Binh Ngo, MD

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

To the Editor:

Syringomas are small, benign, asymptomatic eccrine or apocrine tumors that present as multiple discrete flesh-colored papules. They are more common in females than males.¹ The etiology of eruptive syringomas is unclear, though an inflammatory process has been implicated in the abnormal proliferation of sweat glands.² However, a minority of tumors have been known to have an autosomal-dominant mode of transmission. Multiple or eruptive syringomas are associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and Blau syndrome.³ The clear cell variant has been found to be associated with diabetes mellitus.⁴ Syringomas most commonly appear on the lower eyelids, upper cheeks, neck, and upper chest; presentation on the penis is rare.⁵ We report a case of multiple eruptive syringomas located exclusively on the penis mimicking a sexually transmitted condition.

A 53-year-old man who was otherwise healthy presented with multiple flesh-colored papules on the penis that initially began to develop 30 years prior, but increased crops of lesions appeared 4 to 6 weeks prior to presentation. The patient described the lesions as rashlike, nonpruritic, and sensitive to the touch. He denied any discharge, oozing, crusting, or bleeding from the lesions. He did not report any high-risk sexual behaviors and stated that he was in a monogamous relationship with his wife. He had a medical history of molluscum contagiosum that was diagnosed and treated with cryotherapy 30 years prior; however, he did not have a history of any other sexually transmitted diseases. He also did not have a history of diabetes mellitus or thyroid disease.

Physical examination revealed multiple pink papules on the dorsal and ventral shaft of the penis, measuring 2 to 4 mm in diameter, with koebnerization (Figure 1). Based on clinical examination, the differential included condyloma, inflamed seborrheic keratosis, bowenoid papulosis, atypical molluscum contagiosum, or lichen planus. Consequently, a punch biopsy of the penile shaft was performed and histopathologic examination revealed proliferation of ducts focally that were tadpole shaped and embedded in a sclerotic stroma. The lining of the ducts was composed of cuboidal cells, some with clear cell change. The microscopic findings were consistent with penile syringomas (Figure 2). Laboratory results revealed the patient was negative for human immunodeficiency virus, hepatitis B, hepatitis C, and syphilis. The patient was given topical hydrocortisone butyrate and tacrolimus for symptomatic treatment. He declined further aggressive treatment.

To prevent misdiagnosis and unnecessary treatment, it is important to have syringomas as part of the differential diagnosis when patients present with multiple small flesh-colored papules on the penis. The lesions should be biopsied for accurate diagnosis and to provide reassurance to patients who usually come in for evaluation for fear of having acquired a sexually transmitted disease.

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.

It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.

One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.

The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.

However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.

There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.

The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.

Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.

The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.

All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.

What do you think is the optimal and safest role for PEs in a dermatology practice?

We want to know your views! Tell us what you think.