]; P = .004), and posting a photograph together on social media (-0.50 [-0.70 to -0.30]; P < .001). Compared to those with no acne, participants were more likely to rate individuals with severe acne as having poor hygiene (adjusted coefficient [95% CI], -1.04 [-1.46 to -0.82]; P < .001) and being unattractive (-0.89 [-1.12 to -0.67]; P < .001), unintelligent (-0.42 [-0.63 to -0.22]; P < .001), unlikable (-0.36 [-0.56 to -0.15]; P < .001), immature (-0.52 [-0.74 to -0.30]; P < .001), and untrustworthy (-0.40 [-0.61 to -0.18]; P < .001). There was evidence that the effect size of the association of acne with desire to social distance was greater for individuals with dark skin. Conclusions and Relevance: This survey study demonstrates that stigmatizing attitudes toward patients with acne existed across a variety of social and professional scenarios, with severe acne and acne in darker skin tone being associated with a greater degree of stigma. These findings highlight the need to identify approaches to reduce stigmatizing attitudes in the community and for adequate access to care, which might prevent negative downstream effects related to these stigmatizing attitudes.

Evaluation of DermSat-7 for Assessing Treatment Satisfaction in Patients with Acne.

Importance: Treatment satisfaction is important to achieving therapeutic success in patients with inflammatory dermatological diseases, such as acne. Objective: To evaluate the structural validity, internal consistency, and construct validity of the DermSat-7, a questionnaire-based measure of treatment satisfaction, in patients with acne seen in routine clinical practice. Design, Setting, and Participants: This cross-sectional study included adults with acne who were fluent in English and treated at an outpatient clinic at Brigham and Women's Hospital between July 2022 and May 2023. At each visit, patients completed a self-administered, patient-reported outcome questionnaire, including a patient global assessment (PGA) of their acne severity and the DermSat-7. The DermSat-7 consists of 7 items assessing 3 domains of treatment: effectiveness (3 items), convenience (3 items), and overall satisfaction (1 item). At subsequent visits, patients were asked an anchor item related to change in disease severity ("How has your acne changed compared to your last visit?") that was scored on a 7-point scale (-3 = much worse to 3 = much better). Also at each visit, a dermatologist completed the Comprehensive Acne Severity Scale (CASS). Main Outcomes and Measures: The main outcomes were structural validity (assessed by factor analysis), internal consistency (assessed by Cronbach α), and construct validity (assessed using linear regression models and Pearson correlation coefficients). Results: The analysis included 142 patients with acne (mean [SD] age, 25.1 [5.1] years; 96 females [67.6%]) taking acne medication who completed the DermSat-7. Exploratory factor and confirmatory factor analysis supported the unidimensionality of the 3 DermSat-7 domains. Cronbach α values of 0.89 and 0.80 supported good internal consistency in the effectiveness and convenience domains, respectively. Known-groups validity was supported by increasing DermSat-7 effectiveness and overall satisfaction scores with increasing levels of positive change in disease severity (linear regression coefficient, 7.51; 95% CI, 4.94-10.08; P < .001). Construct validity was further supported by moderate correlations with the anchor, PGA, and CASS scores (effectiveness domain: anchor r = 0.567, PGA r = -0.538, and CASS r = -0.485; overall satisfaction domain: anchor r = 0.467, PGA r = -0.486, and CASS r = -0.489). Conclusion and Relevance: This cross-sectional study found that the DermSat-7 may be an effective tool for measuring treatment satisfaction, particularly effectiveness and overall satisfaction domains, among patients with acne. Further research is needed to examine additional measurement properties of the DermSat-7, such as content validity and interpretability, as well as to validate the DermSat-7 in other populations of patients with acne.

Exploring dermatologists' perspectives on vaccines in dermatology: a qualitative study.

Vaccination rates among adults in the United States, including dermatology patients, remain suboptimal. Previous research has concluded that outpatient specialty offices often have administrative and patient-related barriers to administering vaccines in their clinics, however, this has never been examined specifically in dermatology. This study aims to examine dermatologists' perspectives on vaccine education in dermatology clinics, identify facilitators and barriers to vaccine administration in dermatology clinics, and explore strategies to improve vaccination rates in dermatology patients. Virtual, semi-structured interviews were conducted with board-certified dermatologists to explore their perspectives on vaccines in dermatology clinic. The Consolidated Framework for Implementation Research was used to analyze the data. Participating dermatologists were 60% female (n = 9) and 40% male (n = 6) and had a median of 7 years of clinic experience (min-max: 3-39 years). Vaccine education emerged as one of the prominent themes during the interview with dermatologists, who emphasized the importance of comprehensive vaccine education for both healthcare providers and patients. Barriers identified encompassed patient hesitancy, lack of provider knowledge, resource limitations, and logistical challenges. Dermatologists proposed solutions such as standardized protocols, improved patient communication, enhanced coordination with other healthcare providers, and increased clinic resources. These results emphasize that dermatologists can play a crucial role in advocating for and addressing preventative care through vaccine implementation and provide a high-level framework to think about implementation. Additionally, this study highlights the need for comprehensive vaccine education, systematic implementation strategies, and organizational support within dermatology clinics to improve vaccine administration for patients.

Increased ambient outdoor temperatures are associated with increased disease flaring in hidradenitis suppurativa.

Despite evidence to suggest a relationship between time of year and hidradenitis suppurativa (HS) flaring, no studies have been conducted to date to establish a relationship directly between temperature and flaring. In this study, we aim to validate a classification approach based on administrative data for identifying medical encounters that likely represent HS flares in patient with a known diagnosis of HS within the Mass General Brigham Health System (MGB) and examine the relationship between average daily temperatures and HS disease flaring among patients in Boston. This is a retrospective cohort study. Participants were individuals with HS presenting to emergency departments or dermatology outpatient clinics with disease flares between January 2017 and January 2022. The average number of encounters for HS flares was compared with the temperature for that day and the 3- and 7-day periods prior. There were 2567 patient encounters for HS flares included in the study. Of the total identified HS flares, 75.6% occurred in females and 39.1% occurred in patients who identified as Black. Uniformly small but statistically significant relationships were noted between increased temperature and presentations for hidradenitis suppurativa flare with the highest correlation coefficient (0.0768) noted with a 3-day lag time between the heat experienced and day of presentation for flare. Increased temperature is associated with a small, but statistically significant increase in HS disease flaring. As such, HS disease flaring may rise as global temperatures do, suggesting an increase in the global burden of HS as climate change persists.

Safety and Effectiveness of Oral Nutraceuticals for Treating Acne: A Systematic Review.

Importance: Patients with acne are interested in nutraceuticals as a potential treatment option. However, there is uncertainty regarding the efficacy and safety of these products. Objective: To evaluate the evidence for oral nutraceuticals in the treatment of acne. Evidence Review: The PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched from inception through January 30, 2023, to identify randomized clinical trials evaluating oral nutraceutical interventions (ie, vitamins and minerals, botanical extracts, prebiotics, and probiotics) in individuals with acne. Clinician-reported outcomes (eg, investigator global assessment, lesion counts), patient-reported outcomes (eg, quality of life), and adverse events were extracted from the included studies. The quality of evidence was assessed using the Cochrane Risk of Bias checklist tool for randomized clinical trials. Based on the Risk of Bias tool, articles were converted to Agency for Healthcare Research and Quality standards of good, fair, or poor quality. Findings: A total of 2582 abstracts were identified in the database search, 42 of which met inclusion criteria (a total of 3346 participants). Studies of fair or good quality showed the potential benefit of vitamins B5 and D, botanical extracts (green tea), probiotics, and ω-3 fatty acids in the treatment of acne. These interventions were most frequently associated with decreased lesion counts or improved investigator global assessment scores. Adverse effects were rare for most of the therapies evaluated, but gastrointestinal tract adverse effects were reported for zinc therapy. Conclusions and Relevance: This systematic review suggests a possible role for nutraceutical supplements in the treatment of acne. Physicians should be prepared to discuss the evidence regarding the potential role of nutraceuticals with patients. Many studies were of small size, and future research should focus on larger randomized clinical trials to assess the utility of nutraceuticals in the treatment of acne.

Isotretinoin for Treatment of Acne.

This JAMA Dermatology Patient Page discusses isotretinoin for treatment of acne.