Fractionated Ablation With Trans-Epidermal Pigment Release: A Novel Tattoo Removal Method.

Tattoos continue to be an important way of emotional and/or identity expression for individuals and communities, whether obtained at a tattoo parlor or through communal rituals. Tattoos vary in their complexity, artistic skill, and overall satisfaction; however, in later years many regret the design, color choice, or the idea of a tattoo altogether. Given the uptick in patients wishing for tattoo removal, various techniques have been developed using energy-based devices such as lasers and destructive methods utilizing caustic chemicals or excision. These modalities come with limitations including incomplete tattoo removal, scarring, and dispersion of tattoo dyes into the lymphatics. Considering these limitations, other treatment modalities for tattoo removal must be explored. In this article, we discuss a new technique for tattoo removal using fractionated ablation of tattoo pigment with trans-epidermal pigment release.  J Drugs Dermatol. 2023;22(11):1103-1106     doi:10.36849/JDD.7250.

Examination of Treatment Satisfaction Instruments in Psoriasis: 2017 Results from the Psoriasis Working Group of the International Dermatology Outcome Measures (IDEOM).

BACKGROUND/AIMS: In dermatology clinical trials, assessment of patients' treatment satisfaction is crucial but often lacking. To address this need, IDEOM's Psoriasis Working Group seeks to evaluate, develop, and validate treatment satisfaction instruments for the psoriasis population. The Psoriasis Working Group aimed to determine (1) factors affecting psoriasis patients' satisfaction with their therapies, (2) adequacy of two commonly used generic treatment satisfaction instruments in reflecting the psoriasis patients' perspective, and (3) whether a need exists to develop a new treatment satisfaction instrument. METHODS: Patient perspectives on satisfaction with treatment efficacy, safety, convenience, and overall satisfaction were elicited.Stakeholders were presented with information regarding the feasibility and content validity of two generic treatment instruments, the Treatment Satisfaction Questionnaire for Medication (TSQM) and the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q). We conducted a nominal group discussion and survey to determine whether stakeholders considered these instruments feasible and adequate to address treatment satisfaction for psoriasis therapies. RESULTS: Forty-five stakeholders participated in the nominal group discussion and survey. 53% of participants voted that the TSQM and SATMED-Q are not adequate and that we should create a new dermatology-specific treatment satisfaction instrument. Patients and other stakeholders also provided feedback on aspects of treatment satisfaction important to them. These include speed of onset and durability of therapeutic effect of a medication, permanence of side effects, and convenience of administering the medication. CONCLUSION: Stakeholders, including patients and providers, determined that generic treatment satisfaction questionnaires are not adequate to evaluate treatment satisfaction in psoriasis patients.

Access to Dermatological Care with an Innovative Online Model for Psoriasis Management: Results from a Randomized Controlled Trial.

Background:Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes.Introduction:We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care.Materials and Methods:The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH.Results:At baseline, no differences existed between the groups in difficulties obtaining specialty care. Over 12 months, the mean (standard deviation [SD]) distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care.Discussion:The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH.Conclusions:The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

Are Your Patients Satisfied A Systematic Review of Treatment Satisfaction Measures in Psoriasis.

Treatment satisfaction is paramount to the field of dermatology. Treatment dissatisfaction directly impacts patient outcomes and health care delivery. A critical need exists for standardized, validated treatment satisfaction measures in dermatology. Comprehensive evaluation of the performance of treatment satisfaction instruments used in psoriasis is lacking. We sought to critically appraise the literature on measurement properties of treatment satisfaction instruments used in psoriasis. We performed a systematic review to identify treatment satisfaction instruments used in psoriasis and corresponding studies on their measurement properties. We followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology to inform a best evidence synthesis. Eleven instruments were identified. Six achieved positive content validity ratings, 2 achieved positive reliability and structural validity ratings, and 1 achieved a positive internal consistency rating. The REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) and the Spanish Satisfaction With Treatment of Psoriasis Questionnaire (SSWTPQ) had the highest overall performance. Measurement property data for treatment satisfaction instruments were found to be insufficient in identifying a single best treatment satisfaction instrument for psoriasis. Additional studies are required to better characterize the measurement properties of treatment satisfaction measures and allow for standardized assessments across psoriasis clinical trials and clinical practice.

Oral small molecules for psoriasis.

Psoriasis is chronic inflammatory skin condition that imposes a significant physical and psychosocial burden on patients. Moderate to severe psoriasis often requires systemic treatments, including oral systemic therapies and biologics. An addition to the treatment repository for psoriasis is oral small molecules, which include apremilast, tofacitinib, and ponesimod. Of these 3 medications, only apremilast is currently approved for the treatment of psoriasis. Long-term safety data for apremilast suggest that it has a tolerable safety profile and leads to significant improvement in patients with psoriasis; however, there are few head-to-head comparisons with other oral systemic medications. Tofacitinib and ponesimod have demonstrated clinical efficacy in treating psoriasis; however, further studies are required to understand the benefit-risk profile of these medications in psoriasis patients.

Psoriasis and suicidality: A systematic review and meta-analysis.

BACKGROUND: Psoriasis is associated with psychiatric comorbidities; however, the relationship between psoriasis and suicidality is not well understood. OBJECTIVE: To perform a systematic review and meta-analysis that elucidates the relationship between psoriasis and suicidality. METHODS: Applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched the PubMed, EMBASE, PsycINFO, and Cochrane databases. We searched literature published between 1946 and 2017. RESULTS: We identified 18 studies with a total of 1,767,583 participants, of whom 330,207 had psoriasis. On the basis of random effects modeling, the pooled odds ratio (OR) for suicidal ideation among patients with psoriasis was 2.05 (95% confidence interval [CI], 1.54-2.74). Patients with psoriasis were more likely to exhibit suicidal behaviors (combined attempted and completed suicides) with a pooled OR of 1.26 (95% CI, 1.13-1.40). Subgroup analysis showed that patients with psoriasis were more likely to attempt suicides (OR, 1.32; 95% CI, 1.14-1.54) and complete suicide (OR, 1.20; 95% CI, 1.04-1.39) than those without psoriasis. More severe psoriasis and younger age were associated with greater likelihood of suicidality. LIMITATIONS: There are few studies examining suicidality in conjunction with psoriasis severity. CONCLUSIONS: Patients with psoriasis have a significantly higher likelihood of suicidal ideation, suicide attempts, and completed suicides. Among patients with psoriasis, those who are younger and whose psoriasis is more severe are at particular risk for suicidality.

International Dermatology Outcome Measures (IDEOM) Group 2016 New York Meeting: Meeting Summary and Data from the Psoriasis Working Group.

The International Dermatology Outcome Measures (IDEOM) Group was established to develop validated and standardized patient-centered outcome measures in dermatology that meet the needs of stakeholders and can be used in clinical practice as well as clinical research. At this meeting, we aimed to define the final core domain set to be assessed in psoriasis clinical research and to identify which of the current psoriasis assessment instruments appropriately address those domains. Specifically, we sought to ascertain stakeholder input on domain match and feasibility of multiple psoriasis instruments. We presented 19 physician-reported and 23 patient-reported outcome measures at the meeting. Stakeholders anonymously voted on the validity and feasibility of each instrument. Validity was rated as: green (good), amber (fair), red (poor), and white (not enough information). Feasibility was rated as: green (feasible), amber (concerns about some aspects of feasibility), red (not feasible), and white (not enough information). Eighteen physician-reported and 20 patient-reported instruments received a favorable green or amber rating for validity from the majority of voters. Seventeen physician-reported and 19 patient-reported instruments received a green or amber rating for feasibility from the majority of voters. A significant proportion of the psoriasis instruments received a good or fair vote for measuring their intended psoriasis domains in a feasible manner. We will continue to refine our voting methodology and incorporate patient input into our process of defining psoriasis domains and developing validated instruments.

J Drugs Dermatol. 2017;16(8):770-777.

Direct-Access Online Care for the Management of Atopic Dermatitis: A Randomized Clinical Trial Examining Patient Quality of Life.

BACKGROUND: Atopic dermatitis (AD) is a chronic disease requiring regular follow-up. To increase access to dermatological care, online management of AD is being studied. However, a critical knowledge gap exists in determining AD patients' quality of life in direct-to-patient online models. In this study, we examined quality of life in AD patients managed through a direct-access online model. MATERIALS AND METHODS: We randomized 156 patients to receiving care through a direct-access online platform or in person. Patients were seen for six visits over 12 months. At each visit, the patients completed Dermatology Life Quality Index/Children's Dermatology Life Quality Index (DLQI/CDLQI), and Short Form (SF-12). RESULTS: Between baseline and 12 months, the mean (standard deviation, SD) within-group difference in DLQI score in the online group was 4.1 (±2.3); for the in-person group, the within-group difference was 4.8 (±2.7). The mean (SD) within-group difference in CDLQI score in the online group was 4.7 (±2.8); for the in-person group, the within-group difference was 4.9 (±3.1). The mean (SD) within-group difference in physical component score (PCS) and mental component score (MCS) SF-12 scores in the online group was 6.5 (±3.8) and 8.6 (±4.3); for the in-person group, it was 6.8 (±3.2) and 9.1(±3.8), respectively. The difference in the change in DLQI, CDLQI, SF-12 PCS, and SF-12 MCS scores between the two groups was 0.72 (95% confidence interval [90% CI], -0.97 to 2.41), 0.23 (90% CI, -2.21 to 2.67), 0.34 (90% CI, -1.16 to 1.84), and 0.51 (90% CI, -1.11 to 2.13), respectively. All differences were contained within their equivalence margins. CONCLUSION: Adult and pediatric AD patients receiving direct-access online care had equivalent quality of life outcomes as those see in person. The direct-access online model has the potential to increase access to care for patients with chronic skin diseases.

Quality of life among dermatology patients: a systematic review of investigations using qualitative methods.

INTRODUCTION: Quality of life may be assessed using quantitative or qualitative methods. Quantitative methods are commonly used in research settings; however, they may fail to capture the full range of patient experiences and impact on quality of life. Qualitative methods may be used to address this limitation. In this systematic review, we aim to synthesize data from articles utilizing qualitative methods to assess quality of life in dermatology patients. EVIDENCE ACQUISITION: We performed a systematic review search using the MEDLINE, EMBASE, and SCOPUS databases. The search was conducted using the following search criteria: ("Dermatology" [MeSH]) AND ("Quality of Life" [MeSH]), AND ("Qualitative Research" [MeSH]), searching literature spanning from January 1, 1946 to October 5, 2016. EVIDENCE SYNTHESIS: The systematic review of 15 articles included 533 dermatology patients. Patients expressed frustration over the unpredictability of disease symptoms and having to compensate for the subsequent limitations by altering their daily routines. Patients also reported profound helplessness due to chronic skin disease and social isolation in an effort to hide their disease. Patients noted the patient-provider relationship as a source of support and information exchange, with the goal to form easy to use treatment plans that met both physician and patient expectations. CONCLUSIONS: Qualitative assessment of patient quality of life can provide new insights into the patient experience and the impact of their skin disease. Qualitative methodology may capture meaningful information that may be overlooked by quantitative methods, and it should be included in quality of life research.

Using qualitative methods to understand factors contributing to patient satisfaction among dermatology patients: a systematic review.

PURPOSE: In this systematic review, we aimed to synthesize data that identify factors contributing to patient satisfaction in dermatology care using qualitative methods. MATERIALS AND METHODS: We performed a comprehensive search of the literature using the PubMed database for articles published between January 1, 2000 and February 9, 2015. The initial search yielded 186 articles, of which 13 were included after applying inclusion and exclusion criteria. RESULTS: The systematic review of 13 articles included a total of 330 patients. Using in-field observations and semistructured interviews, studies found that qualitative methods and analysis increased the provider's sensitivity to patient needs and enhanced patient care. Analyses using qualitative methods found increased patient satisfaction in their healthcare provider is associated with (1) confidence in the provider's diagnosis, (2) perception of patient-centered, individualized recommendations and (3) quality of patient education and provider explanation during a visit. CONCLUSIONS: Patient satisfaction is measured using either quantitative or qualitative methods. Quantitative methods result in standardized data that often does not capture the nuances of patient experience. In contrast, qualitative methodology is integral to gathering patient perspectives on patient care and satisfaction and should be included in future research models.

Characteristics of Medical Liability Claims Against Dermatologists From 1991 Through 2015.

Importance: Recognizing malpractice trends in the field of dermatology is important for establishing safeguards for patient care and minimizing liability. However, there is a lack of published data on malpractice claims against dermatologists. Objective: To determine characteristics of medical professional liability claims in the field of dermatology and to compare these claims with those against all physicians. Design, Setting, and Participants: We examined malpractice liability data collected on dermatologists and other physicians insured by companies that report data to the Physician Insurers Association of America Data Sharing Project (PIAA-DSP), a nationally representative liability claims registry. Data analyzed spanned the years 1991 through 2015. Main Outcomes and Measures: Demographic characteristics of dermatologists subject to claims, characteristics of closed claims, medical errors associated with closed claims, and patient outcomes leading to closed claims. Results: Data on a total of 90 743 closed claims were analyzed, 1084 (1.2%) against dermatologists and 89 659 (98.8%) against nondermatologists. More lawsuits were brought against male (n = 753, 69.5%) than female dermatologists (n = 270, 24.9%); 5.6% of claims (n = 61) did not identify the physician's sex. Full-time practitioners (n = 1035, 95.5%) and those in solo practice (n = 600, 55.4%) were more likely to be sued than those in group practices (n = 429, 39.6%) and institutions (n = 31, 2.9%). Most claims against dermatologists were abandoned, withdrawn, or dismissed (n = 735, 67.8%). Between 2006 and 2015, trial verdicts favoring defendants exceeded trial verdicts favoring plaintiffs by a factor of 7. Errors that occurred during a procedure spawned the most claims (n = 305), of which 102 were paid. Misdiagnoses comprised the second-highest number of claims (n = 192), of which 62 were paid. The average recovery per claim was $238 145. The most common procedure leading to claims was skin operations (420 claims, of which 130 were paid). The most common adverse patient outcome associated with claims was dyschromia, resulting in 171 claims, of which 40 were paid. Conclusions and Relevance: Male dermatologists were sued more often than female dermatologists. Overall, alleged errors in procedures and misdiagnosis gave rise to the most lawsuits. Dyschromia was the most common adverse outcome alleged in lawsuits.

Effect of Age of Onset of Psoriasis on Clinical Outcomes with Systemic Treatment in the Psoriasis Longitudinal Assessment and Registry (PSOLAR).

OBJECTIVE: Our objective was to compare therapeutic response among patients with early-onset psoriasis (EOP) and late-onset psoriasis (LOP) receiving adalimumab, etanercept, infliximab, ustekinumab, or methotrexate in the Psoriasis Longitudinal Assessment and Registry (PSOLAR). METHODS: Patients were grouped by age of onset: EOP (age ≤ 40 years) or LOP (age > 40 years). Repeated-measures analysis with logistic regression was used to calculate the adjusted odds ratio (AOR; adjusted for baseline characteristics) for achieving a Physician's Global Assessment score of cleared/minimal (PGA 0/1) or a percentage of body surface area involved with psoriasis < 3% (%BSA < 3) or %BSA < 1 for all patients; similar sensitivity analyses were performed for each treatment group. RESULTS: Of 7511 patients, 5479 (72.9%) had EOP. The LOP group had a higher likelihood of achieving PGA 0/1 after treatment than did the EOP group in all patients (AOR 1.14 [95% confidence interval (CI) 1.05-1.25]; p = 0.0019); the same was true in subgroups of etanercept-treated (AOR 1.38 [95% CI 1.14-1.66]; p = 0.0010) and methotrexate-treated (AOR 1.62 [95% CI 1.16-2.26]; p = 0.0049) patients. No significant difference was found between the EOP and LOP groups with regard to the likelihood of achieving %BSA < 3 or %BSA < 1 among all patients. However, LOP patients were more likely than EOP patients to achieve %BSA < 3 or %BSA < 1 in subgroups treated with infliximab (AOR 1.45 [95% CI 1.09-1.93; p = 0.0103] and AOR 1.36 [95% CI 1.03-1.78; p = 0.0290], respectively) and etanercept (AOR 1.30 [95% CI 1.06-1.61; p = 0.0123] and AOR 1.34 [95% CI 1.09-1.64; p = 0.0053], respectively). CONCLUSION: Our real-world data from PSOLAR indicate that there are differences in some patient characteristics between EOP and LOP and that patients with EOP are less likely than those with LOP to respond to certain systemic treatments. (ClinicalTrials.gov identifier: NCT00508547).

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial.

Importance: Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. Objective: To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. Design, Setting, and Participants: The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. Interventions: Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. Main Outcomes and Measures: The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. Results: Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was -0.27 (95% CI, -0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was -0.05% (95% CI, -1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was -0.11 (95% CI, -0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. Conclusions and Relevance: The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases. Trial Registration: ClinicalTrials.gov Identifier: NCT02358135.

An update on psoriasis and metabolic syndrome: A meta-analysis of observational studies.

The relationship between psoriasis and metabolic syndrome is not well understood. Though multiple epidemiologic studies have suggested a link between psoriasis and metabolic syndrome, there is a lack of a comprehensive meta-analysis synthesizing the results of all available observational studies to date. In this meta-analysis, we examined global data on the relationship between psoriasis and odds of metabolic syndrome by searching for studies published between 1946-2016. Specifically, we analyzed the results from 35 observational studies from 20 countries with 1,450,188 total participants, of which 46,714 were psoriasis patients. The pooled odds ratio based on random effects analysis was 2.14 (95% CI 1.84-2.48). Publication bias was present, as evidenced by an Egger test and graphical visualization through a funnel plot (p = 0.001). Based on this comprehensive meta-analysis, psoriasis patients have higher odds of having metabolic syndrome when compared with the general population.

Relationship between psoriasis and metabolic syndrome: a systematic review.

INTRODUCTION: A number of studies have suggested an epidemiologic association between metabolic syndrome and psoriasis. A systematic review of the literature is necessary to determine whether the synthesis and interpretation of recent studies support the relationship between psoriasis and metabolic syndrome. The objective of this study conducted a comprehensive systematic review that synthesizes and interprets primary observational studies in order to elucidate the relationship between psoriasis and metabolic syndrome. EVIDENCE ACQUISITION: We performed a systematic review search using the MEDLINE, EMBASE, Cochrane Central Register, and SCOPUS databases (1946-2016) and performed a manual search of selected references. We identified English-language, human-subject, observational studies that examined the prevalence of metabolic syndrome in conjunction with psoriasis. EVIDENCE SYNTHESIS: We included data from 17 articles with an aggregate of 28,939 participants, among whom 3791 were psoriasis patients. Overall, the studies reported a higher prevalence of metabolic syndrome in patients with psoriasis. The odds ratio (OR) for metabolic syndrome and psoriasis ranged from 1.39-4.49, and the adjusted OR ranged from 1.29 to 5.14. The studies reported a higher prevalence of the individual components of metabolic syndrome in patients with psoriasis. A dose-response relationship was observed between psoriasis severity and the prevalence of metabolic syndrome. Due to the scarcity of cohort studies, it is difficult to fully examine the impact of psoriasis on the development of metabolic syndrome. Variability in how outcomes were recorded existed among some studies, which made between-study comparisons difficult. CONCLUSIONS: Psoriasis patients have a greater prevalence of metabolic syndrome as well as its individual components when compared to the general population. The odds of metabolic syndrome and its components are higher with increased psoriasis disease severity. Prospective studies are needed to better understand the contribution of psoriasis in the development of metabolic syndrome.