Sonali Nanda, MD

Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another._¹ Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.

Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.² The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.

Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?

Establish a Social Committee

As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.

Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.

Utilize Social Media

Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.

Encourage Local and National Conference Attendance

All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.

In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.

Repair Conflicts and Build a Climate of Collaboration

Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.

It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.

Final Thoughts

Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.

Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another._¹ Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.

Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.² The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.

Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?

Establish a Social Committee

As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.

Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.

Utilize Social Media

Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.

Encourage Local and National Conference Attendance

All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.

In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.

Repair Conflicts and Build a Climate of Collaboration

Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.

It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.

Final Thoughts

Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.

Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another._¹ Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.

Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.² The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.

Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?

Establish a Social Committee

As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.

Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.

Utilize Social Media

Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.

Encourage Local and National Conference Attendance

All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.

In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.

Repair Conflicts and Build a Climate of Collaboration

Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.

It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.

Final Thoughts

Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.