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Prioritize topical treatments in pregnant women
SAN DIEGO – “Some doctors don’t treat them at all, or they undertreat because they’re afraid of prescribing anything,” said dermatologist Kelly H. Tyler, MD.
But the Food and Drug Administration’s new system of prescription drug labeling for pregnant women offers improved insight for dermatologists, and a variety of alternatives are available to commonly used dermatologic drugs that pose risks, said Dr. Tyler, who has a unique perspective on this issue: She used to practice as an ob.gyn.
In her presentation, she provided the following tips when caring for pregnant patients.
Check the prescription drug labeling for pregnant and lactating women
Prior to 2015, the FDA used a letter ratings to denote the risk of medications during pregnancy. The ratings – A, B, C, D, and X – go from “A” showing no fetal risk in controlled studies to “X” in which a drug is contraindicated because “there is no reason to risk use of drug in pregnancy.”
This rating system is problematic, Dr. Tyler said, since it’s imprecise. She noted that about two-thirds of medications have a risk rating of C, which means “Risk cannot be ruled out; human studies may or may not show risk; potential benefits may justify potential risk.” But, she asked, “How are you supposed to know what to do with that kind of information?”
By June 30, 2015, FDA had retired the letter classifications and replaced this system with the Pregnancy and Lactation Labeling final rule, which requires that labels include a pregnancy section with information on pregnancy exposure registries, in addition to risk summaries, clinical considerations, and available data. There are also sections on lactation, including nursing mothers, and females and males of reproductive potential. (This information appears in the prescription drug labeling sections 8.1-8.3.) Labels for medications approved prior to June 30, 2001 did not need to be updated. Labels for newer medications are required to comply within 3-5 years of the 2015 policy change.
Ask female patients about sexual activity
It’s important to ask all premenopausal female patients whether they’re sexually active and whether they are using birth control, trying to conceive, or are currently pregnant. If they’re pregnant, what trimester are they in?
Keep in mind, she said, that women can be pregnant for quite some time without knowing it. Home pregnancy tests may not show positive results for up to 5 weeks after conception, she said. But the embryonic/organogenesis stage – from 2 to 8 weeks – is the most important period for a pregnant mother avoid drugs that could damage the unborn child and is “when you want to avoid most medications,” she said.
Risks don’t end after a few months, however. Dr. Tyler urged dermatologists to keep in mind that the brain, teeth, and bones remain susceptible to damage from teratogenic medications after the eighth week.
Keep topical medications in mind
When it comes to pregnant women, “for most dermatologic therapies, topical medications will be your No. 1 choice” because of less absorption, Dr. Tyler said.
But there are exceptions, she noted. In acne and rosacea, for example, there’s controversy about the safety of topical retinoids. “I would just urge you to not use those medications in pregnancy because you don’t really need to use them,” Dr. Tyler said. “You have other options that are safer.”
Adapalene and tretinoin are listed as category C (risk cannot be ruled out in pregnancy) and topical tazarotene is category X (contraindicated in pregnancy) because of retinoid-like anomalies in animal studies, she said.
Avoid 3 major contraindicated systemic drugs
Isotretinoin, acitretin, and methotrexate are “absolutely contraindicated” for anyone who is pregnant or could become pregnant, Dr. Tyler said.
Use some systemic drugs with caution
Tetracyclines are category D (positive evidence of risk to human fetus, but benefits may outweigh risks of drug) with the highest risk in the second and third trimesters, Dr. Tyler said. “If for some reason you have a patient who’s on tetracycline, stop before she’s in her second trimester.”
She recommended avoiding the antibiotic erythromycin because of studies hinting at risks when used early in pregnancy. Spironolactone is theoretically risky after the week 8 of pregnancy, she said. “Because of the animal studies, we typically do not use this during pregnancy.”
Psoriasis often improves during pregnancy
Psoriasis improves during pregnancy in about half of women with psoriasis and worsens in about 20%, Dr. Tyler said. During pregnancy, topical treatments are the first-line treatment, said Dr. Tyler, who recommends that treatment should begin with topical steroids, then calcipotriene or tacrolimus if needed (J Am Acad Dermatol. 2013 Apr;68[4]:663-71). Cyclosporine is an option, as is phototherapy, she said. In an interview, she noted that phototherapy (narrowband UVB) would be considered next-line therapy in patients who are past the first 28 days of gestation and have failed topical therapy, given they are taking adequate folic acid supplementation, which is present in prenatal vitamins.
“As for biologics, you have to go with older ones that have more data. When we look at newer medications, we don’t know a lot about them,” she said during the presentation.
It’s okay to prescribe oral steroids and antihistamines
Oral steroids are safe during pregnancy, Dr. Tyler said, but “just be judicious” with moderate doses and short durations.
Antihistamines are also appropriate, she said, but be aware of the potential for neonatal sedation during lactation.
As for antibiotics for bacterial infections, azithromycin, penicillins, and cephalosporins are all category B (no risk to human fetus despite possible animal risk; or no risk in animal studies and human studies not done), as are all topical antibiotics except dapsone, which is category C because of a theoretical risk of neonatal hyperbilirubinemia if used near the time of delivery.
Hydroxychloroquine may be appropriate for connective tissue disease, she said, although steroids may be a better option in some cases.
And topical antifungals are considered safer for fungal diseases than systemic medications. She said she prefers clotrimazole and oxiconazole, both category B.
Finally, Dr. Tyler recommended permethrin (category B) for parasitic infections since it has been used extensively in pregnancy without a sign of risk and is the preferred treatment for scabies. It’s a better option than ivermectin, she said.
Postpone surgery until at least the second trimester
If it’s not possible to delay nonemergent dermatologic surgery until after pregnancy, she recommended performing procedures during the second trimester. Destruction of local lesions, however, is safe without anesthesia.
“In summary,” when treating pregnant patients, Dr. Tyler said, “a conservative approach is always best, topical medications are always first-line for any condition, and certain oral medications are safe.”
Dr. Tyler reported no relevant disclosures.
SAN DIEGO – “Some doctors don’t treat them at all, or they undertreat because they’re afraid of prescribing anything,” said dermatologist Kelly H. Tyler, MD.
But the Food and Drug Administration’s new system of prescription drug labeling for pregnant women offers improved insight for dermatologists, and a variety of alternatives are available to commonly used dermatologic drugs that pose risks, said Dr. Tyler, who has a unique perspective on this issue: She used to practice as an ob.gyn.
In her presentation, she provided the following tips when caring for pregnant patients.
Check the prescription drug labeling for pregnant and lactating women
Prior to 2015, the FDA used a letter ratings to denote the risk of medications during pregnancy. The ratings – A, B, C, D, and X – go from “A” showing no fetal risk in controlled studies to “X” in which a drug is contraindicated because “there is no reason to risk use of drug in pregnancy.”
This rating system is problematic, Dr. Tyler said, since it’s imprecise. She noted that about two-thirds of medications have a risk rating of C, which means “Risk cannot be ruled out; human studies may or may not show risk; potential benefits may justify potential risk.” But, she asked, “How are you supposed to know what to do with that kind of information?”
By June 30, 2015, FDA had retired the letter classifications and replaced this system with the Pregnancy and Lactation Labeling final rule, which requires that labels include a pregnancy section with information on pregnancy exposure registries, in addition to risk summaries, clinical considerations, and available data. There are also sections on lactation, including nursing mothers, and females and males of reproductive potential. (This information appears in the prescription drug labeling sections 8.1-8.3.) Labels for medications approved prior to June 30, 2001 did not need to be updated. Labels for newer medications are required to comply within 3-5 years of the 2015 policy change.
Ask female patients about sexual activity
It’s important to ask all premenopausal female patients whether they’re sexually active and whether they are using birth control, trying to conceive, or are currently pregnant. If they’re pregnant, what trimester are they in?
Keep in mind, she said, that women can be pregnant for quite some time without knowing it. Home pregnancy tests may not show positive results for up to 5 weeks after conception, she said. But the embryonic/organogenesis stage – from 2 to 8 weeks – is the most important period for a pregnant mother avoid drugs that could damage the unborn child and is “when you want to avoid most medications,” she said.
Risks don’t end after a few months, however. Dr. Tyler urged dermatologists to keep in mind that the brain, teeth, and bones remain susceptible to damage from teratogenic medications after the eighth week.
Keep topical medications in mind
When it comes to pregnant women, “for most dermatologic therapies, topical medications will be your No. 1 choice” because of less absorption, Dr. Tyler said.
But there are exceptions, she noted. In acne and rosacea, for example, there’s controversy about the safety of topical retinoids. “I would just urge you to not use those medications in pregnancy because you don’t really need to use them,” Dr. Tyler said. “You have other options that are safer.”
Adapalene and tretinoin are listed as category C (risk cannot be ruled out in pregnancy) and topical tazarotene is category X (contraindicated in pregnancy) because of retinoid-like anomalies in animal studies, she said.
Avoid 3 major contraindicated systemic drugs
Isotretinoin, acitretin, and methotrexate are “absolutely contraindicated” for anyone who is pregnant or could become pregnant, Dr. Tyler said.
Use some systemic drugs with caution
Tetracyclines are category D (positive evidence of risk to human fetus, but benefits may outweigh risks of drug) with the highest risk in the second and third trimesters, Dr. Tyler said. “If for some reason you have a patient who’s on tetracycline, stop before she’s in her second trimester.”
She recommended avoiding the antibiotic erythromycin because of studies hinting at risks when used early in pregnancy. Spironolactone is theoretically risky after the week 8 of pregnancy, she said. “Because of the animal studies, we typically do not use this during pregnancy.”
Psoriasis often improves during pregnancy
Psoriasis improves during pregnancy in about half of women with psoriasis and worsens in about 20%, Dr. Tyler said. During pregnancy, topical treatments are the first-line treatment, said Dr. Tyler, who recommends that treatment should begin with topical steroids, then calcipotriene or tacrolimus if needed (J Am Acad Dermatol. 2013 Apr;68[4]:663-71). Cyclosporine is an option, as is phototherapy, she said. In an interview, she noted that phototherapy (narrowband UVB) would be considered next-line therapy in patients who are past the first 28 days of gestation and have failed topical therapy, given they are taking adequate folic acid supplementation, which is present in prenatal vitamins.
“As for biologics, you have to go with older ones that have more data. When we look at newer medications, we don’t know a lot about them,” she said during the presentation.
It’s okay to prescribe oral steroids and antihistamines
Oral steroids are safe during pregnancy, Dr. Tyler said, but “just be judicious” with moderate doses and short durations.
Antihistamines are also appropriate, she said, but be aware of the potential for neonatal sedation during lactation.
As for antibiotics for bacterial infections, azithromycin, penicillins, and cephalosporins are all category B (no risk to human fetus despite possible animal risk; or no risk in animal studies and human studies not done), as are all topical antibiotics except dapsone, which is category C because of a theoretical risk of neonatal hyperbilirubinemia if used near the time of delivery.
Hydroxychloroquine may be appropriate for connective tissue disease, she said, although steroids may be a better option in some cases.
And topical antifungals are considered safer for fungal diseases than systemic medications. She said she prefers clotrimazole and oxiconazole, both category B.
Finally, Dr. Tyler recommended permethrin (category B) for parasitic infections since it has been used extensively in pregnancy without a sign of risk and is the preferred treatment for scabies. It’s a better option than ivermectin, she said.
Postpone surgery until at least the second trimester
If it’s not possible to delay nonemergent dermatologic surgery until after pregnancy, she recommended performing procedures during the second trimester. Destruction of local lesions, however, is safe without anesthesia.
“In summary,” when treating pregnant patients, Dr. Tyler said, “a conservative approach is always best, topical medications are always first-line for any condition, and certain oral medications are safe.”
Dr. Tyler reported no relevant disclosures.
SAN DIEGO – “Some doctors don’t treat them at all, or they undertreat because they’re afraid of prescribing anything,” said dermatologist Kelly H. Tyler, MD.
But the Food and Drug Administration’s new system of prescription drug labeling for pregnant women offers improved insight for dermatologists, and a variety of alternatives are available to commonly used dermatologic drugs that pose risks, said Dr. Tyler, who has a unique perspective on this issue: She used to practice as an ob.gyn.
In her presentation, she provided the following tips when caring for pregnant patients.
Check the prescription drug labeling for pregnant and lactating women
Prior to 2015, the FDA used a letter ratings to denote the risk of medications during pregnancy. The ratings – A, B, C, D, and X – go from “A” showing no fetal risk in controlled studies to “X” in which a drug is contraindicated because “there is no reason to risk use of drug in pregnancy.”
This rating system is problematic, Dr. Tyler said, since it’s imprecise. She noted that about two-thirds of medications have a risk rating of C, which means “Risk cannot be ruled out; human studies may or may not show risk; potential benefits may justify potential risk.” But, she asked, “How are you supposed to know what to do with that kind of information?”
By June 30, 2015, FDA had retired the letter classifications and replaced this system with the Pregnancy and Lactation Labeling final rule, which requires that labels include a pregnancy section with information on pregnancy exposure registries, in addition to risk summaries, clinical considerations, and available data. There are also sections on lactation, including nursing mothers, and females and males of reproductive potential. (This information appears in the prescription drug labeling sections 8.1-8.3.) Labels for medications approved prior to June 30, 2001 did not need to be updated. Labels for newer medications are required to comply within 3-5 years of the 2015 policy change.
Ask female patients about sexual activity
It’s important to ask all premenopausal female patients whether they’re sexually active and whether they are using birth control, trying to conceive, or are currently pregnant. If they’re pregnant, what trimester are they in?
Keep in mind, she said, that women can be pregnant for quite some time without knowing it. Home pregnancy tests may not show positive results for up to 5 weeks after conception, she said. But the embryonic/organogenesis stage – from 2 to 8 weeks – is the most important period for a pregnant mother avoid drugs that could damage the unborn child and is “when you want to avoid most medications,” she said.
Risks don’t end after a few months, however. Dr. Tyler urged dermatologists to keep in mind that the brain, teeth, and bones remain susceptible to damage from teratogenic medications after the eighth week.
Keep topical medications in mind
When it comes to pregnant women, “for most dermatologic therapies, topical medications will be your No. 1 choice” because of less absorption, Dr. Tyler said.
But there are exceptions, she noted. In acne and rosacea, for example, there’s controversy about the safety of topical retinoids. “I would just urge you to not use those medications in pregnancy because you don’t really need to use them,” Dr. Tyler said. “You have other options that are safer.”
Adapalene and tretinoin are listed as category C (risk cannot be ruled out in pregnancy) and topical tazarotene is category X (contraindicated in pregnancy) because of retinoid-like anomalies in animal studies, she said.
Avoid 3 major contraindicated systemic drugs
Isotretinoin, acitretin, and methotrexate are “absolutely contraindicated” for anyone who is pregnant or could become pregnant, Dr. Tyler said.
Use some systemic drugs with caution
Tetracyclines are category D (positive evidence of risk to human fetus, but benefits may outweigh risks of drug) with the highest risk in the second and third trimesters, Dr. Tyler said. “If for some reason you have a patient who’s on tetracycline, stop before she’s in her second trimester.”
She recommended avoiding the antibiotic erythromycin because of studies hinting at risks when used early in pregnancy. Spironolactone is theoretically risky after the week 8 of pregnancy, she said. “Because of the animal studies, we typically do not use this during pregnancy.”
Psoriasis often improves during pregnancy
Psoriasis improves during pregnancy in about half of women with psoriasis and worsens in about 20%, Dr. Tyler said. During pregnancy, topical treatments are the first-line treatment, said Dr. Tyler, who recommends that treatment should begin with topical steroids, then calcipotriene or tacrolimus if needed (J Am Acad Dermatol. 2013 Apr;68[4]:663-71). Cyclosporine is an option, as is phototherapy, she said. In an interview, she noted that phototherapy (narrowband UVB) would be considered next-line therapy in patients who are past the first 28 days of gestation and have failed topical therapy, given they are taking adequate folic acid supplementation, which is present in prenatal vitamins.
“As for biologics, you have to go with older ones that have more data. When we look at newer medications, we don’t know a lot about them,” she said during the presentation.
It’s okay to prescribe oral steroids and antihistamines
Oral steroids are safe during pregnancy, Dr. Tyler said, but “just be judicious” with moderate doses and short durations.
Antihistamines are also appropriate, she said, but be aware of the potential for neonatal sedation during lactation.
As for antibiotics for bacterial infections, azithromycin, penicillins, and cephalosporins are all category B (no risk to human fetus despite possible animal risk; or no risk in animal studies and human studies not done), as are all topical antibiotics except dapsone, which is category C because of a theoretical risk of neonatal hyperbilirubinemia if used near the time of delivery.
Hydroxychloroquine may be appropriate for connective tissue disease, she said, although steroids may be a better option in some cases.
And topical antifungals are considered safer for fungal diseases than systemic medications. She said she prefers clotrimazole and oxiconazole, both category B.
Finally, Dr. Tyler recommended permethrin (category B) for parasitic infections since it has been used extensively in pregnancy without a sign of risk and is the preferred treatment for scabies. It’s a better option than ivermectin, she said.
Postpone surgery until at least the second trimester
If it’s not possible to delay nonemergent dermatologic surgery until after pregnancy, she recommended performing procedures during the second trimester. Destruction of local lesions, however, is safe without anesthesia.
“In summary,” when treating pregnant patients, Dr. Tyler said, “a conservative approach is always best, topical medications are always first-line for any condition, and certain oral medications are safe.”
Dr. Tyler reported no relevant disclosures.
EXPERT ANALYSIS FROM AAD 18
AAD guidelines’ conflict-of-interest policies discussed in pro-con debate
SAN DIEGO – The American Academy of Dermatology’s policies that regulate conflicts of interest among members of its guidelines panels are “pretty good, but could be improved,” Lionel G. Bercovitch, MD, said at the annual meeting of the American Academy Dermatology.
One positive step might be to tighten the current American Academy of Dermatology requirement that more than half of the members in clinical guideline work groups be free of any financial conflicts and the minimum be raised to a higher percentage, such as more than 70%, suggested Dr. Bercovitch, a professor of dermatology at Brown University, Providence, R.I.
But his concern over the adequacy of existing conflict barriers during the writing of clinical guidelines wasn’t shared by Clifford Perlis, MD, who countered that “there are reasons not to waste too much time wringing our hands over conflicts of interest.”
He offered four reasons to support his statement:
- Conflicts of interest are ubiquitous and thus impossible to eliminate.
- Excluding working group members with conflicts can deprive the guidelines of valuable expertise.
- Checks and balances that are already in place in guideline development prevent inappropriate influence from conflicts of interest.
- No evidence has shown that conflicts of interest have inappropriately influenced development of treatment guidelines.
Conflicts of interest may not be as well managed as AAD policies suggest, Dr. Bercovitch noted. He cited a report published in late 2017 that tallied the actual conflicts of 49 people who served as the authors of three AAD guidelines published during 2013-2016. To objectively double check each author’s conflicts the researchers used the Open Payments database run by the Centers for Medicare & Medicaid Services (JAMA Dermatol. 2017 Dec;153[12]:1229-35).
The analysis showed that 40 of the 49 authors (82%) had received some amount of industry payment, 63% had received more than $1,000, and 51% had received more than $10,000. The median amount received from industry was just over $33,000. The analysis also showed that 22 of the 40 authors who received an industry payment had disclosure statements for the guideline they participated in that did not agree with the information in the Open Payments database.
“The AAD relies on information obtained through its self-reported online member disclosure system. This internal system collects updates to disclosed relationships on a real-time, ongoing basis, allowing the AAD to regularly assess any changes,” wrote Dr. Lim and his coauthors. “This provides information in a more meaningful and time-sensitive way” than the Open Payments database. In addition, the Open Payments database “is known to be inaccurate,” while the AAD “relies on information obtained through its self-reported online member disclosure system.” This includes an assessment of the relevancy of the conflict to the guideline involved. “This critical evaluation of relevancy was not addressed in the authors’ analysis,” they added.
They reported an adjusted analysis of the percentage of authors with relevant conflicts for each of the guidelines examined in the initial study. The percentages shrank to zero, 40%, and 43% of the authors with relevant conflicts, percentages that fell within the AAD’s ceiling for an acceptable percentage of work group members with conflicts.
The discussion on this topic was presented during a forum on dermatoethics at the meeting, structured as a debate in which presenters are assigned an ethical argument or point-of-view to discuss and defend. The position taken by the speaker need not (and often does not) correspond to the speaker’s personal views.
SAN DIEGO – The American Academy of Dermatology’s policies that regulate conflicts of interest among members of its guidelines panels are “pretty good, but could be improved,” Lionel G. Bercovitch, MD, said at the annual meeting of the American Academy Dermatology.
One positive step might be to tighten the current American Academy of Dermatology requirement that more than half of the members in clinical guideline work groups be free of any financial conflicts and the minimum be raised to a higher percentage, such as more than 70%, suggested Dr. Bercovitch, a professor of dermatology at Brown University, Providence, R.I.
But his concern over the adequacy of existing conflict barriers during the writing of clinical guidelines wasn’t shared by Clifford Perlis, MD, who countered that “there are reasons not to waste too much time wringing our hands over conflicts of interest.”
He offered four reasons to support his statement:
- Conflicts of interest are ubiquitous and thus impossible to eliminate.
- Excluding working group members with conflicts can deprive the guidelines of valuable expertise.
- Checks and balances that are already in place in guideline development prevent inappropriate influence from conflicts of interest.
- No evidence has shown that conflicts of interest have inappropriately influenced development of treatment guidelines.
Conflicts of interest may not be as well managed as AAD policies suggest, Dr. Bercovitch noted. He cited a report published in late 2017 that tallied the actual conflicts of 49 people who served as the authors of three AAD guidelines published during 2013-2016. To objectively double check each author’s conflicts the researchers used the Open Payments database run by the Centers for Medicare & Medicaid Services (JAMA Dermatol. 2017 Dec;153[12]:1229-35).
The analysis showed that 40 of the 49 authors (82%) had received some amount of industry payment, 63% had received more than $1,000, and 51% had received more than $10,000. The median amount received from industry was just over $33,000. The analysis also showed that 22 of the 40 authors who received an industry payment had disclosure statements for the guideline they participated in that did not agree with the information in the Open Payments database.
“The AAD relies on information obtained through its self-reported online member disclosure system. This internal system collects updates to disclosed relationships on a real-time, ongoing basis, allowing the AAD to regularly assess any changes,” wrote Dr. Lim and his coauthors. “This provides information in a more meaningful and time-sensitive way” than the Open Payments database. In addition, the Open Payments database “is known to be inaccurate,” while the AAD “relies on information obtained through its self-reported online member disclosure system.” This includes an assessment of the relevancy of the conflict to the guideline involved. “This critical evaluation of relevancy was not addressed in the authors’ analysis,” they added.
They reported an adjusted analysis of the percentage of authors with relevant conflicts for each of the guidelines examined in the initial study. The percentages shrank to zero, 40%, and 43% of the authors with relevant conflicts, percentages that fell within the AAD’s ceiling for an acceptable percentage of work group members with conflicts.
The discussion on this topic was presented during a forum on dermatoethics at the meeting, structured as a debate in which presenters are assigned an ethical argument or point-of-view to discuss and defend. The position taken by the speaker need not (and often does not) correspond to the speaker’s personal views.
SAN DIEGO – The American Academy of Dermatology’s policies that regulate conflicts of interest among members of its guidelines panels are “pretty good, but could be improved,” Lionel G. Bercovitch, MD, said at the annual meeting of the American Academy Dermatology.
One positive step might be to tighten the current American Academy of Dermatology requirement that more than half of the members in clinical guideline work groups be free of any financial conflicts and the minimum be raised to a higher percentage, such as more than 70%, suggested Dr. Bercovitch, a professor of dermatology at Brown University, Providence, R.I.
But his concern over the adequacy of existing conflict barriers during the writing of clinical guidelines wasn’t shared by Clifford Perlis, MD, who countered that “there are reasons not to waste too much time wringing our hands over conflicts of interest.”
He offered four reasons to support his statement:
- Conflicts of interest are ubiquitous and thus impossible to eliminate.
- Excluding working group members with conflicts can deprive the guidelines of valuable expertise.
- Checks and balances that are already in place in guideline development prevent inappropriate influence from conflicts of interest.
- No evidence has shown that conflicts of interest have inappropriately influenced development of treatment guidelines.
Conflicts of interest may not be as well managed as AAD policies suggest, Dr. Bercovitch noted. He cited a report published in late 2017 that tallied the actual conflicts of 49 people who served as the authors of three AAD guidelines published during 2013-2016. To objectively double check each author’s conflicts the researchers used the Open Payments database run by the Centers for Medicare & Medicaid Services (JAMA Dermatol. 2017 Dec;153[12]:1229-35).
The analysis showed that 40 of the 49 authors (82%) had received some amount of industry payment, 63% had received more than $1,000, and 51% had received more than $10,000. The median amount received from industry was just over $33,000. The analysis also showed that 22 of the 40 authors who received an industry payment had disclosure statements for the guideline they participated in that did not agree with the information in the Open Payments database.
“The AAD relies on information obtained through its self-reported online member disclosure system. This internal system collects updates to disclosed relationships on a real-time, ongoing basis, allowing the AAD to regularly assess any changes,” wrote Dr. Lim and his coauthors. “This provides information in a more meaningful and time-sensitive way” than the Open Payments database. In addition, the Open Payments database “is known to be inaccurate,” while the AAD “relies on information obtained through its self-reported online member disclosure system.” This includes an assessment of the relevancy of the conflict to the guideline involved. “This critical evaluation of relevancy was not addressed in the authors’ analysis,” they added.
They reported an adjusted analysis of the percentage of authors with relevant conflicts for each of the guidelines examined in the initial study. The percentages shrank to zero, 40%, and 43% of the authors with relevant conflicts, percentages that fell within the AAD’s ceiling for an acceptable percentage of work group members with conflicts.
The discussion on this topic was presented during a forum on dermatoethics at the meeting, structured as a debate in which presenters are assigned an ethical argument or point-of-view to discuss and defend. The position taken by the speaker need not (and often does not) correspond to the speaker’s personal views.
EXPERT ANALYSIS FROM AAD 18
From weekend warriors to pros, athletes are plagued by skin disorders
SAN DIEGO – Think beyond the foot: Fungal infections are just the beginning when it comes to skin disorders in athletes, which include ringworm in wrestlers, “jogger’s nipple” in runners, and more serious conditions – like skin cancer.
“from weekend warriors to professional athletes,” said Brian B. Adams, MD, MPH, professor and chair of the department of dermatology at the University of Cincinnati.
In an interview, he discussed specific risks for athletes, the scarcity of data on skin cancer in athletes, and the hazards posed by cotton clothing.
Skin cancer: Risk seems clear, but data are sparse
“Athletes in general appear to be at increased risk in the long term for skin cancer” since they often play and practice during the hours between 10 a.m. and 4 p.m., when the danger of sun exposure is at its highest, he said. In addition, “sweating removes the sunscreen that athletes put on, and there is evidence that sweating actually increases the chance of burning,” he said.
Skiers and snowboarders face unique sun exposure risks, he added. “Snow reflects up to 100% of UV, so even though they may be in shade, they experience UV. And mountain athletes experience greater amounts of UV as the altitude of the mountain increases: At higher altitudes, the atmosphere has less chance of filtering out the damaging rays.”
While it’s obvious that many athletes face extra sun exposure, Dr. Adams pointed out, “very little is definitively known about the actual degree of risk of athletic activities.”
Still, the research that does exist provides plenty of hints about risk. “Large epidemiological studies showed that recreational activities such as sun exposure on the beach or during water sports were associated with an increased risk of basal cell carcinoma, whereas skiing has been shown to be at increased risk for squamous cell carcinoma,” according to a 2008 report on outdoor sports and skin cancer (Clin Dermatol. 2008 Jan-Feb;26[1]:12-5).
“Risk factors of cutaneous melanoma, such as the number of melanocytic nevi and solar lentigines, have been found to be more frequent in subjects practicing endurance outdoor sports. An increased risk for cutaneous melanoma may be assumed for these athletes,” Dr. Adams commented.
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Another study, this one published in 2006, found more atypical melanocytic nevi, solar lentigines, and lesions suggestive of nonmelanoma skin cancer in marathon runners, compared with a control group, and the risk was associated with the level of training intensity. The control subjects were more sensitive to the sun and had more common melanocytic nevi (Arch Dermatol. 2006 Nov;142[11]:1471-4).
Counseling about sunscreen may actually work
One strategy to reduce sun exposure is to advise athletes to avoid peak sun hours. However, “the key to caring for the athletes is not only recognizing that their sport may play a role in their disease but also realizing that your therapeutic approach must be tailored to minimize disruption to their practices and competitions,” Dr. Adams said.
However, there’s good news for dermatologists who are willing to push: The study also reported that athletes who were encouraged to use sunscreen were significantly more likely to use sunscreen (P less than .0001).
Watch for other conditions, from jogger’s nipple to ringworm
Dr. Adams offered advice about detection, treatment, and prevention of other skin disorders that affect athletes:
- “Jogger’s nipples” and other kinds of chafing. He has learned to recognize the “red eleven” – two vertical streaks of blood on a runner’s shirt – that represent a case of “jogger’s nipples” caused by chafing. Antibacterial ointment or petroleum jelly are useful treatments, he said, and an application of plenty of petroleum jelly on the nipples prior to a run can be helpful. Cotton shirts should be avoided, he said, in favor of synthetic, moisture-wicking shirts and bras. Chafing can also occur in the underarms and inner thighs, he said, and the same treatments and preventive techniques are useful.
- Callused and bleeding “jogger’s toes.” This can strike runners, especially on the second toe, which is often the longest and most likely to strike the toe box of a shoe. Specialty shoes can help prevent this condition, he said.
- Tinea corporis (ringworm) and herpes gladiatorum. In wrestlers, ringworm is known as tinea corporis gladiatorum because the intensity of skin-to-skin contact in wrestling makes the condition especially common in these athletes. Lesions don’t develop as rings at first; instead, they first appear as relatively nonspecific red round lesions and are most likely to be found in the head, neck, and upper extremities, Dr. Adams noted. Herpes gladiatorum is caused by herpes simplex virus 1; it is also seen in wrestlers and caused by skin-to-skin contact. Topical and oral antifungals clear ringworm, while oral antiviral agents are appropriate for herpes gladiatorum, Dr. Adams said. While herpes gladiatorum clears up and is no longer contagious after 4-5 days, he said, it’s not clear how long wrestlers with ringworm should be disqualified from playing.
Dr. Adams disclosed advising Mission, a company that focuses on sunscreen designed by and for athletes.
SAN DIEGO – Think beyond the foot: Fungal infections are just the beginning when it comes to skin disorders in athletes, which include ringworm in wrestlers, “jogger’s nipple” in runners, and more serious conditions – like skin cancer.
“from weekend warriors to professional athletes,” said Brian B. Adams, MD, MPH, professor and chair of the department of dermatology at the University of Cincinnati.
In an interview, he discussed specific risks for athletes, the scarcity of data on skin cancer in athletes, and the hazards posed by cotton clothing.
Skin cancer: Risk seems clear, but data are sparse
“Athletes in general appear to be at increased risk in the long term for skin cancer” since they often play and practice during the hours between 10 a.m. and 4 p.m., when the danger of sun exposure is at its highest, he said. In addition, “sweating removes the sunscreen that athletes put on, and there is evidence that sweating actually increases the chance of burning,” he said.
Skiers and snowboarders face unique sun exposure risks, he added. “Snow reflects up to 100% of UV, so even though they may be in shade, they experience UV. And mountain athletes experience greater amounts of UV as the altitude of the mountain increases: At higher altitudes, the atmosphere has less chance of filtering out the damaging rays.”
While it’s obvious that many athletes face extra sun exposure, Dr. Adams pointed out, “very little is definitively known about the actual degree of risk of athletic activities.”
Still, the research that does exist provides plenty of hints about risk. “Large epidemiological studies showed that recreational activities such as sun exposure on the beach or during water sports were associated with an increased risk of basal cell carcinoma, whereas skiing has been shown to be at increased risk for squamous cell carcinoma,” according to a 2008 report on outdoor sports and skin cancer (Clin Dermatol. 2008 Jan-Feb;26[1]:12-5).
“Risk factors of cutaneous melanoma, such as the number of melanocytic nevi and solar lentigines, have been found to be more frequent in subjects practicing endurance outdoor sports. An increased risk for cutaneous melanoma may be assumed for these athletes,” Dr. Adams commented.
[embed:render:related:node:106865]
Another study, this one published in 2006, found more atypical melanocytic nevi, solar lentigines, and lesions suggestive of nonmelanoma skin cancer in marathon runners, compared with a control group, and the risk was associated with the level of training intensity. The control subjects were more sensitive to the sun and had more common melanocytic nevi (Arch Dermatol. 2006 Nov;142[11]:1471-4).
Counseling about sunscreen may actually work
One strategy to reduce sun exposure is to advise athletes to avoid peak sun hours. However, “the key to caring for the athletes is not only recognizing that their sport may play a role in their disease but also realizing that your therapeutic approach must be tailored to minimize disruption to their practices and competitions,” Dr. Adams said.
However, there’s good news for dermatologists who are willing to push: The study also reported that athletes who were encouraged to use sunscreen were significantly more likely to use sunscreen (P less than .0001).
Watch for other conditions, from jogger’s nipple to ringworm
Dr. Adams offered advice about detection, treatment, and prevention of other skin disorders that affect athletes:
- “Jogger’s nipples” and other kinds of chafing. He has learned to recognize the “red eleven” – two vertical streaks of blood on a runner’s shirt – that represent a case of “jogger’s nipples” caused by chafing. Antibacterial ointment or petroleum jelly are useful treatments, he said, and an application of plenty of petroleum jelly on the nipples prior to a run can be helpful. Cotton shirts should be avoided, he said, in favor of synthetic, moisture-wicking shirts and bras. Chafing can also occur in the underarms and inner thighs, he said, and the same treatments and preventive techniques are useful.
- Callused and bleeding “jogger’s toes.” This can strike runners, especially on the second toe, which is often the longest and most likely to strike the toe box of a shoe. Specialty shoes can help prevent this condition, he said.
- Tinea corporis (ringworm) and herpes gladiatorum. In wrestlers, ringworm is known as tinea corporis gladiatorum because the intensity of skin-to-skin contact in wrestling makes the condition especially common in these athletes. Lesions don’t develop as rings at first; instead, they first appear as relatively nonspecific red round lesions and are most likely to be found in the head, neck, and upper extremities, Dr. Adams noted. Herpes gladiatorum is caused by herpes simplex virus 1; it is also seen in wrestlers and caused by skin-to-skin contact. Topical and oral antifungals clear ringworm, while oral antiviral agents are appropriate for herpes gladiatorum, Dr. Adams said. While herpes gladiatorum clears up and is no longer contagious after 4-5 days, he said, it’s not clear how long wrestlers with ringworm should be disqualified from playing.
Dr. Adams disclosed advising Mission, a company that focuses on sunscreen designed by and for athletes.
SAN DIEGO – Think beyond the foot: Fungal infections are just the beginning when it comes to skin disorders in athletes, which include ringworm in wrestlers, “jogger’s nipple” in runners, and more serious conditions – like skin cancer.
“from weekend warriors to professional athletes,” said Brian B. Adams, MD, MPH, professor and chair of the department of dermatology at the University of Cincinnati.
In an interview, he discussed specific risks for athletes, the scarcity of data on skin cancer in athletes, and the hazards posed by cotton clothing.
Skin cancer: Risk seems clear, but data are sparse
“Athletes in general appear to be at increased risk in the long term for skin cancer” since they often play and practice during the hours between 10 a.m. and 4 p.m., when the danger of sun exposure is at its highest, he said. In addition, “sweating removes the sunscreen that athletes put on, and there is evidence that sweating actually increases the chance of burning,” he said.
Skiers and snowboarders face unique sun exposure risks, he added. “Snow reflects up to 100% of UV, so even though they may be in shade, they experience UV. And mountain athletes experience greater amounts of UV as the altitude of the mountain increases: At higher altitudes, the atmosphere has less chance of filtering out the damaging rays.”
While it’s obvious that many athletes face extra sun exposure, Dr. Adams pointed out, “very little is definitively known about the actual degree of risk of athletic activities.”
Still, the research that does exist provides plenty of hints about risk. “Large epidemiological studies showed that recreational activities such as sun exposure on the beach or during water sports were associated with an increased risk of basal cell carcinoma, whereas skiing has been shown to be at increased risk for squamous cell carcinoma,” according to a 2008 report on outdoor sports and skin cancer (Clin Dermatol. 2008 Jan-Feb;26[1]:12-5).
“Risk factors of cutaneous melanoma, such as the number of melanocytic nevi and solar lentigines, have been found to be more frequent in subjects practicing endurance outdoor sports. An increased risk for cutaneous melanoma may be assumed for these athletes,” Dr. Adams commented.
[embed:render:related:node:106865]
Another study, this one published in 2006, found more atypical melanocytic nevi, solar lentigines, and lesions suggestive of nonmelanoma skin cancer in marathon runners, compared with a control group, and the risk was associated with the level of training intensity. The control subjects were more sensitive to the sun and had more common melanocytic nevi (Arch Dermatol. 2006 Nov;142[11]:1471-4).
Counseling about sunscreen may actually work
One strategy to reduce sun exposure is to advise athletes to avoid peak sun hours. However, “the key to caring for the athletes is not only recognizing that their sport may play a role in their disease but also realizing that your therapeutic approach must be tailored to minimize disruption to their practices and competitions,” Dr. Adams said.
However, there’s good news for dermatologists who are willing to push: The study also reported that athletes who were encouraged to use sunscreen were significantly more likely to use sunscreen (P less than .0001).
Watch for other conditions, from jogger’s nipple to ringworm
Dr. Adams offered advice about detection, treatment, and prevention of other skin disorders that affect athletes:
- “Jogger’s nipples” and other kinds of chafing. He has learned to recognize the “red eleven” – two vertical streaks of blood on a runner’s shirt – that represent a case of “jogger’s nipples” caused by chafing. Antibacterial ointment or petroleum jelly are useful treatments, he said, and an application of plenty of petroleum jelly on the nipples prior to a run can be helpful. Cotton shirts should be avoided, he said, in favor of synthetic, moisture-wicking shirts and bras. Chafing can also occur in the underarms and inner thighs, he said, and the same treatments and preventive techniques are useful.
- Callused and bleeding “jogger’s toes.” This can strike runners, especially on the second toe, which is often the longest and most likely to strike the toe box of a shoe. Specialty shoes can help prevent this condition, he said.
- Tinea corporis (ringworm) and herpes gladiatorum. In wrestlers, ringworm is known as tinea corporis gladiatorum because the intensity of skin-to-skin contact in wrestling makes the condition especially common in these athletes. Lesions don’t develop as rings at first; instead, they first appear as relatively nonspecific red round lesions and are most likely to be found in the head, neck, and upper extremities, Dr. Adams noted. Herpes gladiatorum is caused by herpes simplex virus 1; it is also seen in wrestlers and caused by skin-to-skin contact. Topical and oral antifungals clear ringworm, while oral antiviral agents are appropriate for herpes gladiatorum, Dr. Adams said. While herpes gladiatorum clears up and is no longer contagious after 4-5 days, he said, it’s not clear how long wrestlers with ringworm should be disqualified from playing.
Dr. Adams disclosed advising Mission, a company that focuses on sunscreen designed by and for athletes.
EXPERT ANALYSIS FROM AAD 18
Posttransplant skin conditions vary widely by ethnicity
SAN DIEGO – A new study finds that the risk of skin cancers in organ transplant recipients may vary widely by ethnicity.
“The most important findings from our study are the high rates of keratinocyte neoplasms observed in our white Northern European patients, but also in those of Far East Asian descent. Dermatologists should also appreciate the high risk of Kaposi’s sarcoma (KS) in patients originating from Sub-Saharan Africa,” Jonathan Kentley, MBBS, of Royal London Hospital, said in an interview. He presented the study findings at the annual meeting of the American Academy of Dermatology.
For the study, Dr. Kentley and colleagues sought to better understand .
They analyzed an organ transplant center database for the years 1989-2016, and tracked 1,304 consecutive patients – which included 1,125 with skin problems. The overall population was 64% male with a median age in the early 40s, and almost all (1,276) had undergone renal transplants. A relative handful underwent liver, lung, heart, and pancreas transplants.
The majority of patients (885) were white Northern Europeans, but there were also significant numbers of people with South Asian (202), black African/Caribbean (131) and white/Mediterranean (52) heritage. A small number were Far East Asian (26) and Middle Eastern (8). The median follow-up time for the ethnic groups varied from about 5 years to about 12 years.
The researchers found that basal cell carcinoma was most common in white Northern European patients, at nearly 25%, with other groups under 10%. SCC was common in white Northern European patients and Far East Asians, both at nearly 25%.
By far, KS was the most common in black African/Caribbean patients, at nearly 11%. According to Dr. Kentley, researchers found the number of KS cases to be surprisingly high in this group, “compounded by the fact that we have had a number of additional cases in the past year after we had collected the data for this study.” He attributes the higher number of KS cases in these patients to an increased seroprevalence of its causative agent, human herpesvirus-8, in Sub-Saharan Africa. The rate of KS in the second most commonly affected group – white Mediterranean patients – was almost 2%.
Viral warts were common in most groups, with the rate in both white groups (white Northern European and white Mediterranean) at nearly 60%, and Far East Asians at about 65%. Porokeratosis was by far the most common in white Norther Europeans, at nearly 8%, and sebaceous hyperplasia was common in all groups (more than 20% to about 27%) except in the black African/Caribbean and South Asian groups.
[embed:render:related:node:133758]
All these results were statistically significant with P values less than .05.
“Our study has confirmed the increased risk of keratinocyte cancers in patients of white Northern European descent, as well as providing more information on the increased risk in patients of Far East Asian descent,” Dr. Kentley said. “We have also confirmed the propensity of black African/Caribbean patients to develop Kaposi’s sarcoma in the first 5 years post transplant and highlighted that white Mediterranean patients are also at high risk. Beyond this, we have been able to review the prevalence of rare malignancies, such as Merkel cell carcinoma and appendageal tumors, and highlight that white Northern European patients remain at high risk of developing these conditions.”
As for the impact on clinical practice, “the patterns of skin disease susceptibility we have identified have important implications for rational design of transplant skin surveillance programs, targeted patient (and provider) education, and optimized clinical management,” Dr. Kentley said. “Ultimately, this is likely to have a significant impact on strategic deployment of limited dermatology health care resources.”
[embed:render:related:node:111943]
Specifically, the study suggests that all organ transplant patients receive a baseline skin assessment visit and nurse-led targeted education. Black African/Caribbean patients should be followed up for at least 5 years after transplant.
In the United States, at least 724,000 people have undergone organ transplants since 1988, with most getting kidney transplants, according to the United Network for Organ Sharing (UNOS).
No study funding was reported. The authors had no disclosures.
SOURCE: Kentley J et al. AAD 2018, Session F055.
SAN DIEGO – A new study finds that the risk of skin cancers in organ transplant recipients may vary widely by ethnicity.
“The most important findings from our study are the high rates of keratinocyte neoplasms observed in our white Northern European patients, but also in those of Far East Asian descent. Dermatologists should also appreciate the high risk of Kaposi’s sarcoma (KS) in patients originating from Sub-Saharan Africa,” Jonathan Kentley, MBBS, of Royal London Hospital, said in an interview. He presented the study findings at the annual meeting of the American Academy of Dermatology.
For the study, Dr. Kentley and colleagues sought to better understand .
They analyzed an organ transplant center database for the years 1989-2016, and tracked 1,304 consecutive patients – which included 1,125 with skin problems. The overall population was 64% male with a median age in the early 40s, and almost all (1,276) had undergone renal transplants. A relative handful underwent liver, lung, heart, and pancreas transplants.
The majority of patients (885) were white Northern Europeans, but there were also significant numbers of people with South Asian (202), black African/Caribbean (131) and white/Mediterranean (52) heritage. A small number were Far East Asian (26) and Middle Eastern (8). The median follow-up time for the ethnic groups varied from about 5 years to about 12 years.
The researchers found that basal cell carcinoma was most common in white Northern European patients, at nearly 25%, with other groups under 10%. SCC was common in white Northern European patients and Far East Asians, both at nearly 25%.
By far, KS was the most common in black African/Caribbean patients, at nearly 11%. According to Dr. Kentley, researchers found the number of KS cases to be surprisingly high in this group, “compounded by the fact that we have had a number of additional cases in the past year after we had collected the data for this study.” He attributes the higher number of KS cases in these patients to an increased seroprevalence of its causative agent, human herpesvirus-8, in Sub-Saharan Africa. The rate of KS in the second most commonly affected group – white Mediterranean patients – was almost 2%.
Viral warts were common in most groups, with the rate in both white groups (white Northern European and white Mediterranean) at nearly 60%, and Far East Asians at about 65%. Porokeratosis was by far the most common in white Norther Europeans, at nearly 8%, and sebaceous hyperplasia was common in all groups (more than 20% to about 27%) except in the black African/Caribbean and South Asian groups.
[embed:render:related:node:133758]
All these results were statistically significant with P values less than .05.
“Our study has confirmed the increased risk of keratinocyte cancers in patients of white Northern European descent, as well as providing more information on the increased risk in patients of Far East Asian descent,” Dr. Kentley said. “We have also confirmed the propensity of black African/Caribbean patients to develop Kaposi’s sarcoma in the first 5 years post transplant and highlighted that white Mediterranean patients are also at high risk. Beyond this, we have been able to review the prevalence of rare malignancies, such as Merkel cell carcinoma and appendageal tumors, and highlight that white Northern European patients remain at high risk of developing these conditions.”
As for the impact on clinical practice, “the patterns of skin disease susceptibility we have identified have important implications for rational design of transplant skin surveillance programs, targeted patient (and provider) education, and optimized clinical management,” Dr. Kentley said. “Ultimately, this is likely to have a significant impact on strategic deployment of limited dermatology health care resources.”
[embed:render:related:node:111943]
Specifically, the study suggests that all organ transplant patients receive a baseline skin assessment visit and nurse-led targeted education. Black African/Caribbean patients should be followed up for at least 5 years after transplant.
In the United States, at least 724,000 people have undergone organ transplants since 1988, with most getting kidney transplants, according to the United Network for Organ Sharing (UNOS).
No study funding was reported. The authors had no disclosures.
SOURCE: Kentley J et al. AAD 2018, Session F055.
SAN DIEGO – A new study finds that the risk of skin cancers in organ transplant recipients may vary widely by ethnicity.
“The most important findings from our study are the high rates of keratinocyte neoplasms observed in our white Northern European patients, but also in those of Far East Asian descent. Dermatologists should also appreciate the high risk of Kaposi’s sarcoma (KS) in patients originating from Sub-Saharan Africa,” Jonathan Kentley, MBBS, of Royal London Hospital, said in an interview. He presented the study findings at the annual meeting of the American Academy of Dermatology.
For the study, Dr. Kentley and colleagues sought to better understand .
They analyzed an organ transplant center database for the years 1989-2016, and tracked 1,304 consecutive patients – which included 1,125 with skin problems. The overall population was 64% male with a median age in the early 40s, and almost all (1,276) had undergone renal transplants. A relative handful underwent liver, lung, heart, and pancreas transplants.
The majority of patients (885) were white Northern Europeans, but there were also significant numbers of people with South Asian (202), black African/Caribbean (131) and white/Mediterranean (52) heritage. A small number were Far East Asian (26) and Middle Eastern (8). The median follow-up time for the ethnic groups varied from about 5 years to about 12 years.
The researchers found that basal cell carcinoma was most common in white Northern European patients, at nearly 25%, with other groups under 10%. SCC was common in white Northern European patients and Far East Asians, both at nearly 25%.
By far, KS was the most common in black African/Caribbean patients, at nearly 11%. According to Dr. Kentley, researchers found the number of KS cases to be surprisingly high in this group, “compounded by the fact that we have had a number of additional cases in the past year after we had collected the data for this study.” He attributes the higher number of KS cases in these patients to an increased seroprevalence of its causative agent, human herpesvirus-8, in Sub-Saharan Africa. The rate of KS in the second most commonly affected group – white Mediterranean patients – was almost 2%.
Viral warts were common in most groups, with the rate in both white groups (white Northern European and white Mediterranean) at nearly 60%, and Far East Asians at about 65%. Porokeratosis was by far the most common in white Norther Europeans, at nearly 8%, and sebaceous hyperplasia was common in all groups (more than 20% to about 27%) except in the black African/Caribbean and South Asian groups.
[embed:render:related:node:133758]
All these results were statistically significant with P values less than .05.
“Our study has confirmed the increased risk of keratinocyte cancers in patients of white Northern European descent, as well as providing more information on the increased risk in patients of Far East Asian descent,” Dr. Kentley said. “We have also confirmed the propensity of black African/Caribbean patients to develop Kaposi’s sarcoma in the first 5 years post transplant and highlighted that white Mediterranean patients are also at high risk. Beyond this, we have been able to review the prevalence of rare malignancies, such as Merkel cell carcinoma and appendageal tumors, and highlight that white Northern European patients remain at high risk of developing these conditions.”
As for the impact on clinical practice, “the patterns of skin disease susceptibility we have identified have important implications for rational design of transplant skin surveillance programs, targeted patient (and provider) education, and optimized clinical management,” Dr. Kentley said. “Ultimately, this is likely to have a significant impact on strategic deployment of limited dermatology health care resources.”
[embed:render:related:node:111943]
Specifically, the study suggests that all organ transplant patients receive a baseline skin assessment visit and nurse-led targeted education. Black African/Caribbean patients should be followed up for at least 5 years after transplant.
In the United States, at least 724,000 people have undergone organ transplants since 1988, with most getting kidney transplants, according to the United Network for Organ Sharing (UNOS).
No study funding was reported. The authors had no disclosures.
SOURCE: Kentley J et al. AAD 2018, Session F055.
REPORTING FROM AAD 18
Key clinical point: Skin disorders after organ transplant differ widely by ethnicity.
Major finding: Posttransplant basal cell and squamous cell carcinomas are most common in white Northern Europeans (at nearly 25%), while Kaposi’s sarcoma was higher than expected (nearly 10%) in black African/Caribbean patients.
Study details: Analysis of 1,125 patients from a single transplant center who received organ transplants and developed skin problems over a median follow-up time of 5 to more than 12 years, depending on ethnicity.
Disclosures: No study funding was reported. The authors had no disclosures.
Source: Kentley J et al. AAD 2018, Session F055.
Opinions clash over private equity’s effect on dermatology
SAN DIEGO – Although practices that has been snowballing for a little under a decade is often bemoaned by dermatologists, at least some physicians in the field may see it as a positive development.
“I think private equity investment is good for dermatology,” Clifford Perlis, MD, said at the annual meeting of the American Academy of Dermatology. “Dermatologists should be thrilled that private equity is here.” Investment by private equity companies into dermatology practices “adds value to practices, creates more practice options, enhances advocacy, and better manages the complexity” of practices, claimed Dr. Perlis, a dermatologist and Mohs surgeon who practices in King of Prussia, Pa. The debate on this topic was presented during a forum on dermatoethics at the meeting, structured as a pro and con conversation. The organizers, including Dr. Perlis and Jane Grant-Kels, MD., chose the topics and assigned positions to each presenter, which do not necessarily represent their personal views.*
“The challenges to solo practice have nothing to do with private equity investment. It’s narrower insurance networks” that are squeezing out solo practices. He also expressed skepticism that private equity creates a barrier that interferes with the physician-patient relationship.
“Insurers and administrators already do that,” Dr. Perlis said in an interview. It’s “misguided” to place the blame on the financing. Rejection of private equity investment “clings to an outdated image of how medicine is practiced” that had already been disappearing for several decades before entry of private equity into dermatology began, he noted.
[embed:render:related:node:152321]
But other dermatologists have voiced concern about the changes brought by private equity investment.
“I’m frightened for the future of dermatology,” Jane M. Grant-Kels, MD, said at the meeting. “It shifts control [of patient care] away from dermatologists and into the hands of business and investors who are only interested in profit and not in quality of care,” she added.
[embed:render:related:node:147551]
“Have we learned nothing from dermatopathology, which has been ruined” by private equity, she asked. “The only ones who benefit are those making the private equity investments.” She cited similar, recently published views from other dermatologists, such as a recently published viewpoint article written by Jack S. Resneck Jr., MD, professor of dermatology, University of California, San Francisco (JAMA Dermatol. 2018 Jan 1;154[1]:13-4).
Dr. Perlis and Dr. Grant-Kels had no disclosures. They spoke during a session on dermatoethics at the AAD annual meeting. In an interview, Dr. Perlis said that his own personal views on this topic are far more nuanced.*
*This article was updated on April 4, 2018.
SAN DIEGO – Although practices that has been snowballing for a little under a decade is often bemoaned by dermatologists, at least some physicians in the field may see it as a positive development.
“I think private equity investment is good for dermatology,” Clifford Perlis, MD, said at the annual meeting of the American Academy of Dermatology. “Dermatologists should be thrilled that private equity is here.” Investment by private equity companies into dermatology practices “adds value to practices, creates more practice options, enhances advocacy, and better manages the complexity” of practices, claimed Dr. Perlis, a dermatologist and Mohs surgeon who practices in King of Prussia, Pa. The debate on this topic was presented during a forum on dermatoethics at the meeting, structured as a pro and con conversation. The organizers, including Dr. Perlis and Jane Grant-Kels, MD., chose the topics and assigned positions to each presenter, which do not necessarily represent their personal views.*
“The challenges to solo practice have nothing to do with private equity investment. It’s narrower insurance networks” that are squeezing out solo practices. He also expressed skepticism that private equity creates a barrier that interferes with the physician-patient relationship.
“Insurers and administrators already do that,” Dr. Perlis said in an interview. It’s “misguided” to place the blame on the financing. Rejection of private equity investment “clings to an outdated image of how medicine is practiced” that had already been disappearing for several decades before entry of private equity into dermatology began, he noted.
[embed:render:related:node:152321]
But other dermatologists have voiced concern about the changes brought by private equity investment.
“I’m frightened for the future of dermatology,” Jane M. Grant-Kels, MD, said at the meeting. “It shifts control [of patient care] away from dermatologists and into the hands of business and investors who are only interested in profit and not in quality of care,” she added.
[embed:render:related:node:147551]
“Have we learned nothing from dermatopathology, which has been ruined” by private equity, she asked. “The only ones who benefit are those making the private equity investments.” She cited similar, recently published views from other dermatologists, such as a recently published viewpoint article written by Jack S. Resneck Jr., MD, professor of dermatology, University of California, San Francisco (JAMA Dermatol. 2018 Jan 1;154[1]:13-4).
Dr. Perlis and Dr. Grant-Kels had no disclosures. They spoke during a session on dermatoethics at the AAD annual meeting. In an interview, Dr. Perlis said that his own personal views on this topic are far more nuanced.*
*This article was updated on April 4, 2018.
SAN DIEGO – Although practices that has been snowballing for a little under a decade is often bemoaned by dermatologists, at least some physicians in the field may see it as a positive development.
“I think private equity investment is good for dermatology,” Clifford Perlis, MD, said at the annual meeting of the American Academy of Dermatology. “Dermatologists should be thrilled that private equity is here.” Investment by private equity companies into dermatology practices “adds value to practices, creates more practice options, enhances advocacy, and better manages the complexity” of practices, claimed Dr. Perlis, a dermatologist and Mohs surgeon who practices in King of Prussia, Pa. The debate on this topic was presented during a forum on dermatoethics at the meeting, structured as a pro and con conversation. The organizers, including Dr. Perlis and Jane Grant-Kels, MD., chose the topics and assigned positions to each presenter, which do not necessarily represent their personal views.*
“The challenges to solo practice have nothing to do with private equity investment. It’s narrower insurance networks” that are squeezing out solo practices. He also expressed skepticism that private equity creates a barrier that interferes with the physician-patient relationship.
“Insurers and administrators already do that,” Dr. Perlis said in an interview. It’s “misguided” to place the blame on the financing. Rejection of private equity investment “clings to an outdated image of how medicine is practiced” that had already been disappearing for several decades before entry of private equity into dermatology began, he noted.
[embed:render:related:node:152321]
But other dermatologists have voiced concern about the changes brought by private equity investment.
“I’m frightened for the future of dermatology,” Jane M. Grant-Kels, MD, said at the meeting. “It shifts control [of patient care] away from dermatologists and into the hands of business and investors who are only interested in profit and not in quality of care,” she added.
[embed:render:related:node:147551]
“Have we learned nothing from dermatopathology, which has been ruined” by private equity, she asked. “The only ones who benefit are those making the private equity investments.” She cited similar, recently published views from other dermatologists, such as a recently published viewpoint article written by Jack S. Resneck Jr., MD, professor of dermatology, University of California, San Francisco (JAMA Dermatol. 2018 Jan 1;154[1]:13-4).
Dr. Perlis and Dr. Grant-Kels had no disclosures. They spoke during a session on dermatoethics at the AAD annual meeting. In an interview, Dr. Perlis said that his own personal views on this topic are far more nuanced.*
*This article was updated on April 4, 2018.
EXPERT ANALYSIS FROM AAD 18
U.S. adolescent malignant melanoma nearly halved during 2000-2014
SAN DIEGO – based on information from a National Cancer Institute database.
The substantial drop in new cases of malignant melanoma in Americans aged 10-19 years over the most recent 15-year period with data available contrasts with a stable rate among children aged 0-9 years, and a steadily rising rate among adults during the same period, Ryan C. Kelm said at the annual meeting of the American Academy of Dermatology.
Mr. Kelm and his associates studied U.S. data compiled from 2000 to 2014 by the SEER Program, maintained by the National Cancer Institute. They identified 1,796 patients aged 0-19 years diagnosed with malignant melanoma (218 children and 1,578 adolescents). The overall incidence rate for the entire 15-year period was just over 1 case per million among children and just under 9 cases per million among adolescents. In contrast, the adult U.S. incidence rate estimates for 2018 are pegged at 260 per million among non-Hispanic whites, 40 per million among Hispanics, and 10 per million among black Americans, according to the American Cancer Society.
An additional analysis showed a notable difference in incidence rates over the 15-year period studied, depending on age. In children aged 0-9 years, the annual incidence rate held roughly steady at just under 2 cases per million throughout the 15 years. But among adolescents, the rate fell over time, from about 10-12 cases per million during 2000-2004 to about 5-7 cases per million during 2010-2014. In 2001, the rate was about 11 cases per million, and in 2013, the rate was about 6 cases per million. This contrasts with the adult rate, which has “risen rapidly over the past 30 years,” according to the American Cancer Society’s 2018 report.
[embed:render:related:node:159299]
The SEER data also showed that distribution of melanoma histologic types differed by age. Among adolescents the most common identified form was “superficial spreading,” in 32%, with nodular in 6%, mixed epithelioid and spindle cell in 2%, and “not otherwise specified” in 54%. In children, the most commonly identified form was mixed epithelioid and spindle cell, in 10%, followed by nodular in 9%, and superficial spreading in 9%, with 63% not otherwise specified.
SOURCE: Kelm RC et al. AAD 18, Abstract 6722.
SAN DIEGO – based on information from a National Cancer Institute database.
The substantial drop in new cases of malignant melanoma in Americans aged 10-19 years over the most recent 15-year period with data available contrasts with a stable rate among children aged 0-9 years, and a steadily rising rate among adults during the same period, Ryan C. Kelm said at the annual meeting of the American Academy of Dermatology.
Mr. Kelm and his associates studied U.S. data compiled from 2000 to 2014 by the SEER Program, maintained by the National Cancer Institute. They identified 1,796 patients aged 0-19 years diagnosed with malignant melanoma (218 children and 1,578 adolescents). The overall incidence rate for the entire 15-year period was just over 1 case per million among children and just under 9 cases per million among adolescents. In contrast, the adult U.S. incidence rate estimates for 2018 are pegged at 260 per million among non-Hispanic whites, 40 per million among Hispanics, and 10 per million among black Americans, according to the American Cancer Society.
An additional analysis showed a notable difference in incidence rates over the 15-year period studied, depending on age. In children aged 0-9 years, the annual incidence rate held roughly steady at just under 2 cases per million throughout the 15 years. But among adolescents, the rate fell over time, from about 10-12 cases per million during 2000-2004 to about 5-7 cases per million during 2010-2014. In 2001, the rate was about 11 cases per million, and in 2013, the rate was about 6 cases per million. This contrasts with the adult rate, which has “risen rapidly over the past 30 years,” according to the American Cancer Society’s 2018 report.
[embed:render:related:node:159299]
The SEER data also showed that distribution of melanoma histologic types differed by age. Among adolescents the most common identified form was “superficial spreading,” in 32%, with nodular in 6%, mixed epithelioid and spindle cell in 2%, and “not otherwise specified” in 54%. In children, the most commonly identified form was mixed epithelioid and spindle cell, in 10%, followed by nodular in 9%, and superficial spreading in 9%, with 63% not otherwise specified.
SOURCE: Kelm RC et al. AAD 18, Abstract 6722.
SAN DIEGO – based on information from a National Cancer Institute database.
The substantial drop in new cases of malignant melanoma in Americans aged 10-19 years over the most recent 15-year period with data available contrasts with a stable rate among children aged 0-9 years, and a steadily rising rate among adults during the same period, Ryan C. Kelm said at the annual meeting of the American Academy of Dermatology.
Mr. Kelm and his associates studied U.S. data compiled from 2000 to 2014 by the SEER Program, maintained by the National Cancer Institute. They identified 1,796 patients aged 0-19 years diagnosed with malignant melanoma (218 children and 1,578 adolescents). The overall incidence rate for the entire 15-year period was just over 1 case per million among children and just under 9 cases per million among adolescents. In contrast, the adult U.S. incidence rate estimates for 2018 are pegged at 260 per million among non-Hispanic whites, 40 per million among Hispanics, and 10 per million among black Americans, according to the American Cancer Society.
An additional analysis showed a notable difference in incidence rates over the 15-year period studied, depending on age. In children aged 0-9 years, the annual incidence rate held roughly steady at just under 2 cases per million throughout the 15 years. But among adolescents, the rate fell over time, from about 10-12 cases per million during 2000-2004 to about 5-7 cases per million during 2010-2014. In 2001, the rate was about 11 cases per million, and in 2013, the rate was about 6 cases per million. This contrasts with the adult rate, which has “risen rapidly over the past 30 years,” according to the American Cancer Society’s 2018 report.
[embed:render:related:node:159299]
The SEER data also showed that distribution of melanoma histologic types differed by age. Among adolescents the most common identified form was “superficial spreading,” in 32%, with nodular in 6%, mixed epithelioid and spindle cell in 2%, and “not otherwise specified” in 54%. In children, the most commonly identified form was mixed epithelioid and spindle cell, in 10%, followed by nodular in 9%, and superficial spreading in 9%, with 63% not otherwise specified.
SOURCE: Kelm RC et al. AAD 18, Abstract 6722.
REPORTING FROM AAD 18
Key clinical point: U.S. incident malignant melanoma in adolescents dropped by nearly 50% during 2000-2014.
Major finding: Malignant melanoma occurred in about 11 adolescents per million in 2001 and about 6 per million in 2013.
Study details: Review of data collected in the SEER database of the National Cancer Institute.
Disclosures: Mr. Kelm had no disclosures.
Source: Kelm RC et al. AAD 18, Abstract 6722.
VIDEO: Device-based therapy for onychomycosis
REPORTING FROM AAD 18
SAN DIEGO – which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.
“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.
In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.
Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.
Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.
Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.
REPORTING FROM AAD 18
SAN DIEGO – which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.
“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.
In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.
Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.
Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.
Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.
REPORTING FROM AAD 18
SAN DIEGO – which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.
“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.
In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.
Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.
Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.
Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.
Dermatology residency match: Is the glut of applications for limited positions corrupting the process?
SAN DIEGO – Whether was the topic of discussion at a session on dermatoethics at the annual meeting of the American Academy of Dermatology.
“I think it is unethical and we need to address it,” Jane M. Grant-Kels, MD, said during the session. “What we are doing through the process of physicians getting into dermatology residency programs is telling them to lie to us and to do well on a single examination,” the United States Medical Licensing Examination.
Lionel G. Bercovitch, MD, is among the dermatologists who acknowledge the unarguable fact that application rates are high but don’t see it as a crisis of credibility.
“I don’t believe that dermatology match is broken, unethical, or unfair. The match is not perfect, but it’s fair,” contended Dr. Bercovitch, professor of dermatology at Brown University, Providence, R.I. “The problem [of an application glut] is real, but it’s not an ethical issue.”
Dr. Grant-Kels sees it in ethical terms because, in her view, “everyone is gaming the system. It makes applicants liars” when they profess interest in moving to a remote location or planning to practice a certain type of dermatology.
The “extremely competitive” process leads a majority of applicants to “shot gun” their filings to many programs such that dermatology residency programs are “deluged” with applications, Dr. Grant-Kels said. Data from the Association of American Medical Colleges for 2017 showed an average of just over 500 applications received by each U.S. dermatology residency program.
As a result, residency programs feel forced to apply blind filters that generally cull out more than a third of the applications received. Dr. Grant-Kels decried the need for programs to impose arbitrary barriers to entering dermatology based on a score from a single examination or other criteria like membership in Alpha Omega Alpha or current location.
“Blanket screening methods run the risk of excluding genuinely interested and qualified candidates who do not fall above a threshold. This violates the principal of nonmaleficence,” she said. “Screens are unfair.”
[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/dermatology-residency-match?iframe=1"}]
Dr. Grant-Kels proposed a pair of potential remedies: putting a cap on the number of applications someone can make and – a more realistic approach – mentors’ giving guidance to prospective applicants.
“It’s a problem that kids are applying to dermatology programs who have no business applying, who really don’t have a chance,” she said.
Dr. Bercovitch noted that most dermatology residency programs are too small and that, while the number of residency slots has been rising, it has not kept pace with increasing demand from physicians seeking residency slots. He saw no ethical reason for physicians to feel they should rein in the number of applications they file, and he said the only obligations for residency programs are to strictly adhere to the Match rules and both federal and state civil rights and labor laws and to be nondiscriminatory and avoid nepotism and conflicts of interest. Because programs cannot seriously consider nor interview several hundred applicants each year, some type of filtering is needed, and no filter is fair or perfect, he conceded.
“Filters are inherently unfair” to certain applicants, “but how else to effectively screen” hundreds of applications, Dr. Bercovitch asked.
“We need to talk about this. It’s not a good system. If we don’t talk about it, it will never change,” Dr. Grant-Kels said.
Dr. Grant-Kels and Dr. Bercovitch had no disclosures.
SAN DIEGO – Whether was the topic of discussion at a session on dermatoethics at the annual meeting of the American Academy of Dermatology.
“I think it is unethical and we need to address it,” Jane M. Grant-Kels, MD, said during the session. “What we are doing through the process of physicians getting into dermatology residency programs is telling them to lie to us and to do well on a single examination,” the United States Medical Licensing Examination.
Lionel G. Bercovitch, MD, is among the dermatologists who acknowledge the unarguable fact that application rates are high but don’t see it as a crisis of credibility.
“I don’t believe that dermatology match is broken, unethical, or unfair. The match is not perfect, but it’s fair,” contended Dr. Bercovitch, professor of dermatology at Brown University, Providence, R.I. “The problem [of an application glut] is real, but it’s not an ethical issue.”
Dr. Grant-Kels sees it in ethical terms because, in her view, “everyone is gaming the system. It makes applicants liars” when they profess interest in moving to a remote location or planning to practice a certain type of dermatology.
The “extremely competitive” process leads a majority of applicants to “shot gun” their filings to many programs such that dermatology residency programs are “deluged” with applications, Dr. Grant-Kels said. Data from the Association of American Medical Colleges for 2017 showed an average of just over 500 applications received by each U.S. dermatology residency program.
As a result, residency programs feel forced to apply blind filters that generally cull out more than a third of the applications received. Dr. Grant-Kels decried the need for programs to impose arbitrary barriers to entering dermatology based on a score from a single examination or other criteria like membership in Alpha Omega Alpha or current location.
“Blanket screening methods run the risk of excluding genuinely interested and qualified candidates who do not fall above a threshold. This violates the principal of nonmaleficence,” she said. “Screens are unfair.”
[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/dermatology-residency-match?iframe=1"}]
Dr. Grant-Kels proposed a pair of potential remedies: putting a cap on the number of applications someone can make and – a more realistic approach – mentors’ giving guidance to prospective applicants.
“It’s a problem that kids are applying to dermatology programs who have no business applying, who really don’t have a chance,” she said.
Dr. Bercovitch noted that most dermatology residency programs are too small and that, while the number of residency slots has been rising, it has not kept pace with increasing demand from physicians seeking residency slots. He saw no ethical reason for physicians to feel they should rein in the number of applications they file, and he said the only obligations for residency programs are to strictly adhere to the Match rules and both federal and state civil rights and labor laws and to be nondiscriminatory and avoid nepotism and conflicts of interest. Because programs cannot seriously consider nor interview several hundred applicants each year, some type of filtering is needed, and no filter is fair or perfect, he conceded.
“Filters are inherently unfair” to certain applicants, “but how else to effectively screen” hundreds of applications, Dr. Bercovitch asked.
“We need to talk about this. It’s not a good system. If we don’t talk about it, it will never change,” Dr. Grant-Kels said.
Dr. Grant-Kels and Dr. Bercovitch had no disclosures.
SAN DIEGO – Whether was the topic of discussion at a session on dermatoethics at the annual meeting of the American Academy of Dermatology.
“I think it is unethical and we need to address it,” Jane M. Grant-Kels, MD, said during the session. “What we are doing through the process of physicians getting into dermatology residency programs is telling them to lie to us and to do well on a single examination,” the United States Medical Licensing Examination.
Lionel G. Bercovitch, MD, is among the dermatologists who acknowledge the unarguable fact that application rates are high but don’t see it as a crisis of credibility.
“I don’t believe that dermatology match is broken, unethical, or unfair. The match is not perfect, but it’s fair,” contended Dr. Bercovitch, professor of dermatology at Brown University, Providence, R.I. “The problem [of an application glut] is real, but it’s not an ethical issue.”
Dr. Grant-Kels sees it in ethical terms because, in her view, “everyone is gaming the system. It makes applicants liars” when they profess interest in moving to a remote location or planning to practice a certain type of dermatology.
The “extremely competitive” process leads a majority of applicants to “shot gun” their filings to many programs such that dermatology residency programs are “deluged” with applications, Dr. Grant-Kels said. Data from the Association of American Medical Colleges for 2017 showed an average of just over 500 applications received by each U.S. dermatology residency program.
As a result, residency programs feel forced to apply blind filters that generally cull out more than a third of the applications received. Dr. Grant-Kels decried the need for programs to impose arbitrary barriers to entering dermatology based on a score from a single examination or other criteria like membership in Alpha Omega Alpha or current location.
“Blanket screening methods run the risk of excluding genuinely interested and qualified candidates who do not fall above a threshold. This violates the principal of nonmaleficence,” she said. “Screens are unfair.”
[polldaddy:{"method":"iframe","type":"survey","src":"//newspolls2017.polldaddy.com/s/dermatology-residency-match?iframe=1"}]
Dr. Grant-Kels proposed a pair of potential remedies: putting a cap on the number of applications someone can make and – a more realistic approach – mentors’ giving guidance to prospective applicants.
“It’s a problem that kids are applying to dermatology programs who have no business applying, who really don’t have a chance,” she said.
Dr. Bercovitch noted that most dermatology residency programs are too small and that, while the number of residency slots has been rising, it has not kept pace with increasing demand from physicians seeking residency slots. He saw no ethical reason for physicians to feel they should rein in the number of applications they file, and he said the only obligations for residency programs are to strictly adhere to the Match rules and both federal and state civil rights and labor laws and to be nondiscriminatory and avoid nepotism and conflicts of interest. Because programs cannot seriously consider nor interview several hundred applicants each year, some type of filtering is needed, and no filter is fair or perfect, he conceded.
“Filters are inherently unfair” to certain applicants, “but how else to effectively screen” hundreds of applications, Dr. Bercovitch asked.
“We need to talk about this. It’s not a good system. If we don’t talk about it, it will never change,” Dr. Grant-Kels said.
Dr. Grant-Kels and Dr. Bercovitch had no disclosures.
EXPERT ANALYSIS FROM AAD 18
ALT-70 score outperformed thermal imaging for cellulitis diagnosis
SAN DIEGO – A simple scoring system surpassed thermal imaging for diagnosing lower extremity cellulitis in a head-to-head, single-center comparison in 67 patients.
The ALT-70 score – which tallies points for asymmetry, leukocytosis, tachycardia, and age of at least 70 years – produced a positive predictive value for lower-extremity cellulitis (LEC) of 80.4% and a negative predictive value of 90.9%, compared with values of 75.5% and 57.1%, respectively, for thermal imaging when researchers applied both methods to 67 patients, said David G. Li, a clinical research fellow in the department of dermatology at Brigham and Women’s Hospital, Boston, where the study was conducted.
The senior author of Mr. Li’s report, Arash Mostaghimi, MD, director of the inpatient consultation service, department of dermatology at Brigham and Women’s, was also lead investigator for the team of dermatology researchers – from his center and from Massachusetts General Hospital in Boston – who recently devised the ALT-70 scoring system for diagnosing LEC (J Amer Acad Dermatol. 2017 April;76[4]:618-25.e2).
The four-item survey can generate a score of 0-7, with a score of 0-2 suggesting need for additional monitoring, a score of 3-4 initiating a dermatology consult, and a score of 5-7 triggering immediate treatment for cellulitis, Mr. Li said. The 2017 review of ALT-70 showed that among 259 patients, those with a score of 0-2 had an 83% likelihood of having pseudocellulitis, while patients with a score of 5-7 had an 82% likelihood of having true cellulitis.
The current study enrolled 67 patients who had a presumptive diagnosis of LEC while in the emergency department or inpatient wards during a 7-month period. In addition to undergoing blinded assessment by both thermal imaging and by ALT-70 scoring, all patients also underwent blinded assessment by a board-certified dermatologist, who provided the definitive diagnosis. The attending dermatologists determined that 46 of the patients had true LEC and 21 patients did not.
The calculated sensitivity of ALT-70 was 97.8%, compared with 87.0% for thermal imaging. Specificity was 47.6% for ALT-70 and 38.1% for thermal imaging, Mr. Li reported at the annual meeting of the American Academy of Dermatology.
He also presented an analysis of the results when he combined both methods, with a positive on both assessments required to produce a positive LEC diagnosis. This resulted in a positive predictive value of 86.7%, slightly higher than the 80.4% from ALT-70 alone, but the combination produced a negative predictive value of 68.2%, substantially less than the 90.9% rate with ALT-70 alone. This demonstrated the “marginal benefit” from combining the two methods, he said.
In a receiver operating characteristic curve analysis, in which the area under the curve (c-statistic) reflects a diagnostic test’s validity, ALT-70 produced a c-statistic of 0.85, thermal imaging had a c-statistic of 0.63, and when combined, the c-statistic was 0.88.
Mr. Li called for validation of the findings using larger and different patient populations.
He had no reported disclosures.
SOURCE: Li DG et al. AAD 18, Abstract 6744.
SAN DIEGO – A simple scoring system surpassed thermal imaging for diagnosing lower extremity cellulitis in a head-to-head, single-center comparison in 67 patients.
The ALT-70 score – which tallies points for asymmetry, leukocytosis, tachycardia, and age of at least 70 years – produced a positive predictive value for lower-extremity cellulitis (LEC) of 80.4% and a negative predictive value of 90.9%, compared with values of 75.5% and 57.1%, respectively, for thermal imaging when researchers applied both methods to 67 patients, said David G. Li, a clinical research fellow in the department of dermatology at Brigham and Women’s Hospital, Boston, where the study was conducted.
The senior author of Mr. Li’s report, Arash Mostaghimi, MD, director of the inpatient consultation service, department of dermatology at Brigham and Women’s, was also lead investigator for the team of dermatology researchers – from his center and from Massachusetts General Hospital in Boston – who recently devised the ALT-70 scoring system for diagnosing LEC (J Amer Acad Dermatol. 2017 April;76[4]:618-25.e2).
The four-item survey can generate a score of 0-7, with a score of 0-2 suggesting need for additional monitoring, a score of 3-4 initiating a dermatology consult, and a score of 5-7 triggering immediate treatment for cellulitis, Mr. Li said. The 2017 review of ALT-70 showed that among 259 patients, those with a score of 0-2 had an 83% likelihood of having pseudocellulitis, while patients with a score of 5-7 had an 82% likelihood of having true cellulitis.
The current study enrolled 67 patients who had a presumptive diagnosis of LEC while in the emergency department or inpatient wards during a 7-month period. In addition to undergoing blinded assessment by both thermal imaging and by ALT-70 scoring, all patients also underwent blinded assessment by a board-certified dermatologist, who provided the definitive diagnosis. The attending dermatologists determined that 46 of the patients had true LEC and 21 patients did not.
The calculated sensitivity of ALT-70 was 97.8%, compared with 87.0% for thermal imaging. Specificity was 47.6% for ALT-70 and 38.1% for thermal imaging, Mr. Li reported at the annual meeting of the American Academy of Dermatology.
He also presented an analysis of the results when he combined both methods, with a positive on both assessments required to produce a positive LEC diagnosis. This resulted in a positive predictive value of 86.7%, slightly higher than the 80.4% from ALT-70 alone, but the combination produced a negative predictive value of 68.2%, substantially less than the 90.9% rate with ALT-70 alone. This demonstrated the “marginal benefit” from combining the two methods, he said.
In a receiver operating characteristic curve analysis, in which the area under the curve (c-statistic) reflects a diagnostic test’s validity, ALT-70 produced a c-statistic of 0.85, thermal imaging had a c-statistic of 0.63, and when combined, the c-statistic was 0.88.
Mr. Li called for validation of the findings using larger and different patient populations.
He had no reported disclosures.
SOURCE: Li DG et al. AAD 18, Abstract 6744.
SAN DIEGO – A simple scoring system surpassed thermal imaging for diagnosing lower extremity cellulitis in a head-to-head, single-center comparison in 67 patients.
The ALT-70 score – which tallies points for asymmetry, leukocytosis, tachycardia, and age of at least 70 years – produced a positive predictive value for lower-extremity cellulitis (LEC) of 80.4% and a negative predictive value of 90.9%, compared with values of 75.5% and 57.1%, respectively, for thermal imaging when researchers applied both methods to 67 patients, said David G. Li, a clinical research fellow in the department of dermatology at Brigham and Women’s Hospital, Boston, where the study was conducted.
The senior author of Mr. Li’s report, Arash Mostaghimi, MD, director of the inpatient consultation service, department of dermatology at Brigham and Women’s, was also lead investigator for the team of dermatology researchers – from his center and from Massachusetts General Hospital in Boston – who recently devised the ALT-70 scoring system for diagnosing LEC (J Amer Acad Dermatol. 2017 April;76[4]:618-25.e2).
The four-item survey can generate a score of 0-7, with a score of 0-2 suggesting need for additional monitoring, a score of 3-4 initiating a dermatology consult, and a score of 5-7 triggering immediate treatment for cellulitis, Mr. Li said. The 2017 review of ALT-70 showed that among 259 patients, those with a score of 0-2 had an 83% likelihood of having pseudocellulitis, while patients with a score of 5-7 had an 82% likelihood of having true cellulitis.
The current study enrolled 67 patients who had a presumptive diagnosis of LEC while in the emergency department or inpatient wards during a 7-month period. In addition to undergoing blinded assessment by both thermal imaging and by ALT-70 scoring, all patients also underwent blinded assessment by a board-certified dermatologist, who provided the definitive diagnosis. The attending dermatologists determined that 46 of the patients had true LEC and 21 patients did not.
The calculated sensitivity of ALT-70 was 97.8%, compared with 87.0% for thermal imaging. Specificity was 47.6% for ALT-70 and 38.1% for thermal imaging, Mr. Li reported at the annual meeting of the American Academy of Dermatology.
He also presented an analysis of the results when he combined both methods, with a positive on both assessments required to produce a positive LEC diagnosis. This resulted in a positive predictive value of 86.7%, slightly higher than the 80.4% from ALT-70 alone, but the combination produced a negative predictive value of 68.2%, substantially less than the 90.9% rate with ALT-70 alone. This demonstrated the “marginal benefit” from combining the two methods, he said.
In a receiver operating characteristic curve analysis, in which the area under the curve (c-statistic) reflects a diagnostic test’s validity, ALT-70 produced a c-statistic of 0.85, thermal imaging had a c-statistic of 0.63, and when combined, the c-statistic was 0.88.
Mr. Li called for validation of the findings using larger and different patient populations.
He had no reported disclosures.
SOURCE: Li DG et al. AAD 18, Abstract 6744.
REPORTING FROM AAD 18
Key clinical point: The ALT-70 score surpassed thermal imaging for diagnosing lower-extremity cellulitis.
Major finding: Positive and negative predictive values were 80.4% and 90.9% for ALT-70 and 75.5% and 57.1% for thermal imaging.
Study details: A single-center study with 67 patients.
Disclosures: Mr. Li had no disclosures.
Source: Li DG et al. AAD 18, Abstract 6744.
Study finds AD accounts for hundreds of thousands of annual ED visits
SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.
The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.
He and his coauthor, Lauren Kwa, also with the department of dermatology at Northwestern, conducted the analysis to better understand the role of AD in emergency care. “Many AD patients experience severe, unpredictable flares and worsening chronic disease that warrant urgent treatment,” Dr. Silverberg said. “However, patients typically don’t have instant access to outpatient dermatological care and may be forced to turn to the urgent care setting.”
Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”
He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.
During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.
The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).
The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).
The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”
What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.
No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.
SOURCE: Silverberg, J et al. Poster 7021.
SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.
The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.
He and his coauthor, Lauren Kwa, also with the department of dermatology at Northwestern, conducted the analysis to better understand the role of AD in emergency care. “Many AD patients experience severe, unpredictable flares and worsening chronic disease that warrant urgent treatment,” Dr. Silverberg said. “However, patients typically don’t have instant access to outpatient dermatological care and may be forced to turn to the urgent care setting.”
Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”
He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.
During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.
The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).
The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).
The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”
What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.
No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.
SOURCE: Silverberg, J et al. Poster 7021.
SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.
The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.
He and his coauthor, Lauren Kwa, also with the department of dermatology at Northwestern, conducted the analysis to better understand the role of AD in emergency care. “Many AD patients experience severe, unpredictable flares and worsening chronic disease that warrant urgent treatment,” Dr. Silverberg said. “However, patients typically don’t have instant access to outpatient dermatological care and may be forced to turn to the urgent care setting.”
Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”
He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.
During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.
The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).
The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).
The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”
What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.
No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.
SOURCE: Silverberg, J et al. Poster 7021.
REPORTING FROM AAD 18
Key clinical point: ED visits for atopic dermatitis are common, and their numbers are growing.
Major finding: An estimated 1.86 million ED visits in the United States from 2006 to 2012 were linked to a primary diagnosis of AD.
Study details: Analysis of data from the Nationwide Emergency Department Sample for 2006-2016.
Disclosures: No study funding was reported. The authors had no relevant disclosures.
Source: Silverberg J et al. Poster 7021.
