Nadine Shabeeb, MD, MPH

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

An article recently was published in The New York Times with a headline that read, “Dermatology Has a Problem With Skin Color.” ¹ The article featured interviews with many well-known dermatologists who are experts in skin of color (SOC), and their points followed a similar pattern—skin disease often looks different in patients with darker skin, and diagnoses often are delayed or missed altogether as a consequence of clinical uncertainty. The article included an interview with Jenna Lester, MD, who leads the SOC clinic at the University of California, San Francisco. In the article, she discussed how dermatologists are trained to recognize findings through pattern recognition. However, if we are only trained to diagnose dermatologic diseases on white skin, we will be unable to recognize diseases in patients with darker skin, leading to suboptimal patient care. ¹

Dermatology is a visual specialty, and residents go through thousands of photographs during residency training to distinguish different presentations and unique findings of a variety of skin diseases. Nevertheless, to Dr. Lester’s point, our learning is limited by the photographs and patients that we see.

Additionally, residents training in locations without diverse patient populations rely even more on images in educational resources to recognize clinical presentations in patients with darker skin. A study was published in Cutis earlier this year that surveyed dermatology residents about multiethnic training in residency.² It showed that residents training in less ethnically diverse areas such as the Midwest and Northwest were more likely to agree that dedicated multiethnic clinics and rotations are important to gain competence compared to residents training in more ethnically diverse regions such as the Southeast, Northeast, and Southwest. Most residents believed 1 to 5 hours per month of lectures covering conditions affecting SOC and/or multiethnic skin are needed to become competent.²

Limitations of Educational Resources

The images in dermatology educational resources do not reflect the diversity of our country’s population. A research letter recently was published in the Journal of the American Academy of Dermatology (JAAD) in which the authors assessed the number of images of dark skin—Fitzpatrick skin types V and VI—in dermatology educational resources.³ The authors analyzed images from 8 resources commonly used to study dermatology, including 6 printed texts and 2 online resources. Of the printed texts, Andrews’ Diseases of the Skin had the highest percentage of images of dark skin at 19.9%. Overall, VisualDx had the highest percentage of photographs of dark skin at 28.5%, while DermNet NZ had the lowest of all resources at only 2.8%.³

Similarly, a research letter published in the British Journal of Dermatology reviewed images in 2 standard dermatology textbooks.⁴ Although images of SOC made up 22% to 32% of the overall content, the number of images of sexually transmitted infections in SOC was disproportionate (47%–58%) compared to images of non–sexually transmitted infections (28%). The authors also stated that communities of color often have legacies of mistrust with the health care system, and diagnostic uncertainty can further impair the physician-patient relationship.⁴

The lack of diversity in clinical images and research was further exemplified by recent publications regarding the perniolike eruption associated with coronavirus disease 2019 (COVID-19), commonly referred to as COVID toes. A research letter was published in the British Journal of Dermatology earlier this year about the lack of images of SOC in publications about the cutaneous manifestations of COVID-19.⁵ At that time, there were zero published images of cutaneous COVID-19 manifestations in Fitzpatrick skin types V and VI, yet COVID-19 disproportionately affects Black individuals and other people of color.^5,6 A case series recently was published in JAAD Case Reports that included images of cutaneous COVID-19 findings in patients with Fitzpatrick skin types III through V.⁷ The authors noted that the findings were more subtle on darker skin as the erythema was harder to discern. The inability to identify the perniolike eruption ultimately can delay diagnosis.⁷

Resident Education

Over the past few months, I have reflected on my role as a dermatology resident and my dedication to antiracism in my personal and professional life. It is not a valid response or excuse to say that certain diagnoses are harder to make because of darker skin tone. It is our responsibility to do better for all patients. To that end, our educational resources should reflect our entire patient population.

I have been working with my coresident Annika Weinhammer, MD, on a quality improvement project to strengthen our educational curriculum at the University of Wisconsin regarding SOC. This project aims to enhance our skills as dermatologists in diagnosing and treating diseases in SOC. Moving forward, we have set an expectation that all didactic lectures must include images of SOC. Below, I have listed some of our initiatives along with recommendations for educational resources. There are multiple dermatology textbooks focused on SOC, including the following:

• Clinical Cases in Skin of Color: Adnexal, Inflammation, Infections, and Pigmentary Disorders ⁸
• Clinical Cases in Skin of Color: Medical, Oncological and Hair Disorders, and Cosmetic Dermatology ⁹
• Dermatology Atlas for Skin of Color ¹⁰
• Fundamentals of Ethnic Hair: The Dermatologist’s Perspective ¹¹
• Light-Based Therapies for Skin of Color ¹²
• Pediatric Skin of Color ¹³
• Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment ¹⁴
• Taylor and Kelly’s Dermatology for Skin of Color ¹⁵
• Treatments for Skin of Color ¹⁶

Our program has provided residents with Taylor and Kelly’s Dermatology for Skin of Color¹⁵ and Treatments for Skin of Color.¹⁶ Residents and medical students should search their institution’s electronic library for e-books and other resources including VisualDx, which includes many photographs of SOC that can be used and cited in resident didactics.

There also are a variety of online resources. Mind the Gap is a handbook written by Malone Mukwende, a medical student in London.^17,18 The handbook focuses on common clinical signs and how they present in black and brown skin. Another online resource with clinical images is Skin Deep (https://dftbskindeep.com/), a project aimed at improving the diversity of pediatric skin images. An additional online resource is Brown Skin Matters on Instagram (@brownskinmatters) that shows photographs of dermatologic conditions in SOC; however, these photographs are submitted by users and not independently verified.

I also encourage residents to join the Skin of Color Society, which promotes awareness and excellence within the special interest area of SOC. Some of the society's initiatives include educational series, networking events, diversity town halls, and a scientific symposium. Patient information for common dermatologic diagnoses exists on the society's website (https://skinofcolorsociety.org/). The society waives membership fees for resident applicants who provide a letter of good standing from their residency program. The society hosted the Skin of Color Update virtually this year (September 12–13, 2020). It costs $49 to attend, and the recorded lectures are available to stream through the end of 2020. Our department sponsored residents to attend virtually.

Finally, our department has been taking steps to implement antiracism measures in how we work, learn, conduct research, and treat patients. We are leading a resident book club discussing How to Be an Antiracist¹⁹ by Ibram X. Kendi. Residents are involved in the local chapter of White Coats for Black Lives (https://whitecoats4blacklives.org/). We also have compiled a list of antiracism resources that was shared with the department, including books, documentaries, podcasts, local and online Black-owned businesses to support, and local Black-led nonprofits. 

Final Thoughts

Dermatology residents must be comfortable diagnosing and treating diseases in darker skin tones to provide the best possible care for patients with SOC. Although some common dermatology educational resources have a paucity of clinical images of SOC, there are a variety of additional educational resources through textbooks and websites.

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Resident wellness is a topic that has become increasingly important in recent years due to physician burnout. A prior Cutis Resident Corner column discussed the prevalence of physician burnout and how it can affect dermatologists.¹ When discussing resident burnout, dermatology may not be a specialty that immediately comes to mind, considering that dermatology is mostly outpatient based, with few emergencies and critically ill patients. In a JAMA study assessing levels of burnout by specialty, dermatology residents were the lowest at approximately 30%.² However, this still means that 3 out of every 10 dermatology residents feel burnt out.

Burnout in Dermatology

In 2017, results from a survey of 112 dermatology residents in Canada about burnout was published in the British Journal of Dermatology.³ The numbers were staggering; the results showed that more than 50% of dermatology residents experienced high levels of emotional exhaustion and depersonalization, and 40% had low levels of personal accomplishment. Additionally, 52% experienced low or depressed mood, 20% reported feelings of hurting themselves within the last year, and more than 25% had high anxiety levels.³

Dermatology requires a high level of daily studying, which is a major source of stress for many dermatology residents. The survey of dermatology residents in Canada showed that the top stressor for 61% of survey respondents was studying, specifically for the board examination.³ Dermatology is an academically rigorous specialty. We are responsible for recognizing every disease process affecting the skin, including hundreds that are extremely uncommon. We must understand these disease processes at a molecular level from a basic science standpoint and at a microscopic level through our knowledge of dermatopathology. Much of what we see in clinic are bread-and-butter dermatologic conditions that do not necessarily correlate with the rare diseases that we study. This differs from other specialties in which residents learn much of their specialty knowledge through their clinical work.

Current Challenges

We are training in a uniquely challenging time, providing care for our patients amid the coronavirus disease 2019 pandemic. Many of us are dealing with constant levels of stress and worry about the health and safety of ourselves, along with our friends, families, and patients. Some residents have been redeployed to work in unfamiliar roles in the emergency department or hospital wards, while others adjust to new roles in teledermatology. I also cannot talk about resident wellness without recognizing the challenges faced by physicians who are racial and religious minorities. This is especially true for black physicians, as they face unconscious biases and microaggressions daily derived from implicit racism; this leads to discrimination in every area of life and ultimately harms their emotional and psychological well-being.⁴ Additionally, black physicians are underrepresented in dermatology, making up only 4.3% of dermatology residents in the 2013-2014 academic year.^5,6 Underrepresentation can serve as a major stressor for racial and religious minorities and should be considered when addressing resident wellness to ensure their voices are heard and validated.

Focusing on Wellness

What can we do to improve wellness? A viewpoint published in JAMA Surgery in 2015 by Salles et al⁷ from the Stanford University Department of Surgery (Stanford, California) discussed their Balance in Life (BIL) program, which was established after one of their residency graduates tragically died by suicide shortly after graduating from residency. The BIL program addresses 4 different facets of well-being—professional, physical, psychological, and social—and lists the specific actions taken to improve these areas of well-being.⁷

I completed my transitional year residency at St. Vincent Hospital (Indianapolis, Indiana). The program emphasizes the importance of resident wellness. They established a department-sponsored well-being program to improve resident wellness,⁸ with its objectives aligning with the 4 areas of well-being that were outlined in the Stanford viewpoint.⁷ A short Q&A with me was published in the supplemental material as a way of highlighting their residents.⁹ I will outline the 4 areas of well-being, with suggestions based on the Stanford BIL program, the well-being innovation program at St. Vincent, and initiatives at my current dermatology residency program at the University of Wisconsin (UW) in Madison.

The 4 Areas of Well-being

Professional Well-being

Stanford BIL Program
One of the changes implemented was starting a resident mentorship program. Each junior resident selects a senior resident as a mentor with department-sponsored quarterly lunch meetings.⁷ Another initiative is a leadership training program, which includes an outdoor rope course each year focusing on leadership and team building.⁷

UW Dermatology
Monthly meetings are held with our program director and coordinator so that we can address any concerns or issues as they arise and brainstorm solutions together. During the coronavirus disease 2019 pandemic, we had weekly resident town halls with department leadership with transparency about our institution’s current status.

Physical Well-being

Stanford BIL Program
One method of improving physical well-being included stocking healthy snacks for residents and providing incoming residents with a guide of physicians, dentists, and fitness venues to promote regular health care. We have adopted the same at UW with healthy snacks available in our resident workroom.

St. Vincent Internal Medicine Wellness
There are monthly fitness challenges for a variety of physical wellness activities such as sleep, mindfulness minutes, nutrition, and step challenges.⁸

UW Dermatology
In addition to healthy snacks in our workroom, we also have various discounted fitness classes available for employees, along with discounts on gym memberships, kayak rentals, and city bike-share programs.

Psychological Well-Being

Stanford BIL Program
They enlisted a clinical psychologist available for residents to talk to regularly about any issues they face and to help manage stress in their lives.⁷

St. Vincent Internal Medicine Wellness
Faculty and coordinators provide S.A.F.E.—secure, affirming, friendly, and empathetic—zones to provide confidential and judgment-free support for residents.⁸ They also host photography competitions; residents submit photographs of nature, and the winning photographs are printed and displayed throughout the work area.

UW Dermatology
We have made changes to beautify our resident workroom with photograph collages of residents and other assorted décor to make it a more work-friendly space.

Social Well-being

Common themes highlighted by all 3 programs include the importance of socializing outside of the workplace, team-building activities, and resident retreats. Social media accounts on Instagram at St. Vincent (@stvimresidency) and at UW (@uwderm) highlight resident accomplishments and promote interconnectedness when residents are not together in clinics or hospitals.

Final Thoughts

Resident wellness will continue to be an important topic for discussion in the future, especially given the uncertain times right now during our training. Focusing on the 4 areas of well-being can help to prevent burnout and improve resident wellness.

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Low-dose naltrexone (LDN) has shown efficacy in off-label treatment of a variety of inflammatory diseases ranging from Crohn disease to multiple sclerosis.¹ There are limited data about the use of LDN in dermatology, but reports regarding how it works as an anti-inflammatory agent have been published.^1,2

Naltrexone is an opioid receptor antagonist that originally was approved by the US Food and Drug Administration to treat addiction to alcohol, opiates, and heroin.² The dose of naltrexone to treat addiction ranges from 50 to 100 mg/d, and at these levels the effects of opioids are blocked for 24 hours; however, the dosing for LDN is much lower, ranging from 1.5 to 4.5 mg/d.³ At this low dose, naltrexone partially binds to various opioid receptors, leading to a temporary blockade.⁴ One of the downstream effects of this opioid receptor blockade is a paradoxical increase in endogenous endorphins.³

In addition to opioid blockage, lower doses of naltrexone have anti-inflammatory effects by inhibiting nonopioid receptors. Naltrexone blocks toll-like receptor 4, which is found on keratinocytes and also on macrophages such as microglia.⁵ These macrophages also contain inflammatory compounds such as tumor necrosis factor α and IL-6. Low-dose naltrexone can suppress levels of these inflammatory markers. It is important to note that these anti-inflammatory effects have not been observed at the standard higher doses of naltrexone.¹

When to Use

Low-dose naltrexone is a treatment option for inflammatory dermatologic conditions. A recent review of the literature outlined the use of LDN in a variety of inflammatory skin conditions. Improvement was noted in patients with Hailey-Hailey disease, lichen planopilaris, and various types of pruritus (ie, aquagenic, cholestatic, uremic, atopic dermatitis related).³ A case report of LDN successfully treating a patient with psoriasis also has been published.⁶ We often use LDN at the University of Wisconsin (Madison, Wisconsin) to treat patients with psoriasis. Ekelem et al³ also discussed patients with skin conditions that either had no response or worsened with naltrexone treatment, including various types of pruritus (ie, uremic, mycosis fungoides related, other causes of pruritus). Importantly, in the majority of cases without an improved response, the dose used was 50 mg/d.³ Higher doses of naltrexone are not known to have anti-inflammatory effects.

Low-dose naltrexone can be considered as a treatment option in patients with contraindications to other systemic anti-inflammatory treatments; for example, patients with a history of malignancy may prefer to avoid treatment with biologic agents. Low-dose naltrexone also can be considered as a treatment option in patients who are uncomfortable with the side-effect profiles of other systemic anti-inflammatory treatments, such as the risk for leukemias and lymphomas associated with biologic agents, the risk for liver toxicity with methotrexate, or the risk for hyperlipidemia with acitretin.

How to Monitor

The following monitoring information is adapted from the practice of Apple Bodemer, MD, a board-certified dermatologist at the University of Wisconsin (Madison, Wisconsin) who also is fellowship trained in integrative medicine.

There is a paucity of published data about LDN dosing for inflammatory skin diseases. However, prescribers should be aware that LDN can alter thyroid hormone levels, especially in patients with autoimmune thyroid disease. If a thyroid-stimulating hormone (TSH) level within reference range has not been noted in the last year, consider screening with a TSH test and also assessing for a personal or family history of thyroid disease. If the TSH level is within reference range, there generally is no need to monitor while treating with LDN. Consider checking TSH levels every 4 months in patients with thyroid disease while they are on LDN therapy and be sure to educate them about symptoms of hyperthyroidism.

Side Effects

Low-dose naltrexone has a minimal side-effect profile with self-limited side effects that often resolve within approximately 1 week. One of the most commonly reported side effects is sleep disturbance with vivid dreams, which has been reported in 37% of participants.¹ If your patients experience this side effect, you can reassure them that it improves with time. You also can switch to morning dosing to try and alleviate sleep disturbances at night. Another possible side effect is gastrointestinal tract upset. Importantly, there is no known abuse potential for LDN.¹ To stop LDN, patients should be stable for 6 to 12 months, and there is no need to wean them off it.

Cost and Availability

Because use of LDN in dermatology is considered off label and it is not approved by the US Food and Drug Administration to treat any medical conditions, it must be prescribed through a compounding pharmacy, usually without insurance coverage. The monthly cost is approximately $30 depending on the pharmacy (unpublished data), which may be cost prohibitive for patients, so it is important to counsel them about price before starting treatment.

Final Thoughts

Low-dose naltrexone is an alternative treatment option that can be considered in patients with inflammatory skin diseases. It has a favorable side-effect profile, especially compared to other systemic anti-inflammatory agents; however, additional studies are needed to learn more about its safety and efficacy. If patients ask you about LDN, the information provided here can guide you with how it works and how to prescribe it.

Low-dose naltrexone (LDN) has shown efficacy in off-label treatment of a variety of inflammatory diseases ranging from Crohn disease to multiple sclerosis.¹ There are limited data about the use of LDN in dermatology, but reports regarding how it works as an anti-inflammatory agent have been published.^1,2

Naltrexone is an opioid receptor antagonist that originally was approved by the US Food and Drug Administration to treat addiction to alcohol, opiates, and heroin.² The dose of naltrexone to treat addiction ranges from 50 to 100 mg/d, and at these levels the effects of opioids are blocked for 24 hours; however, the dosing for LDN is much lower, ranging from 1.5 to 4.5 mg/d.³ At this low dose, naltrexone partially binds to various opioid receptors, leading to a temporary blockade.⁴ One of the downstream effects of this opioid receptor blockade is a paradoxical increase in endogenous endorphins.³

In addition to opioid blockage, lower doses of naltrexone have anti-inflammatory effects by inhibiting nonopioid receptors. Naltrexone blocks toll-like receptor 4, which is found on keratinocytes and also on macrophages such as microglia.⁵ These macrophages also contain inflammatory compounds such as tumor necrosis factor α and IL-6. Low-dose naltrexone can suppress levels of these inflammatory markers. It is important to note that these anti-inflammatory effects have not been observed at the standard higher doses of naltrexone.¹

When to Use

Low-dose naltrexone is a treatment option for inflammatory dermatologic conditions. A recent review of the literature outlined the use of LDN in a variety of inflammatory skin conditions. Improvement was noted in patients with Hailey-Hailey disease, lichen planopilaris, and various types of pruritus (ie, aquagenic, cholestatic, uremic, atopic dermatitis related).³ A case report of LDN successfully treating a patient with psoriasis also has been published.⁶ We often use LDN at the University of Wisconsin (Madison, Wisconsin) to treat patients with psoriasis. Ekelem et al³ also discussed patients with skin conditions that either had no response or worsened with naltrexone treatment, including various types of pruritus (ie, uremic, mycosis fungoides related, other causes of pruritus). Importantly, in the majority of cases without an improved response, the dose used was 50 mg/d.³ Higher doses of naltrexone are not known to have anti-inflammatory effects.

Low-dose naltrexone can be considered as a treatment option in patients with contraindications to other systemic anti-inflammatory treatments; for example, patients with a history of malignancy may prefer to avoid treatment with biologic agents. Low-dose naltrexone also can be considered as a treatment option in patients who are uncomfortable with the side-effect profiles of other systemic anti-inflammatory treatments, such as the risk for leukemias and lymphomas associated with biologic agents, the risk for liver toxicity with methotrexate, or the risk for hyperlipidemia with acitretin.

How to Monitor

The following monitoring information is adapted from the practice of Apple Bodemer, MD, a board-certified dermatologist at the University of Wisconsin (Madison, Wisconsin) who also is fellowship trained in integrative medicine.

There is a paucity of published data about LDN dosing for inflammatory skin diseases. However, prescribers should be aware that LDN can alter thyroid hormone levels, especially in patients with autoimmune thyroid disease. If a thyroid-stimulating hormone (TSH) level within reference range has not been noted in the last year, consider screening with a TSH test and also assessing for a personal or family history of thyroid disease. If the TSH level is within reference range, there generally is no need to monitor while treating with LDN. Consider checking TSH levels every 4 months in patients with thyroid disease while they are on LDN therapy and be sure to educate them about symptoms of hyperthyroidism.

Side Effects

Low-dose naltrexone has a minimal side-effect profile with self-limited side effects that often resolve within approximately 1 week. One of the most commonly reported side effects is sleep disturbance with vivid dreams, which has been reported in 37% of participants.¹ If your patients experience this side effect, you can reassure them that it improves with time. You also can switch to morning dosing to try and alleviate sleep disturbances at night. Another possible side effect is gastrointestinal tract upset. Importantly, there is no known abuse potential for LDN.¹ To stop LDN, patients should be stable for 6 to 12 months, and there is no need to wean them off it.

Cost and Availability

Because use of LDN in dermatology is considered off label and it is not approved by the US Food and Drug Administration to treat any medical conditions, it must be prescribed through a compounding pharmacy, usually without insurance coverage. The monthly cost is approximately $30 depending on the pharmacy (unpublished data), which may be cost prohibitive for patients, so it is important to counsel them about price before starting treatment.

Final Thoughts

Low-dose naltrexone is an alternative treatment option that can be considered in patients with inflammatory skin diseases. It has a favorable side-effect profile, especially compared to other systemic anti-inflammatory agents; however, additional studies are needed to learn more about its safety and efficacy. If patients ask you about LDN, the information provided here can guide you with how it works and how to prescribe it.

Low-dose naltrexone (LDN) has shown efficacy in off-label treatment of a variety of inflammatory diseases ranging from Crohn disease to multiple sclerosis.¹ There are limited data about the use of LDN in dermatology, but reports regarding how it works as an anti-inflammatory agent have been published.^1,2

Naltrexone is an opioid receptor antagonist that originally was approved by the US Food and Drug Administration to treat addiction to alcohol, opiates, and heroin.² The dose of naltrexone to treat addiction ranges from 50 to 100 mg/d, and at these levels the effects of opioids are blocked for 24 hours; however, the dosing for LDN is much lower, ranging from 1.5 to 4.5 mg/d.³ At this low dose, naltrexone partially binds to various opioid receptors, leading to a temporary blockade.⁴ One of the downstream effects of this opioid receptor blockade is a paradoxical increase in endogenous endorphins.³

In addition to opioid blockage, lower doses of naltrexone have anti-inflammatory effects by inhibiting nonopioid receptors. Naltrexone blocks toll-like receptor 4, which is found on keratinocytes and also on macrophages such as microglia.⁵ These macrophages also contain inflammatory compounds such as tumor necrosis factor α and IL-6. Low-dose naltrexone can suppress levels of these inflammatory markers. It is important to note that these anti-inflammatory effects have not been observed at the standard higher doses of naltrexone.¹

When to Use

Low-dose naltrexone is a treatment option for inflammatory dermatologic conditions. A recent review of the literature outlined the use of LDN in a variety of inflammatory skin conditions. Improvement was noted in patients with Hailey-Hailey disease, lichen planopilaris, and various types of pruritus (ie, aquagenic, cholestatic, uremic, atopic dermatitis related).³ A case report of LDN successfully treating a patient with psoriasis also has been published.⁶ We often use LDN at the University of Wisconsin (Madison, Wisconsin) to treat patients with psoriasis. Ekelem et al³ also discussed patients with skin conditions that either had no response or worsened with naltrexone treatment, including various types of pruritus (ie, uremic, mycosis fungoides related, other causes of pruritus). Importantly, in the majority of cases without an improved response, the dose used was 50 mg/d.³ Higher doses of naltrexone are not known to have anti-inflammatory effects.

Low-dose naltrexone can be considered as a treatment option in patients with contraindications to other systemic anti-inflammatory treatments; for example, patients with a history of malignancy may prefer to avoid treatment with biologic agents. Low-dose naltrexone also can be considered as a treatment option in patients who are uncomfortable with the side-effect profiles of other systemic anti-inflammatory treatments, such as the risk for leukemias and lymphomas associated with biologic agents, the risk for liver toxicity with methotrexate, or the risk for hyperlipidemia with acitretin.

How to Monitor

The following monitoring information is adapted from the practice of Apple Bodemer, MD, a board-certified dermatologist at the University of Wisconsin (Madison, Wisconsin) who also is fellowship trained in integrative medicine.

There is a paucity of published data about LDN dosing for inflammatory skin diseases. However, prescribers should be aware that LDN can alter thyroid hormone levels, especially in patients with autoimmune thyroid disease. If a thyroid-stimulating hormone (TSH) level within reference range has not been noted in the last year, consider screening with a TSH test and also assessing for a personal or family history of thyroid disease. If the TSH level is within reference range, there generally is no need to monitor while treating with LDN. Consider checking TSH levels every 4 months in patients with thyroid disease while they are on LDN therapy and be sure to educate them about symptoms of hyperthyroidism.

Side Effects

Low-dose naltrexone has a minimal side-effect profile with self-limited side effects that often resolve within approximately 1 week. One of the most commonly reported side effects is sleep disturbance with vivid dreams, which has been reported in 37% of participants.¹ If your patients experience this side effect, you can reassure them that it improves with time. You also can switch to morning dosing to try and alleviate sleep disturbances at night. Another possible side effect is gastrointestinal tract upset. Importantly, there is no known abuse potential for LDN.¹ To stop LDN, patients should be stable for 6 to 12 months, and there is no need to wean them off it.

Cost and Availability

Because use of LDN in dermatology is considered off label and it is not approved by the US Food and Drug Administration to treat any medical conditions, it must be prescribed through a compounding pharmacy, usually without insurance coverage. The monthly cost is approximately $30 depending on the pharmacy (unpublished data), which may be cost prohibitive for patients, so it is important to counsel them about price before starting treatment.

Final Thoughts

Low-dose naltrexone is an alternative treatment option that can be considered in patients with inflammatory skin diseases. It has a favorable side-effect profile, especially compared to other systemic anti-inflammatory agents; however, additional studies are needed to learn more about its safety and efficacy. If patients ask you about LDN, the information provided here can guide you with how it works and how to prescribe it.