Jenny E. Murase, MD

Biologics have revolutionized dermatologic treatment, offering substantial relief from chronic and ­debilitating skin conditions such as psoriasis, hidradenitis suppurativa, atopic dermatitis (AD), chronic urticaria, and immunobullous diseases (eg, pemphigus vulgaris, bullous pemphigoid). By drastically decreasing symptom burden, biologics have the potential to transform patients’ lives by improving their overall quality of life (QOL). However, the use of biologics during ­pregnancy raises critical considerations, especially ­regarding safety.

Biologics for Cutaneous Conditions

Biologics—tumor necrosis factor (TNF) α inhibitors; IL-17, IL-23, IL-12, and IL-36 inhibitors; and agents such as omalizumab and dupilumab—have shown remarkable efficacy in controlling severe or recalcitrant dermatologic conditions and typically are more effective than traditional systemic therapies.¹ For instance, randomized clinical trials (RCTs) and real-world data have shown that patients with psoriasis can achieve considerable skin clearance with biologics, greatly enhancing QOL.² Adalimumab and secukinumab, which have been approved for use in moderate to severe cases of hidradenitis suppurativa, reduce the frequency of painful nodules and abscesses, thereby decreasing pain and improving QOL. Dupilumab, an IL-4/13 receptor antagonist, has revolutionized the treatment of AD by drastically reducing itch and skin lesions and improving QOL.³ For chronic urticaria, the anti-IgE antibody omalizumab has effectively reduced the incidence of hives and itching, providing pronounced symptom relief when traditional antihistamines fail.⁴ Use of rituximab, an anti-CD20 monoclonal antibody, has led to remission in severe cases of pemphigus vulgaris and bullous pemphigoid.⁵

Impact of Untreated Cutaneous Conditions in Pregnancy

When treating patients who are pregnant, dermatologists must consider the health of both the expectant mother and the developing fetus. This dual focus complicates decision-making, particularly with the use of biologics. Untreated cutaneous conditions can profoundly impact a pregnant patient’s health and QOL as well as lead to pregnancy complications affecting the fetus, such as preterm birth or low birth weight. In some studies, moderate to severe psoriasis has been associated with increased risk for complications during pregnancy, including preeclampsia and intrauterine growth restriction.⁶ Although specific data on hidradenitis suppurativa are lacking, the highly inflammatory nature of the condition suggests similar adverse effects on pregnancy.⁷ Atopic dermatitis can be exacerbated during pregnancy due to a shift in the immune system to become more allergic dominant.⁸ Generalized pustular psoriasis manifests with widespread pustules, fever, and systemic inflammation, posing serious risks to both the mother and the fetus if left untreated⁹; in such a life-threatening scenario, the use of potent treatments such as spesolimab, an IL-36 receptor antagonist, may be warranted. Therefore, managing these conditions effectively is crucial not only for the mother’s health but also for fetal well-being.

Which Biologics Can Dermatologists Safely Prescribe?

Despite the benefits, many dermatologists are hesitant to prescribe biologics to pregnant patients due to the lack of understanding and definitive safety data.^10,11 Although there are no RCTs that involve pregnant patients, current evidence suggests that several biologics are not teratogenic and do not cause fetal malformations. Extensive postexposure data support the safety of TNF-α inhibitors during pregnancy.¹² Research has shown that children exposed to these agents in utero have normal development, infection rates, and vaccination outcomes comparable to nonexposed children. For example, a systematic review and meta-analysis found no significant increase in the risk for major congenital malformations, spontaneous abortions, or preterm births among patients exposed to anti–TNF-α agents during pregnancy.² The Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project has provided valuable real-world data indicating that the use of TNF-α inhibitors in pregnancy, particularly during the first trimester, does not substantially elevate the risk for adverse outcomes.¹³ These findings have been corroborated by several other registry studies and RCTs, providing a robust safety profile for these agents during pregnancy.¹⁴

Similarly, postexposure data on IL-17 and IL-12/23 inhibitors indicate a favorable safety profile, though the sample sizes are smaller than those for anti–TNF-α agents.^12,14 Studies of drugs such as secukinumab (IL-17 inhibitor), guselkumab (IL-23 inhibitor), or ustekinumab (IL-12/23 inhibitor) have shown no association with teratogenic effects or increased risk for miscarriage.¹⁴ However, agents such as spesolimab (IL-36 inhibitor) are relatively new, and ongoing studies are expected to provide more comprehensive safety data.¹⁵ Similarly, omalizumab and dupilumab have not been associated with increased risk for fetal malformations or adverse pregnancy outcomes. Omalizumab, indicated for chronic urticaria, has a good safety profile in pregnancy, with no significant increase in adverse outcomes reported in studies and registries.¹⁶ Dupilumab, used for AD, has demonstrated safety in pregnancy, with ongoing studies continuing to monitor outcomes.¹⁷

Conversely, rituximab (an anti-CD20 antibody for autoimmune bullous diseases) has shown evidence of adverse pregnancy outcomes, including fetal harm.¹⁸ Its use generally is discouraged unless deemed absolutely necessary, and no safer alternatives are available. Rituximab can cross the placenta, especially in the second and third trimesters, and has been associated with B-cell depletion in the fetus, leading to potential immunosuppression and increased risk for infections.⁵

Although the data on the safety of biologics in pregnancy are largely reassuring, it is essential to recognize that potential risks have not been ruled out entirely. There are extensive safety data for anti–TNF-α inhibitors, which provides a level of confidence; although newer agents such as IL-17 and IL-23 inhibitors have shown promising early results, further research is required to solidify their safety profiles during pregnancy.

Dermatologists must balance the risks and benefits of using biologics in pregnant patients. This decision-­making process involves careful consideration of the severity of the mother’s condition, the potential risks to the fetus, and the availability of alternative treatments. For many severe dermatologic conditions, the benefits of biologics in controlling disease activity and improving QOL may outweigh the potential risks, especially when other treatments have failed or are not suitable.

Final Thoughts

The increasing use of biologics in dermatology has undoubtedly improved the management of severe skin conditions, substantially enhancing patients’ QOL. As more data become available and clinical guidelines evolve, health care providers will be better equipped to make informed decisions about the use of biologics, particularly in pregnant patients. Collaborative efforts between dermatologists, obstetricians, and researchers will help refine treatment guidelines and ensure that pregnant patients with severe dermatologic conditions receive the best possible care.

For now, although the current evidence supports the safety of many biologics during pregnancy,^10,11 individualized care and informed decision-making remain paramount. Careful management and adherence to current guidelines make it possible to navigate the complexities of treating severe dermatologic conditions in pregnant patients, ensuring the best outcomes for both mother and child.

Biologics have revolutionized dermatologic treatment, offering substantial relief from chronic and ­debilitating skin conditions such as psoriasis, hidradenitis suppurativa, atopic dermatitis (AD), chronic urticaria, and immunobullous diseases (eg, pemphigus vulgaris, bullous pemphigoid). By drastically decreasing symptom burden, biologics have the potential to transform patients’ lives by improving their overall quality of life (QOL). However, the use of biologics during ­pregnancy raises critical considerations, especially ­regarding safety.

Biologics for Cutaneous Conditions

Biologics—tumor necrosis factor (TNF) α inhibitors; IL-17, IL-23, IL-12, and IL-36 inhibitors; and agents such as omalizumab and dupilumab—have shown remarkable efficacy in controlling severe or recalcitrant dermatologic conditions and typically are more effective than traditional systemic therapies.¹ For instance, randomized clinical trials (RCTs) and real-world data have shown that patients with psoriasis can achieve considerable skin clearance with biologics, greatly enhancing QOL.² Adalimumab and secukinumab, which have been approved for use in moderate to severe cases of hidradenitis suppurativa, reduce the frequency of painful nodules and abscesses, thereby decreasing pain and improving QOL. Dupilumab, an IL-4/13 receptor antagonist, has revolutionized the treatment of AD by drastically reducing itch and skin lesions and improving QOL.³ For chronic urticaria, the anti-IgE antibody omalizumab has effectively reduced the incidence of hives and itching, providing pronounced symptom relief when traditional antihistamines fail.⁴ Use of rituximab, an anti-CD20 monoclonal antibody, has led to remission in severe cases of pemphigus vulgaris and bullous pemphigoid.⁵

Impact of Untreated Cutaneous Conditions in Pregnancy

When treating patients who are pregnant, dermatologists must consider the health of both the expectant mother and the developing fetus. This dual focus complicates decision-making, particularly with the use of biologics. Untreated cutaneous conditions can profoundly impact a pregnant patient’s health and QOL as well as lead to pregnancy complications affecting the fetus, such as preterm birth or low birth weight. In some studies, moderate to severe psoriasis has been associated with increased risk for complications during pregnancy, including preeclampsia and intrauterine growth restriction.⁶ Although specific data on hidradenitis suppurativa are lacking, the highly inflammatory nature of the condition suggests similar adverse effects on pregnancy.⁷ Atopic dermatitis can be exacerbated during pregnancy due to a shift in the immune system to become more allergic dominant.⁸ Generalized pustular psoriasis manifests with widespread pustules, fever, and systemic inflammation, posing serious risks to both the mother and the fetus if left untreated⁹; in such a life-threatening scenario, the use of potent treatments such as spesolimab, an IL-36 receptor antagonist, may be warranted. Therefore, managing these conditions effectively is crucial not only for the mother’s health but also for fetal well-being.

Which Biologics Can Dermatologists Safely Prescribe?

Despite the benefits, many dermatologists are hesitant to prescribe biologics to pregnant patients due to the lack of understanding and definitive safety data.^10,11 Although there are no RCTs that involve pregnant patients, current evidence suggests that several biologics are not teratogenic and do not cause fetal malformations. Extensive postexposure data support the safety of TNF-α inhibitors during pregnancy.¹² Research has shown that children exposed to these agents in utero have normal development, infection rates, and vaccination outcomes comparable to nonexposed children. For example, a systematic review and meta-analysis found no significant increase in the risk for major congenital malformations, spontaneous abortions, or preterm births among patients exposed to anti–TNF-α agents during pregnancy.² The Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project has provided valuable real-world data indicating that the use of TNF-α inhibitors in pregnancy, particularly during the first trimester, does not substantially elevate the risk for adverse outcomes.¹³ These findings have been corroborated by several other registry studies and RCTs, providing a robust safety profile for these agents during pregnancy.¹⁴

Similarly, postexposure data on IL-17 and IL-12/23 inhibitors indicate a favorable safety profile, though the sample sizes are smaller than those for anti–TNF-α agents.^12,14 Studies of drugs such as secukinumab (IL-17 inhibitor), guselkumab (IL-23 inhibitor), or ustekinumab (IL-12/23 inhibitor) have shown no association with teratogenic effects or increased risk for miscarriage.¹⁴ However, agents such as spesolimab (IL-36 inhibitor) are relatively new, and ongoing studies are expected to provide more comprehensive safety data.¹⁵ Similarly, omalizumab and dupilumab have not been associated with increased risk for fetal malformations or adverse pregnancy outcomes. Omalizumab, indicated for chronic urticaria, has a good safety profile in pregnancy, with no significant increase in adverse outcomes reported in studies and registries.¹⁶ Dupilumab, used for AD, has demonstrated safety in pregnancy, with ongoing studies continuing to monitor outcomes.¹⁷

Conversely, rituximab (an anti-CD20 antibody for autoimmune bullous diseases) has shown evidence of adverse pregnancy outcomes, including fetal harm.¹⁸ Its use generally is discouraged unless deemed absolutely necessary, and no safer alternatives are available. Rituximab can cross the placenta, especially in the second and third trimesters, and has been associated with B-cell depletion in the fetus, leading to potential immunosuppression and increased risk for infections.⁵

Although the data on the safety of biologics in pregnancy are largely reassuring, it is essential to recognize that potential risks have not been ruled out entirely. There are extensive safety data for anti–TNF-α inhibitors, which provides a level of confidence; although newer agents such as IL-17 and IL-23 inhibitors have shown promising early results, further research is required to solidify their safety profiles during pregnancy.

Dermatologists must balance the risks and benefits of using biologics in pregnant patients. This decision-­making process involves careful consideration of the severity of the mother’s condition, the potential risks to the fetus, and the availability of alternative treatments. For many severe dermatologic conditions, the benefits of biologics in controlling disease activity and improving QOL may outweigh the potential risks, especially when other treatments have failed or are not suitable.

Final Thoughts

The increasing use of biologics in dermatology has undoubtedly improved the management of severe skin conditions, substantially enhancing patients’ QOL. As more data become available and clinical guidelines evolve, health care providers will be better equipped to make informed decisions about the use of biologics, particularly in pregnant patients. Collaborative efforts between dermatologists, obstetricians, and researchers will help refine treatment guidelines and ensure that pregnant patients with severe dermatologic conditions receive the best possible care.

For now, although the current evidence supports the safety of many biologics during pregnancy,^10,11 individualized care and informed decision-making remain paramount. Careful management and adherence to current guidelines make it possible to navigate the complexities of treating severe dermatologic conditions in pregnant patients, ensuring the best outcomes for both mother and child.

Biologics have revolutionized dermatologic treatment, offering substantial relief from chronic and ­debilitating skin conditions such as psoriasis, hidradenitis suppurativa, atopic dermatitis (AD), chronic urticaria, and immunobullous diseases (eg, pemphigus vulgaris, bullous pemphigoid). By drastically decreasing symptom burden, biologics have the potential to transform patients’ lives by improving their overall quality of life (QOL). However, the use of biologics during ­pregnancy raises critical considerations, especially ­regarding safety.

Biologics for Cutaneous Conditions

Biologics—tumor necrosis factor (TNF) α inhibitors; IL-17, IL-23, IL-12, and IL-36 inhibitors; and agents such as omalizumab and dupilumab—have shown remarkable efficacy in controlling severe or recalcitrant dermatologic conditions and typically are more effective than traditional systemic therapies.¹ For instance, randomized clinical trials (RCTs) and real-world data have shown that patients with psoriasis can achieve considerable skin clearance with biologics, greatly enhancing QOL.² Adalimumab and secukinumab, which have been approved for use in moderate to severe cases of hidradenitis suppurativa, reduce the frequency of painful nodules and abscesses, thereby decreasing pain and improving QOL. Dupilumab, an IL-4/13 receptor antagonist, has revolutionized the treatment of AD by drastically reducing itch and skin lesions and improving QOL.³ For chronic urticaria, the anti-IgE antibody omalizumab has effectively reduced the incidence of hives and itching, providing pronounced symptom relief when traditional antihistamines fail.⁴ Use of rituximab, an anti-CD20 monoclonal antibody, has led to remission in severe cases of pemphigus vulgaris and bullous pemphigoid.⁵

Impact of Untreated Cutaneous Conditions in Pregnancy

When treating patients who are pregnant, dermatologists must consider the health of both the expectant mother and the developing fetus. This dual focus complicates decision-making, particularly with the use of biologics. Untreated cutaneous conditions can profoundly impact a pregnant patient’s health and QOL as well as lead to pregnancy complications affecting the fetus, such as preterm birth or low birth weight. In some studies, moderate to severe psoriasis has been associated with increased risk for complications during pregnancy, including preeclampsia and intrauterine growth restriction.⁶ Although specific data on hidradenitis suppurativa are lacking, the highly inflammatory nature of the condition suggests similar adverse effects on pregnancy.⁷ Atopic dermatitis can be exacerbated during pregnancy due to a shift in the immune system to become more allergic dominant.⁸ Generalized pustular psoriasis manifests with widespread pustules, fever, and systemic inflammation, posing serious risks to both the mother and the fetus if left untreated⁹; in such a life-threatening scenario, the use of potent treatments such as spesolimab, an IL-36 receptor antagonist, may be warranted. Therefore, managing these conditions effectively is crucial not only for the mother’s health but also for fetal well-being.

Which Biologics Can Dermatologists Safely Prescribe?

Despite the benefits, many dermatologists are hesitant to prescribe biologics to pregnant patients due to the lack of understanding and definitive safety data.^10,11 Although there are no RCTs that involve pregnant patients, current evidence suggests that several biologics are not teratogenic and do not cause fetal malformations. Extensive postexposure data support the safety of TNF-α inhibitors during pregnancy.¹² Research has shown that children exposed to these agents in utero have normal development, infection rates, and vaccination outcomes comparable to nonexposed children. For example, a systematic review and meta-analysis found no significant increase in the risk for major congenital malformations, spontaneous abortions, or preterm births among patients exposed to anti–TNF-α agents during pregnancy.² The Organization of Teratology Information Specialists Autoimmune Diseases in Pregnancy Project has provided valuable real-world data indicating that the use of TNF-α inhibitors in pregnancy, particularly during the first trimester, does not substantially elevate the risk for adverse outcomes.¹³ These findings have been corroborated by several other registry studies and RCTs, providing a robust safety profile for these agents during pregnancy.¹⁴

Similarly, postexposure data on IL-17 and IL-12/23 inhibitors indicate a favorable safety profile, though the sample sizes are smaller than those for anti–TNF-α agents.^12,14 Studies of drugs such as secukinumab (IL-17 inhibitor), guselkumab (IL-23 inhibitor), or ustekinumab (IL-12/23 inhibitor) have shown no association with teratogenic effects or increased risk for miscarriage.¹⁴ However, agents such as spesolimab (IL-36 inhibitor) are relatively new, and ongoing studies are expected to provide more comprehensive safety data.¹⁵ Similarly, omalizumab and dupilumab have not been associated with increased risk for fetal malformations or adverse pregnancy outcomes. Omalizumab, indicated for chronic urticaria, has a good safety profile in pregnancy, with no significant increase in adverse outcomes reported in studies and registries.¹⁶ Dupilumab, used for AD, has demonstrated safety in pregnancy, with ongoing studies continuing to monitor outcomes.¹⁷

Conversely, rituximab (an anti-CD20 antibody for autoimmune bullous diseases) has shown evidence of adverse pregnancy outcomes, including fetal harm.¹⁸ Its use generally is discouraged unless deemed absolutely necessary, and no safer alternatives are available. Rituximab can cross the placenta, especially in the second and third trimesters, and has been associated with B-cell depletion in the fetus, leading to potential immunosuppression and increased risk for infections.⁵

Although the data on the safety of biologics in pregnancy are largely reassuring, it is essential to recognize that potential risks have not been ruled out entirely. There are extensive safety data for anti–TNF-α inhibitors, which provides a level of confidence; although newer agents such as IL-17 and IL-23 inhibitors have shown promising early results, further research is required to solidify their safety profiles during pregnancy.

Dermatologists must balance the risks and benefits of using biologics in pregnant patients. This decision-­making process involves careful consideration of the severity of the mother’s condition, the potential risks to the fetus, and the availability of alternative treatments. For many severe dermatologic conditions, the benefits of biologics in controlling disease activity and improving QOL may outweigh the potential risks, especially when other treatments have failed or are not suitable.

Final Thoughts

The increasing use of biologics in dermatology has undoubtedly improved the management of severe skin conditions, substantially enhancing patients’ QOL. As more data become available and clinical guidelines evolve, health care providers will be better equipped to make informed decisions about the use of biologics, particularly in pregnant patients. Collaborative efforts between dermatologists, obstetricians, and researchers will help refine treatment guidelines and ensure that pregnant patients with severe dermatologic conditions receive the best possible care.

For now, although the current evidence supports the safety of many biologics during pregnancy,^10,11 individualized care and informed decision-making remain paramount. Careful management and adherence to current guidelines make it possible to navigate the complexities of treating severe dermatologic conditions in pregnant patients, ensuring the best outcomes for both mother and child.

Practice Gap

Skin picking disorder is characterized by repetitive deliberate manipulation of the skin that causes noticeable tissue damage. It affects approximately 1.6% of adults in the United States and is associated with marked distress as well as a psychosocial impact.¹ Complications of skin picking disorder can include ulceration, infection, scarring, and disfigurement.

Cognitive behavioral therapy (CBT) techniques have been established to be effective in treating skin picking disorder.² Although referral to a mental health professional is appropriate for patients with skin picking disorder, many of them may not be interested. Cognitive behavioral therapy for diseases at the intersection of psychiatry and dermatology typically is not included in dermatology curricula. Therefore, dermatologists should be aware of CBT techniques that can mitigate the impact of skin picking disorder for patients who decline referral to a mental health professional.

The Technique

Cognitive behavioral therapy is one of the more effective forms of psychotherapy for the treatment of skin picking disorder. Consistent utilization of CBT techniques can achieve relatively permanent change in brain function and contribute to long-term treatment outcomes. A particularly useful CBT technique for skin picking disorder is habit reversal therapy (HRT)(Table). Studies have shown that HRT techniques have demonstrated efficacy in skin picking disorder with sustained impact.³ Patients treated with HRT have reported a greater decrease in skin picking compared with controls after only 3 sessions (P<.01).⁴ There are 3 elements to HRT:

1. Sensitization and awareness training: This facet of HRT involves helping the patient become attuned to warning signals, or feelings, that precede their skin picking, as skin picking often occurs automatically without the patient noticing. Such feelings can include tingling of the skin, tension, and a feeling of being overwhelmed.⁵ Ideally, the physician works with the patient to identify 2 or 3 warning signals that precede skin picking behavior.

2. Competing response training: The patient is encouraged to substitute skin picking with a preventive behavior—for example, crossing the arms and gently squeezing the fists—that is incompatible with skin picking. The preventive behavior should be performed for at least 1 minute as soon as a warning signal appears or skin picking behavior starts. After 1 minute, if the urge for skin picking recurs, then the patient should repeat the preventive behavior.⁵ It can be helpful to practice the preventive behavior with the patient once in the clinic.

3. Social support: This technique involves identifying a close social contact of the patient (eg, relative, friend, partner) to help the patient increase their awareness of skin picking behavior and encourage them to perform the preventive behavior.⁵ The purpose of identifying a close social contact is to ensure accountability for the patient in their day-to-day life, given the limited scope of the relationship between the patient and the dermatologist.

Other practical solutions to skin picking include advising patients to cut their nails short; using finger cots to cover the nails and thus lessen the potential for skin injury; and using a sensory toy, such as a fidget spinner, to distract or occupy the patient when they feel the urge for skin picking.

Practice Implications

Although skin picking disorder is a challenging condition to manage, there are proven techniques for treatment. Techniques drawn from HRT are quite practical and can be implemented by dermatologists for patients with skin picking disorder to reduce the burden of their disease.

Practice Gap

Skin picking disorder is characterized by repetitive deliberate manipulation of the skin that causes noticeable tissue damage. It affects approximately 1.6% of adults in the United States and is associated with marked distress as well as a psychosocial impact.¹ Complications of skin picking disorder can include ulceration, infection, scarring, and disfigurement.

Cognitive behavioral therapy (CBT) techniques have been established to be effective in treating skin picking disorder.² Although referral to a mental health professional is appropriate for patients with skin picking disorder, many of them may not be interested. Cognitive behavioral therapy for diseases at the intersection of psychiatry and dermatology typically is not included in dermatology curricula. Therefore, dermatologists should be aware of CBT techniques that can mitigate the impact of skin picking disorder for patients who decline referral to a mental health professional.

The Technique

Cognitive behavioral therapy is one of the more effective forms of psychotherapy for the treatment of skin picking disorder. Consistent utilization of CBT techniques can achieve relatively permanent change in brain function and contribute to long-term treatment outcomes. A particularly useful CBT technique for skin picking disorder is habit reversal therapy (HRT)(Table). Studies have shown that HRT techniques have demonstrated efficacy in skin picking disorder with sustained impact.³ Patients treated with HRT have reported a greater decrease in skin picking compared with controls after only 3 sessions (P<.01).⁴ There are 3 elements to HRT:

1. Sensitization and awareness training: This facet of HRT involves helping the patient become attuned to warning signals, or feelings, that precede their skin picking, as skin picking often occurs automatically without the patient noticing. Such feelings can include tingling of the skin, tension, and a feeling of being overwhelmed.⁵ Ideally, the physician works with the patient to identify 2 or 3 warning signals that precede skin picking behavior.

2. Competing response training: The patient is encouraged to substitute skin picking with a preventive behavior—for example, crossing the arms and gently squeezing the fists—that is incompatible with skin picking. The preventive behavior should be performed for at least 1 minute as soon as a warning signal appears or skin picking behavior starts. After 1 minute, if the urge for skin picking recurs, then the patient should repeat the preventive behavior.⁵ It can be helpful to practice the preventive behavior with the patient once in the clinic.

3. Social support: This technique involves identifying a close social contact of the patient (eg, relative, friend, partner) to help the patient increase their awareness of skin picking behavior and encourage them to perform the preventive behavior.⁵ The purpose of identifying a close social contact is to ensure accountability for the patient in their day-to-day life, given the limited scope of the relationship between the patient and the dermatologist.

Other practical solutions to skin picking include advising patients to cut their nails short; using finger cots to cover the nails and thus lessen the potential for skin injury; and using a sensory toy, such as a fidget spinner, to distract or occupy the patient when they feel the urge for skin picking.

Practice Implications

Although skin picking disorder is a challenging condition to manage, there are proven techniques for treatment. Techniques drawn from HRT are quite practical and can be implemented by dermatologists for patients with skin picking disorder to reduce the burden of their disease.

Practice Gap

Skin picking disorder is characterized by repetitive deliberate manipulation of the skin that causes noticeable tissue damage. It affects approximately 1.6% of adults in the United States and is associated with marked distress as well as a psychosocial impact.¹ Complications of skin picking disorder can include ulceration, infection, scarring, and disfigurement.

Cognitive behavioral therapy (CBT) techniques have been established to be effective in treating skin picking disorder.² Although referral to a mental health professional is appropriate for patients with skin picking disorder, many of them may not be interested. Cognitive behavioral therapy for diseases at the intersection of psychiatry and dermatology typically is not included in dermatology curricula. Therefore, dermatologists should be aware of CBT techniques that can mitigate the impact of skin picking disorder for patients who decline referral to a mental health professional.

The Technique

Cognitive behavioral therapy is one of the more effective forms of psychotherapy for the treatment of skin picking disorder. Consistent utilization of CBT techniques can achieve relatively permanent change in brain function and contribute to long-term treatment outcomes. A particularly useful CBT technique for skin picking disorder is habit reversal therapy (HRT)(Table). Studies have shown that HRT techniques have demonstrated efficacy in skin picking disorder with sustained impact.³ Patients treated with HRT have reported a greater decrease in skin picking compared with controls after only 3 sessions (P<.01).⁴ There are 3 elements to HRT:

1. Sensitization and awareness training: This facet of HRT involves helping the patient become attuned to warning signals, or feelings, that precede their skin picking, as skin picking often occurs automatically without the patient noticing. Such feelings can include tingling of the skin, tension, and a feeling of being overwhelmed.⁵ Ideally, the physician works with the patient to identify 2 or 3 warning signals that precede skin picking behavior.

2. Competing response training: The patient is encouraged to substitute skin picking with a preventive behavior—for example, crossing the arms and gently squeezing the fists—that is incompatible with skin picking. The preventive behavior should be performed for at least 1 minute as soon as a warning signal appears or skin picking behavior starts. After 1 minute, if the urge for skin picking recurs, then the patient should repeat the preventive behavior.⁵ It can be helpful to practice the preventive behavior with the patient once in the clinic.

3. Social support: This technique involves identifying a close social contact of the patient (eg, relative, friend, partner) to help the patient increase their awareness of skin picking behavior and encourage them to perform the preventive behavior.⁵ The purpose of identifying a close social contact is to ensure accountability for the patient in their day-to-day life, given the limited scope of the relationship between the patient and the dermatologist.

Other practical solutions to skin picking include advising patients to cut their nails short; using finger cots to cover the nails and thus lessen the potential for skin injury; and using a sensory toy, such as a fidget spinner, to distract or occupy the patient when they feel the urge for skin picking.

Practice Implications

Although skin picking disorder is a challenging condition to manage, there are proven techniques for treatment. Techniques drawn from HRT are quite practical and can be implemented by dermatologists for patients with skin picking disorder to reduce the burden of their disease.

The impacts of anthropogenic climate change on human health are numerous and growing. The evidence that climate change is occurring due to the burning of fossil fuels is substantial, with a 2019 report elevating the data supporting anthropogenic climate change to a gold standard 5-sigma level of significance.¹ In the peer-reviewed scientific literature, the consensus that humans are causing climate change is greater than 99%.² Both the American Medical Association and the American College of Physicians have acknowledged the health impacts of climate change and importance for action. They encourage physicians to engage in environmentally sustainable practices and to advocate for effective climate change mitigation strategies.^3,4 A survey of dermatologists also found that 99.3% (n=148) recognize climate change is occurring, and similarly high numbers are concerned about its health impacts.⁵

Notably, the health care industry must grapple not only with the health impacts of climate change but with the fact that the health care sector itself is responsible for a large amount of carbon emissions.⁶ The global health care industry as a whole produces enough carbon emissions to be ranked as the fifth largest emitting nation in the world.⁷ A quarter of these emissions are attributed to the US health care system.^8,9 Climate science has shown we must limit CO₂ emissions to avoid catastrophic climate change, with the sixth assessment report of the United Nations’ Intergovernmental Panel on Climate Change and the Paris Agreement targeting large emission reductions within the next decade.¹⁰ In August 2021, the US Department of Health and Human Services created the Office of Climate Change and Health Equity. Assistant Secretary for Health ADM Rachel L. Levine, MD, has committed to reducing the carbon emissions from the health care sector by 25% in the next decade, in line with scientific consensus regarding necessary changes.¹¹

The dermatologic impacts of climate change are myriad. Rising temperatures, increasing air and water pollution, and stratospheric ozone depletion will lead to expanded geographic ranges of vector-borne diseases, worsening of chronic skin conditions such as atopic dermatitis/eczema and pemphigus, and increasing rates of skin cancer.¹² For instance, warmer temperatures have allowed mosquitoes of the Aedes genus to infest new areas, leading to outbreaks of viral illnesses with cutaneous manifestations such as dengue, chikungunya, and Zika virus in previously nonindigenous regions.¹³ Rising temperatures also have been associated with an expanding geographic range of tick- and sandfly-borne illnesses such as Lyme disease, Rocky Mountain spotted fever, and cutaneous leishmaniasis.^13,14 Additionally, short-term exposure to air pollution from wildfire smoke has been associated with an increased use of health care services by patients with atopic dermatitis.¹⁵ Increased levels of air pollutants also have been found to be associated with psoriasis flares as well as hyperpigmentation and wrinkle formation.^16,17 Skin cancer incidence is predicted to rise due to increased UV radiation exposure secondary to stratospheric ozone depletion.¹⁸

Although the effects of climate change are significant and the magnitude of the climate crisis may feel overwhelming, it is essential to avoid doomerism and focus on meaningful impactful actions. Current CO₂ emissions will remain in the atmosphere for hundreds to thousands of years, and the choices we make now commit future generations to live in a world shaped by our decisions. Importantly, there are impactful and low-cost, cost-effective, or cost-saving changes that can be made to mitigate the climate crisis. Herein, we provide 10 practical actionable interventions for dermatologists to help combat climate change.

10 Interventions for Dermatologists to Combat Climate Change

1. Consider switching to renewable sources of energy. Making this switch often is the most impactful decision a dermatologist can make to address climate change. The electricity sector is the largest source of greenhouse gas emissions in the US health care system, and dermatology outpatient practices in particular have been observed to have a higher peak energy consumption than most other specialties studied.^19,20 Many dermatology practices—both privately owned and academic—can switch to renewable energy seamlessly through power purchase agreements (PPAs), which are contracts between power providers and private entities to install renewable energy equipment or source renewable energy from offsite sources at a fixed rate. Using PPAs instead of traditional fossil fuel energy can provide cost savings as well as protect buyers from electrical price volatility. Numerous health care systems utilize PPAs such as Kaiser Permanente, Cleveland Clinic, and Rochester Regional Health. Additionally, dermatologists can directly purchase renewable energy equipment and eventually receive a return on investment from substantially lowered electric bills. It is important to note that the cost of commercial solar energy systems has decreased 69% since 2010 with further cost reductions predicted.^21,22

2. Reduce standby power consumption. This refers to the use of electricity by a device when it appears to be off or is not in use, which can lead to considerable energy consumption and subsequently a larger carbon footprint for your practice. Ensuring electronics such as phone chargers, light fixtures, television screens, and computers are switched off prior to the end of the workday can make a large difference; for instance, a single radiology department at the University of Maryland (College Park, Maryland) found that if clinical workstations were shut down when not in use after an 8-hour workday, it would save 83,866 kWh of energy and $9225.33 per year.²³ Additionally, using power strips with an automatic shutoff feature to shut off power to devices not in use provides a more convenient way to reduce standby power.

3. Optimize thermostat settings. An analysis of energy consumption in 157,000 US health care facilities found that space heating and cooling accounted for 40% of their total energy consumption.²⁴ Thus, ensuring your thermostat and heating/cooling systems are working efficiently can conserve a substantial amount of energy. For maximum efficiency, it is recommended to set air conditioners to 74 °F (24 °C) and heaters to 68 °F (20 °C) or employ smart thermostats to optimally adjust temperatures when the office is not in use.²⁵ In addition, routinely replacing or cleaning air conditioner filters can lower energy consumption by 5% to 15%.²⁶ Similarly, improving insulation and ruggedization of both homes and offices may reduce heating and cooling waste and limit costs and emissions as a result.

4. Offer bicycle racks and charging ports for electric vehicles. In the United States, transportation generates more greenhouse gas emissions than any other source, primarily due to the burning of fossil fuels to power automobiles, trains, and planes. Because bicycles do not consume any fossil fuels and the use of electric vehicles has been found to result in substantial air pollution health benefits, encouraging the use of both can make a considerable positive impact on our climate.²⁷ Providing these resources not only allows those who already travel sustainably to continue to do so but also serves as a reminder to your patients that sustainability is important to you as their health care provider. As electric vehicle sales continue to climb, infrastructure to support their use, including charging stations, will grow in importance. A physician’s office that offers a car-charging station may soon have a competitive advantage over others in the area.

5. Ensure properly regulated medical waste management. Regulated medical waste (also known as infectious medical waste or red bag waste) refers to health care–generated waste unsuitable for disposal in municipal solid waste systems due to concern for the spread of infectious or pathogenic materials. This waste largely is disposed via incineration, which harms the environment in a multitude of ways—both through harmful byproducts and from the CO₂ emissions required to ship the waste to special processing facilities.²⁸ Incineration of regulated medical waste emits potent toxins such as dioxins and furans as well as particulate matter, which contribute to air pollution. Ensuring only materials with infectious potential (as defined by each state’s Environmental Protection Agency) are disposed in regulated medical waste containers can dramatically reduce the harmful effects of incineration. Additionally, limiting regulated medical waste can be very cost-effective, as its disposal is 5- to 10-times more expensive than that of unregulated medical waste.²⁹ Simple nudge measures such as educating staff about what waste goes in which receptacle, placing signage over the red bag waste to prompt staff to pause to consider if use of that bin is required before utilizing, using weights or clasps to make opening red bag waste containers slightly harder, and positioning different trash receptacles in different parts of examination rooms may help reduce inappropriate use of red bag waste.

6. Consider virtual platforms when possible. Due to the COVID-19 pandemic, virtual meeting platforms saw a considerable increase in usage by dermatologists. Teledermatology for patient care became much more widely adopted, and traditionally in-person meetings turned virtual.³⁰ The reduction in emissions from these changes was remarkable. A recent study looking at the environmental impact of 3 months of teledermatology visits early during the COVID-19 pandemic found that 1476 teledermatology appointments saved 55,737 miles of car travel, equivalent to 15.37 metric tons of CO₂.³¹ Whether for patient care when appropriate, academic conferences and continuing medical education credit, or for interviews (eg, medical students, residents, other staff), use of virtual platforms can reduce unnecessary travel and therefore substantially reduce travel-related emissions. When travel is unavoidable, consider exploring validated vetted companies that offer carbon offsets to reduce the harmful environmental impact of high-emission flights.

7. Limit use of single-use disposable items. Although single-use items such as examination gloves or needles are necessary in a dermatology practice, there are many opportunities to incorporate reusable items in your workplace. For instance, you can replace plastic cutlery and single-use plates in kitchen or dining areas with reusable alternatives. Additionally, using reusable isolation gowns instead of their single-use counterparts can help reduce waste; a reusable isolation gown system for providers including laundering services was found to consume 28% less energy and emit 30% fewer greenhouse gases than a single-use isolation gown system.³² Similarly, opting for reusable instruments instead of single-use instruments when possible also can help reduce your practice’s carbon footprint. Carefully evaluating each part of your “dermatology visit supply chain” may offer opportunities to utilize additional cost-saving, environmentally friendly options; for example, an individually plastic-wrapped Dermablade vs a bulk-packaged blade for shave biopsies has a higher cost and worse environmental impact. A single gauze often is sufficient for shave biopsies, but many practices open a plastic container of bulk gauze, much of which results in waste that too often is inappropriately disposed of as regulated medical waste despite not being saturated in blood/body fluids.

8. Educate on the effects of climate change. Dermatologists and other physicians have the unique opportunity to teach members of their community every day through patient care. Physicians are trusted messengers, and appropriately counseling patients regarding the risks of climate change and its effects on their dermatologic health is in line with both American Medical Association and American College of Physicians guidelines.^3,4 For instance, patients with Lyme disease in Canada or Maine were unheard of a few decades ago, but now they are common; flares of atopic dermatitis in regions adjacent to recent wildfires may be attributable to harmful particulate matter resulting from fossil-fueled climate change and record droughts. Educating medical trainees on the impacts of climate change is just as vital, as it is a topic that often is neglected in medical school and residency curricula.³³

9. Install water-efficient toilets and faucets. Anthropogenic climate change has been shown to increase the duration and intensity of droughts throughout the world.³⁴ Much of the western United States also is experiencing record droughts. One way in which dermatology practices can work to combat droughts is through the use of water-conserving toilets, faucets, and urinals. Using water fixtures with the US Environmental Protection Agency’s WaterSense label is a convenient way to do so. The WaterSense label helps identify water fixtures certified to use at least 20% less water as well as save energy and decrease water costs.

10. Advocate through local and national organizations. There are numerous ways in which dermatologists can advocate for action against climate change. Joining professional organizations focused on addressing the climate crisis can help you connect with fellow dermatologists and physicians. The Expert Resource Group on Climate Change and Environmental Issues affiliated with the American Academy of Dermatology (AAD) is one such organization with many opportunities to raise awareness within the field of dermatology. The AAD recently joined the Medical Society Consortium on Climate and Health, an organization providing opportunities for policy and media outreach as well as research on climate change. Advocacy also can mean joining your local chapter of Physicians for Social Responsibility or encouraging divestment from fossil fuel companies within your institution. Voicing support for climate change–focused lectures at events such as grand rounds and society meetings at the local, regional, and state-wide levels can help raise awareness. As the dermatologic effects of climate change grow, being knowledgeable of the views of future leaders in our specialty and country on this issue will become increasingly important.

Final Thoughts

In addition to the climate-friendly decisions one can make as a dermatologist, there are many personal lifestyle choices to consider. Small dietary changes such as limiting consumption of beef and minimizing food waste can have large downstream effects. Opting for transportation via train and limiting air travel are both impactful decisions in reducing CO₂ emissions. Similarly, switching to an electric vehicle or vehicle with minimal emissions can work to reduce greenhouse gas accumulation. For additional resources, note the AAD has partnered with My Green Doctor, a nonprofit service for health care practices that includes practical cost-saving suggestions to support sustainability in physician practices.

A recent joint publication in more than 200 medical journals described climate change as the greatest threat to global public health.³⁵ Climate change is having devastating effects on dermatologic health and will only continue to do so if not addressed now. Dermatologists have the opportunity to join with our colleagues in the house of medicine and to take action to fight climate change and mitigate the health impacts on our patients, the population, and future generations.

The impacts of anthropogenic climate change on human health are numerous and growing. The evidence that climate change is occurring due to the burning of fossil fuels is substantial, with a 2019 report elevating the data supporting anthropogenic climate change to a gold standard 5-sigma level of significance.¹ In the peer-reviewed scientific literature, the consensus that humans are causing climate change is greater than 99%.² Both the American Medical Association and the American College of Physicians have acknowledged the health impacts of climate change and importance for action. They encourage physicians to engage in environmentally sustainable practices and to advocate for effective climate change mitigation strategies.^3,4 A survey of dermatologists also found that 99.3% (n=148) recognize climate change is occurring, and similarly high numbers are concerned about its health impacts.⁵

Notably, the health care industry must grapple not only with the health impacts of climate change but with the fact that the health care sector itself is responsible for a large amount of carbon emissions.⁶ The global health care industry as a whole produces enough carbon emissions to be ranked as the fifth largest emitting nation in the world.⁷ A quarter of these emissions are attributed to the US health care system.^8,9 Climate science has shown we must limit CO₂ emissions to avoid catastrophic climate change, with the sixth assessment report of the United Nations’ Intergovernmental Panel on Climate Change and the Paris Agreement targeting large emission reductions within the next decade.¹⁰ In August 2021, the US Department of Health and Human Services created the Office of Climate Change and Health Equity. Assistant Secretary for Health ADM Rachel L. Levine, MD, has committed to reducing the carbon emissions from the health care sector by 25% in the next decade, in line with scientific consensus regarding necessary changes.¹¹

The dermatologic impacts of climate change are myriad. Rising temperatures, increasing air and water pollution, and stratospheric ozone depletion will lead to expanded geographic ranges of vector-borne diseases, worsening of chronic skin conditions such as atopic dermatitis/eczema and pemphigus, and increasing rates of skin cancer.¹² For instance, warmer temperatures have allowed mosquitoes of the Aedes genus to infest new areas, leading to outbreaks of viral illnesses with cutaneous manifestations such as dengue, chikungunya, and Zika virus in previously nonindigenous regions.¹³ Rising temperatures also have been associated with an expanding geographic range of tick- and sandfly-borne illnesses such as Lyme disease, Rocky Mountain spotted fever, and cutaneous leishmaniasis.^13,14 Additionally, short-term exposure to air pollution from wildfire smoke has been associated with an increased use of health care services by patients with atopic dermatitis.¹⁵ Increased levels of air pollutants also have been found to be associated with psoriasis flares as well as hyperpigmentation and wrinkle formation.^16,17 Skin cancer incidence is predicted to rise due to increased UV radiation exposure secondary to stratospheric ozone depletion.¹⁸

Although the effects of climate change are significant and the magnitude of the climate crisis may feel overwhelming, it is essential to avoid doomerism and focus on meaningful impactful actions. Current CO₂ emissions will remain in the atmosphere for hundreds to thousands of years, and the choices we make now commit future generations to live in a world shaped by our decisions. Importantly, there are impactful and low-cost, cost-effective, or cost-saving changes that can be made to mitigate the climate crisis. Herein, we provide 10 practical actionable interventions for dermatologists to help combat climate change.

10 Interventions for Dermatologists to Combat Climate Change

1. Consider switching to renewable sources of energy. Making this switch often is the most impactful decision a dermatologist can make to address climate change. The electricity sector is the largest source of greenhouse gas emissions in the US health care system, and dermatology outpatient practices in particular have been observed to have a higher peak energy consumption than most other specialties studied.^19,20 Many dermatology practices—both privately owned and academic—can switch to renewable energy seamlessly through power purchase agreements (PPAs), which are contracts between power providers and private entities to install renewable energy equipment or source renewable energy from offsite sources at a fixed rate. Using PPAs instead of traditional fossil fuel energy can provide cost savings as well as protect buyers from electrical price volatility. Numerous health care systems utilize PPAs such as Kaiser Permanente, Cleveland Clinic, and Rochester Regional Health. Additionally, dermatologists can directly purchase renewable energy equipment and eventually receive a return on investment from substantially lowered electric bills. It is important to note that the cost of commercial solar energy systems has decreased 69% since 2010 with further cost reductions predicted.^21,22

2. Reduce standby power consumption. This refers to the use of electricity by a device when it appears to be off or is not in use, which can lead to considerable energy consumption and subsequently a larger carbon footprint for your practice. Ensuring electronics such as phone chargers, light fixtures, television screens, and computers are switched off prior to the end of the workday can make a large difference; for instance, a single radiology department at the University of Maryland (College Park, Maryland) found that if clinical workstations were shut down when not in use after an 8-hour workday, it would save 83,866 kWh of energy and $9225.33 per year.²³ Additionally, using power strips with an automatic shutoff feature to shut off power to devices not in use provides a more convenient way to reduce standby power.

3. Optimize thermostat settings. An analysis of energy consumption in 157,000 US health care facilities found that space heating and cooling accounted for 40% of their total energy consumption.²⁴ Thus, ensuring your thermostat and heating/cooling systems are working efficiently can conserve a substantial amount of energy. For maximum efficiency, it is recommended to set air conditioners to 74 °F (24 °C) and heaters to 68 °F (20 °C) or employ smart thermostats to optimally adjust temperatures when the office is not in use.²⁵ In addition, routinely replacing or cleaning air conditioner filters can lower energy consumption by 5% to 15%.²⁶ Similarly, improving insulation and ruggedization of both homes and offices may reduce heating and cooling waste and limit costs and emissions as a result.

4. Offer bicycle racks and charging ports for electric vehicles. In the United States, transportation generates more greenhouse gas emissions than any other source, primarily due to the burning of fossil fuels to power automobiles, trains, and planes. Because bicycles do not consume any fossil fuels and the use of electric vehicles has been found to result in substantial air pollution health benefits, encouraging the use of both can make a considerable positive impact on our climate.²⁷ Providing these resources not only allows those who already travel sustainably to continue to do so but also serves as a reminder to your patients that sustainability is important to you as their health care provider. As electric vehicle sales continue to climb, infrastructure to support their use, including charging stations, will grow in importance. A physician’s office that offers a car-charging station may soon have a competitive advantage over others in the area.

5. Ensure properly regulated medical waste management. Regulated medical waste (also known as infectious medical waste or red bag waste) refers to health care–generated waste unsuitable for disposal in municipal solid waste systems due to concern for the spread of infectious or pathogenic materials. This waste largely is disposed via incineration, which harms the environment in a multitude of ways—both through harmful byproducts and from the CO₂ emissions required to ship the waste to special processing facilities.²⁸ Incineration of regulated medical waste emits potent toxins such as dioxins and furans as well as particulate matter, which contribute to air pollution. Ensuring only materials with infectious potential (as defined by each state’s Environmental Protection Agency) are disposed in regulated medical waste containers can dramatically reduce the harmful effects of incineration. Additionally, limiting regulated medical waste can be very cost-effective, as its disposal is 5- to 10-times more expensive than that of unregulated medical waste.²⁹ Simple nudge measures such as educating staff about what waste goes in which receptacle, placing signage over the red bag waste to prompt staff to pause to consider if use of that bin is required before utilizing, using weights or clasps to make opening red bag waste containers slightly harder, and positioning different trash receptacles in different parts of examination rooms may help reduce inappropriate use of red bag waste.

6. Consider virtual platforms when possible. Due to the COVID-19 pandemic, virtual meeting platforms saw a considerable increase in usage by dermatologists. Teledermatology for patient care became much more widely adopted, and traditionally in-person meetings turned virtual.³⁰ The reduction in emissions from these changes was remarkable. A recent study looking at the environmental impact of 3 months of teledermatology visits early during the COVID-19 pandemic found that 1476 teledermatology appointments saved 55,737 miles of car travel, equivalent to 15.37 metric tons of CO₂.³¹ Whether for patient care when appropriate, academic conferences and continuing medical education credit, or for interviews (eg, medical students, residents, other staff), use of virtual platforms can reduce unnecessary travel and therefore substantially reduce travel-related emissions. When travel is unavoidable, consider exploring validated vetted companies that offer carbon offsets to reduce the harmful environmental impact of high-emission flights.

7. Limit use of single-use disposable items. Although single-use items such as examination gloves or needles are necessary in a dermatology practice, there are many opportunities to incorporate reusable items in your workplace. For instance, you can replace plastic cutlery and single-use plates in kitchen or dining areas with reusable alternatives. Additionally, using reusable isolation gowns instead of their single-use counterparts can help reduce waste; a reusable isolation gown system for providers including laundering services was found to consume 28% less energy and emit 30% fewer greenhouse gases than a single-use isolation gown system.³² Similarly, opting for reusable instruments instead of single-use instruments when possible also can help reduce your practice’s carbon footprint. Carefully evaluating each part of your “dermatology visit supply chain” may offer opportunities to utilize additional cost-saving, environmentally friendly options; for example, an individually plastic-wrapped Dermablade vs a bulk-packaged blade for shave biopsies has a higher cost and worse environmental impact. A single gauze often is sufficient for shave biopsies, but many practices open a plastic container of bulk gauze, much of which results in waste that too often is inappropriately disposed of as regulated medical waste despite not being saturated in blood/body fluids.

8. Educate on the effects of climate change. Dermatologists and other physicians have the unique opportunity to teach members of their community every day through patient care. Physicians are trusted messengers, and appropriately counseling patients regarding the risks of climate change and its effects on their dermatologic health is in line with both American Medical Association and American College of Physicians guidelines.^3,4 For instance, patients with Lyme disease in Canada or Maine were unheard of a few decades ago, but now they are common; flares of atopic dermatitis in regions adjacent to recent wildfires may be attributable to harmful particulate matter resulting from fossil-fueled climate change and record droughts. Educating medical trainees on the impacts of climate change is just as vital, as it is a topic that often is neglected in medical school and residency curricula.³³

9. Install water-efficient toilets and faucets. Anthropogenic climate change has been shown to increase the duration and intensity of droughts throughout the world.³⁴ Much of the western United States also is experiencing record droughts. One way in which dermatology practices can work to combat droughts is through the use of water-conserving toilets, faucets, and urinals. Using water fixtures with the US Environmental Protection Agency’s WaterSense label is a convenient way to do so. The WaterSense label helps identify water fixtures certified to use at least 20% less water as well as save energy and decrease water costs.

10. Advocate through local and national organizations. There are numerous ways in which dermatologists can advocate for action against climate change. Joining professional organizations focused on addressing the climate crisis can help you connect with fellow dermatologists and physicians. The Expert Resource Group on Climate Change and Environmental Issues affiliated with the American Academy of Dermatology (AAD) is one such organization with many opportunities to raise awareness within the field of dermatology. The AAD recently joined the Medical Society Consortium on Climate and Health, an organization providing opportunities for policy and media outreach as well as research on climate change. Advocacy also can mean joining your local chapter of Physicians for Social Responsibility or encouraging divestment from fossil fuel companies within your institution. Voicing support for climate change–focused lectures at events such as grand rounds and society meetings at the local, regional, and state-wide levels can help raise awareness. As the dermatologic effects of climate change grow, being knowledgeable of the views of future leaders in our specialty and country on this issue will become increasingly important.

Final Thoughts

In addition to the climate-friendly decisions one can make as a dermatologist, there are many personal lifestyle choices to consider. Small dietary changes such as limiting consumption of beef and minimizing food waste can have large downstream effects. Opting for transportation via train and limiting air travel are both impactful decisions in reducing CO₂ emissions. Similarly, switching to an electric vehicle or vehicle with minimal emissions can work to reduce greenhouse gas accumulation. For additional resources, note the AAD has partnered with My Green Doctor, a nonprofit service for health care practices that includes practical cost-saving suggestions to support sustainability in physician practices.

A recent joint publication in more than 200 medical journals described climate change as the greatest threat to global public health.³⁵ Climate change is having devastating effects on dermatologic health and will only continue to do so if not addressed now. Dermatologists have the opportunity to join with our colleagues in the house of medicine and to take action to fight climate change and mitigate the health impacts on our patients, the population, and future generations.

The impacts of anthropogenic climate change on human health are numerous and growing. The evidence that climate change is occurring due to the burning of fossil fuels is substantial, with a 2019 report elevating the data supporting anthropogenic climate change to a gold standard 5-sigma level of significance.¹ In the peer-reviewed scientific literature, the consensus that humans are causing climate change is greater than 99%.² Both the American Medical Association and the American College of Physicians have acknowledged the health impacts of climate change and importance for action. They encourage physicians to engage in environmentally sustainable practices and to advocate for effective climate change mitigation strategies.^3,4 A survey of dermatologists also found that 99.3% (n=148) recognize climate change is occurring, and similarly high numbers are concerned about its health impacts.⁵

Notably, the health care industry must grapple not only with the health impacts of climate change but with the fact that the health care sector itself is responsible for a large amount of carbon emissions.⁶ The global health care industry as a whole produces enough carbon emissions to be ranked as the fifth largest emitting nation in the world.⁷ A quarter of these emissions are attributed to the US health care system.^8,9 Climate science has shown we must limit CO₂ emissions to avoid catastrophic climate change, with the sixth assessment report of the United Nations’ Intergovernmental Panel on Climate Change and the Paris Agreement targeting large emission reductions within the next decade.¹⁰ In August 2021, the US Department of Health and Human Services created the Office of Climate Change and Health Equity. Assistant Secretary for Health ADM Rachel L. Levine, MD, has committed to reducing the carbon emissions from the health care sector by 25% in the next decade, in line with scientific consensus regarding necessary changes.¹¹

The dermatologic impacts of climate change are myriad. Rising temperatures, increasing air and water pollution, and stratospheric ozone depletion will lead to expanded geographic ranges of vector-borne diseases, worsening of chronic skin conditions such as atopic dermatitis/eczema and pemphigus, and increasing rates of skin cancer.¹² For instance, warmer temperatures have allowed mosquitoes of the Aedes genus to infest new areas, leading to outbreaks of viral illnesses with cutaneous manifestations such as dengue, chikungunya, and Zika virus in previously nonindigenous regions.¹³ Rising temperatures also have been associated with an expanding geographic range of tick- and sandfly-borne illnesses such as Lyme disease, Rocky Mountain spotted fever, and cutaneous leishmaniasis.^13,14 Additionally, short-term exposure to air pollution from wildfire smoke has been associated with an increased use of health care services by patients with atopic dermatitis.¹⁵ Increased levels of air pollutants also have been found to be associated with psoriasis flares as well as hyperpigmentation and wrinkle formation.^16,17 Skin cancer incidence is predicted to rise due to increased UV radiation exposure secondary to stratospheric ozone depletion.¹⁸

Although the effects of climate change are significant and the magnitude of the climate crisis may feel overwhelming, it is essential to avoid doomerism and focus on meaningful impactful actions. Current CO₂ emissions will remain in the atmosphere for hundreds to thousands of years, and the choices we make now commit future generations to live in a world shaped by our decisions. Importantly, there are impactful and low-cost, cost-effective, or cost-saving changes that can be made to mitigate the climate crisis. Herein, we provide 10 practical actionable interventions for dermatologists to help combat climate change.

10 Interventions for Dermatologists to Combat Climate Change

1. Consider switching to renewable sources of energy. Making this switch often is the most impactful decision a dermatologist can make to address climate change. The electricity sector is the largest source of greenhouse gas emissions in the US health care system, and dermatology outpatient practices in particular have been observed to have a higher peak energy consumption than most other specialties studied.^19,20 Many dermatology practices—both privately owned and academic—can switch to renewable energy seamlessly through power purchase agreements (PPAs), which are contracts between power providers and private entities to install renewable energy equipment or source renewable energy from offsite sources at a fixed rate. Using PPAs instead of traditional fossil fuel energy can provide cost savings as well as protect buyers from electrical price volatility. Numerous health care systems utilize PPAs such as Kaiser Permanente, Cleveland Clinic, and Rochester Regional Health. Additionally, dermatologists can directly purchase renewable energy equipment and eventually receive a return on investment from substantially lowered electric bills. It is important to note that the cost of commercial solar energy systems has decreased 69% since 2010 with further cost reductions predicted.^21,22

2. Reduce standby power consumption. This refers to the use of electricity by a device when it appears to be off or is not in use, which can lead to considerable energy consumption and subsequently a larger carbon footprint for your practice. Ensuring electronics such as phone chargers, light fixtures, television screens, and computers are switched off prior to the end of the workday can make a large difference; for instance, a single radiology department at the University of Maryland (College Park, Maryland) found that if clinical workstations were shut down when not in use after an 8-hour workday, it would save 83,866 kWh of energy and $9225.33 per year.²³ Additionally, using power strips with an automatic shutoff feature to shut off power to devices not in use provides a more convenient way to reduce standby power.

3. Optimize thermostat settings. An analysis of energy consumption in 157,000 US health care facilities found that space heating and cooling accounted for 40% of their total energy consumption.²⁴ Thus, ensuring your thermostat and heating/cooling systems are working efficiently can conserve a substantial amount of energy. For maximum efficiency, it is recommended to set air conditioners to 74 °F (24 °C) and heaters to 68 °F (20 °C) or employ smart thermostats to optimally adjust temperatures when the office is not in use.²⁵ In addition, routinely replacing or cleaning air conditioner filters can lower energy consumption by 5% to 15%.²⁶ Similarly, improving insulation and ruggedization of both homes and offices may reduce heating and cooling waste and limit costs and emissions as a result.

4. Offer bicycle racks and charging ports for electric vehicles. In the United States, transportation generates more greenhouse gas emissions than any other source, primarily due to the burning of fossil fuels to power automobiles, trains, and planes. Because bicycles do not consume any fossil fuels and the use of electric vehicles has been found to result in substantial air pollution health benefits, encouraging the use of both can make a considerable positive impact on our climate.²⁷ Providing these resources not only allows those who already travel sustainably to continue to do so but also serves as a reminder to your patients that sustainability is important to you as their health care provider. As electric vehicle sales continue to climb, infrastructure to support their use, including charging stations, will grow in importance. A physician’s office that offers a car-charging station may soon have a competitive advantage over others in the area.

5. Ensure properly regulated medical waste management. Regulated medical waste (also known as infectious medical waste or red bag waste) refers to health care–generated waste unsuitable for disposal in municipal solid waste systems due to concern for the spread of infectious or pathogenic materials. This waste largely is disposed via incineration, which harms the environment in a multitude of ways—both through harmful byproducts and from the CO₂ emissions required to ship the waste to special processing facilities.²⁸ Incineration of regulated medical waste emits potent toxins such as dioxins and furans as well as particulate matter, which contribute to air pollution. Ensuring only materials with infectious potential (as defined by each state’s Environmental Protection Agency) are disposed in regulated medical waste containers can dramatically reduce the harmful effects of incineration. Additionally, limiting regulated medical waste can be very cost-effective, as its disposal is 5- to 10-times more expensive than that of unregulated medical waste.²⁹ Simple nudge measures such as educating staff about what waste goes in which receptacle, placing signage over the red bag waste to prompt staff to pause to consider if use of that bin is required before utilizing, using weights or clasps to make opening red bag waste containers slightly harder, and positioning different trash receptacles in different parts of examination rooms may help reduce inappropriate use of red bag waste.

6. Consider virtual platforms when possible. Due to the COVID-19 pandemic, virtual meeting platforms saw a considerable increase in usage by dermatologists. Teledermatology for patient care became much more widely adopted, and traditionally in-person meetings turned virtual.³⁰ The reduction in emissions from these changes was remarkable. A recent study looking at the environmental impact of 3 months of teledermatology visits early during the COVID-19 pandemic found that 1476 teledermatology appointments saved 55,737 miles of car travel, equivalent to 15.37 metric tons of CO₂.³¹ Whether for patient care when appropriate, academic conferences and continuing medical education credit, or for interviews (eg, medical students, residents, other staff), use of virtual platforms can reduce unnecessary travel and therefore substantially reduce travel-related emissions. When travel is unavoidable, consider exploring validated vetted companies that offer carbon offsets to reduce the harmful environmental impact of high-emission flights.

7. Limit use of single-use disposable items. Although single-use items such as examination gloves or needles are necessary in a dermatology practice, there are many opportunities to incorporate reusable items in your workplace. For instance, you can replace plastic cutlery and single-use plates in kitchen or dining areas with reusable alternatives. Additionally, using reusable isolation gowns instead of their single-use counterparts can help reduce waste; a reusable isolation gown system for providers including laundering services was found to consume 28% less energy and emit 30% fewer greenhouse gases than a single-use isolation gown system.³² Similarly, opting for reusable instruments instead of single-use instruments when possible also can help reduce your practice’s carbon footprint. Carefully evaluating each part of your “dermatology visit supply chain” may offer opportunities to utilize additional cost-saving, environmentally friendly options; for example, an individually plastic-wrapped Dermablade vs a bulk-packaged blade for shave biopsies has a higher cost and worse environmental impact. A single gauze often is sufficient for shave biopsies, but many practices open a plastic container of bulk gauze, much of which results in waste that too often is inappropriately disposed of as regulated medical waste despite not being saturated in blood/body fluids.

8. Educate on the effects of climate change. Dermatologists and other physicians have the unique opportunity to teach members of their community every day through patient care. Physicians are trusted messengers, and appropriately counseling patients regarding the risks of climate change and its effects on their dermatologic health is in line with both American Medical Association and American College of Physicians guidelines.^3,4 For instance, patients with Lyme disease in Canada or Maine were unheard of a few decades ago, but now they are common; flares of atopic dermatitis in regions adjacent to recent wildfires may be attributable to harmful particulate matter resulting from fossil-fueled climate change and record droughts. Educating medical trainees on the impacts of climate change is just as vital, as it is a topic that often is neglected in medical school and residency curricula.³³

9. Install water-efficient toilets and faucets. Anthropogenic climate change has been shown to increase the duration and intensity of droughts throughout the world.³⁴ Much of the western United States also is experiencing record droughts. One way in which dermatology practices can work to combat droughts is through the use of water-conserving toilets, faucets, and urinals. Using water fixtures with the US Environmental Protection Agency’s WaterSense label is a convenient way to do so. The WaterSense label helps identify water fixtures certified to use at least 20% less water as well as save energy and decrease water costs.

10. Advocate through local and national organizations. There are numerous ways in which dermatologists can advocate for action against climate change. Joining professional organizations focused on addressing the climate crisis can help you connect with fellow dermatologists and physicians. The Expert Resource Group on Climate Change and Environmental Issues affiliated with the American Academy of Dermatology (AAD) is one such organization with many opportunities to raise awareness within the field of dermatology. The AAD recently joined the Medical Society Consortium on Climate and Health, an organization providing opportunities for policy and media outreach as well as research on climate change. Advocacy also can mean joining your local chapter of Physicians for Social Responsibility or encouraging divestment from fossil fuel companies within your institution. Voicing support for climate change–focused lectures at events such as grand rounds and society meetings at the local, regional, and state-wide levels can help raise awareness. As the dermatologic effects of climate change grow, being knowledgeable of the views of future leaders in our specialty and country on this issue will become increasingly important.

Final Thoughts

In addition to the climate-friendly decisions one can make as a dermatologist, there are many personal lifestyle choices to consider. Small dietary changes such as limiting consumption of beef and minimizing food waste can have large downstream effects. Opting for transportation via train and limiting air travel are both impactful decisions in reducing CO₂ emissions. Similarly, switching to an electric vehicle or vehicle with minimal emissions can work to reduce greenhouse gas accumulation. For additional resources, note the AAD has partnered with My Green Doctor, a nonprofit service for health care practices that includes practical cost-saving suggestions to support sustainability in physician practices.

A recent joint publication in more than 200 medical journals described climate change as the greatest threat to global public health.³⁵ Climate change is having devastating effects on dermatologic health and will only continue to do so if not addressed now. Dermatologists have the opportunity to join with our colleagues in the house of medicine and to take action to fight climate change and mitigate the health impacts on our patients, the population, and future generations.

To the Editor:

A 33-year-old woman presented with tenderness of the left breast and nipple of 2 weeks’ duration and fever of 2 days’ duration. The pain was so severe it precluded nursing. She rented a hospital-grade electric breast pump to continue lactation but only could produce 1 ounce of milk daily. The mother had been breastfeeding her 13-month-old twins since birth and did not report any prior difficulties with breastfeeding. Both twins had a history of mucosal sores 2 months prior and a recent outbreak of perioral vesicles following an upper respiratory tract illness that was consistent with gingivostomatitis, followed by a cutaneous outbreak secondary to herpes simplex virus (HSV) type 1 infection. The patient had no known history of HSV infection. Prior to presentation the patient was treated with oral dicloxacillin and then cephalexin for suspected bacterial mastitis. She also had used combination clotrimazole-betamethasone cream for possible superficial candidiasis. The patient had no relief with these treatments.

Physical examination revealed approximately 20 microvesicles (<1 mm) on an erythematous base clustered around the left areola (Figure). Erythematous streaks were noted from the medial aspect of the areolar margin extending to the central sternum. The left breast was firm and engorged but without apparent plugged lactiferous ducts. There was no lymphadenopathy. No lesions were present on the palms, soles, and oral mucosa.

The patient was empirically treated with valacyclovir, trimethoprim-sulfamethoxazole, and nonsteroidal anti-inflammatory drugs while awaiting laboratory results. Bacterial cultures were negative. Viral titers revealed positive combination HSV-1 and HSV-2 IgM (4.64 [<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]) and negative HSV-1 and HSV-2 IgG (<0.91[<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]), which confirmed the diagnosis of primary HSV infection. Two months later viral titers were positive for HSV-1 IgG (1.3) and negative for HSV-2 IgG (<0.91).

At 1-week follow-up the patient reported that the fever had subsided 1 day after initial presentation. After commencement of antiviral therapy, she continued to have some mild residual tenderness, but the vesicles had crusted over and markedly improved. Upon further questioning, the patient’s husband had a history of oral HSV-1 and was likely the primary source for the infection in the infants.

Herpes simplex virus infection primarily is transmitted through direct mucocutaneous contact with either oral or genital lesions of an infected individual. Transmission of HSV from infant to mother rarely is described. A PubMed search of articles indexed for MEDLINE using the terms herpes mastitis, herpes of the breast, infant to maternal transmission, gingivostomatitis, primary herpes, and breastfeeding yielded 4 reported cases of HSV of the nipple in breastfeeding women from children with herpetic gingivostomatitis.^1-4

Herpes simplex virus infection is common in neonatal and pediatric populations. In the United States, more than 30% of children (aged <14 years) have evidence of HSV-1 infection on serology. Herpes simplex virus infections in children can range from uncomplicated mucocutaneous diseases to severe life-threatening infections involving the central nervous system. In children, antivirals should be initiated within 72 hours of symptom onset to prevent more serious complications. Diagnostic testing was not performed on the infants in this case because the 72-hour treatment window had passed. In particular, neonates (aged <3 months) will require intravenous antivirals to prevent the development of central nervous system disease, which occurs in 33% of neonatal HSV infections.⁵ It is critically important to confirm the diagnosis of HSV in a breastfeeding woman, when clinically indicated, with a viral culture, serology, direct immunofluorescence assay, polymerase chain reaction, or Tzanck smear because other conditions such as plugged lactiferous ducts, candidal mastitis, or bacterial mastitis may mimic HSV. Rapid and accurate diagnosis of the breastfeeding woman with HSV of the nipple can help identify children with herpetic gingivostomatitis that is not readily apparent.

To the Editor:

A 33-year-old woman presented with tenderness of the left breast and nipple of 2 weeks’ duration and fever of 2 days’ duration. The pain was so severe it precluded nursing. She rented a hospital-grade electric breast pump to continue lactation but only could produce 1 ounce of milk daily. The mother had been breastfeeding her 13-month-old twins since birth and did not report any prior difficulties with breastfeeding. Both twins had a history of mucosal sores 2 months prior and a recent outbreak of perioral vesicles following an upper respiratory tract illness that was consistent with gingivostomatitis, followed by a cutaneous outbreak secondary to herpes simplex virus (HSV) type 1 infection. The patient had no known history of HSV infection. Prior to presentation the patient was treated with oral dicloxacillin and then cephalexin for suspected bacterial mastitis. She also had used combination clotrimazole-betamethasone cream for possible superficial candidiasis. The patient had no relief with these treatments.

Physical examination revealed approximately 20 microvesicles (<1 mm) on an erythematous base clustered around the left areola (Figure). Erythematous streaks were noted from the medial aspect of the areolar margin extending to the central sternum. The left breast was firm and engorged but without apparent plugged lactiferous ducts. There was no lymphadenopathy. No lesions were present on the palms, soles, and oral mucosa.

The patient was empirically treated with valacyclovir, trimethoprim-sulfamethoxazole, and nonsteroidal anti-inflammatory drugs while awaiting laboratory results. Bacterial cultures were negative. Viral titers revealed positive combination HSV-1 and HSV-2 IgM (4.64 [<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]) and negative HSV-1 and HSV-2 IgG (<0.91[<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]), which confirmed the diagnosis of primary HSV infection. Two months later viral titers were positive for HSV-1 IgG (1.3) and negative for HSV-2 IgG (<0.91).

At 1-week follow-up the patient reported that the fever had subsided 1 day after initial presentation. After commencement of antiviral therapy, she continued to have some mild residual tenderness, but the vesicles had crusted over and markedly improved. Upon further questioning, the patient’s husband had a history of oral HSV-1 and was likely the primary source for the infection in the infants.

Herpes simplex virus infection primarily is transmitted through direct mucocutaneous contact with either oral or genital lesions of an infected individual. Transmission of HSV from infant to mother rarely is described. A PubMed search of articles indexed for MEDLINE using the terms herpes mastitis, herpes of the breast, infant to maternal transmission, gingivostomatitis, primary herpes, and breastfeeding yielded 4 reported cases of HSV of the nipple in breastfeeding women from children with herpetic gingivostomatitis.^1-4

Herpes simplex virus infection is common in neonatal and pediatric populations. In the United States, more than 30% of children (aged <14 years) have evidence of HSV-1 infection on serology. Herpes simplex virus infections in children can range from uncomplicated mucocutaneous diseases to severe life-threatening infections involving the central nervous system. In children, antivirals should be initiated within 72 hours of symptom onset to prevent more serious complications. Diagnostic testing was not performed on the infants in this case because the 72-hour treatment window had passed. In particular, neonates (aged <3 months) will require intravenous antivirals to prevent the development of central nervous system disease, which occurs in 33% of neonatal HSV infections.⁵ It is critically important to confirm the diagnosis of HSV in a breastfeeding woman, when clinically indicated, with a viral culture, serology, direct immunofluorescence assay, polymerase chain reaction, or Tzanck smear because other conditions such as plugged lactiferous ducts, candidal mastitis, or bacterial mastitis may mimic HSV. Rapid and accurate diagnosis of the breastfeeding woman with HSV of the nipple can help identify children with herpetic gingivostomatitis that is not readily apparent.

To the Editor:

A 33-year-old woman presented with tenderness of the left breast and nipple of 2 weeks’ duration and fever of 2 days’ duration. The pain was so severe it precluded nursing. She rented a hospital-grade electric breast pump to continue lactation but only could produce 1 ounce of milk daily. The mother had been breastfeeding her 13-month-old twins since birth and did not report any prior difficulties with breastfeeding. Both twins had a history of mucosal sores 2 months prior and a recent outbreak of perioral vesicles following an upper respiratory tract illness that was consistent with gingivostomatitis, followed by a cutaneous outbreak secondary to herpes simplex virus (HSV) type 1 infection. The patient had no known history of HSV infection. Prior to presentation the patient was treated with oral dicloxacillin and then cephalexin for suspected bacterial mastitis. She also had used combination clotrimazole-betamethasone cream for possible superficial candidiasis. The patient had no relief with these treatments.

Physical examination revealed approximately 20 microvesicles (<1 mm) on an erythematous base clustered around the left areola (Figure). Erythematous streaks were noted from the medial aspect of the areolar margin extending to the central sternum. The left breast was firm and engorged but without apparent plugged lactiferous ducts. There was no lymphadenopathy. No lesions were present on the palms, soles, and oral mucosa.

The patient was empirically treated with valacyclovir, trimethoprim-sulfamethoxazole, and nonsteroidal anti-inflammatory drugs while awaiting laboratory results. Bacterial cultures were negative. Viral titers revealed positive combination HSV-1 and HSV-2 IgM (4.64 [<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]) and negative HSV-1 and HSV-2 IgG (<0.91[<0.91=negative, 0.91–1.09=equivocal, >1.09=positive]), which confirmed the diagnosis of primary HSV infection. Two months later viral titers were positive for HSV-1 IgG (1.3) and negative for HSV-2 IgG (<0.91).

At 1-week follow-up the patient reported that the fever had subsided 1 day after initial presentation. After commencement of antiviral therapy, she continued to have some mild residual tenderness, but the vesicles had crusted over and markedly improved. Upon further questioning, the patient’s husband had a history of oral HSV-1 and was likely the primary source for the infection in the infants.

Herpes simplex virus infection primarily is transmitted through direct mucocutaneous contact with either oral or genital lesions of an infected individual. Transmission of HSV from infant to mother rarely is described. A PubMed search of articles indexed for MEDLINE using the terms herpes mastitis, herpes of the breast, infant to maternal transmission, gingivostomatitis, primary herpes, and breastfeeding yielded 4 reported cases of HSV of the nipple in breastfeeding women from children with herpetic gingivostomatitis.^1-4

Herpes simplex virus infection is common in neonatal and pediatric populations. In the United States, more than 30% of children (aged <14 years) have evidence of HSV-1 infection on serology. Herpes simplex virus infections in children can range from uncomplicated mucocutaneous diseases to severe life-threatening infections involving the central nervous system. In children, antivirals should be initiated within 72 hours of symptom onset to prevent more serious complications. Diagnostic testing was not performed on the infants in this case because the 72-hour treatment window had passed. In particular, neonates (aged <3 months) will require intravenous antivirals to prevent the development of central nervous system disease, which occurs in 33% of neonatal HSV infections.⁵ It is critically important to confirm the diagnosis of HSV in a breastfeeding woman, when clinically indicated, with a viral culture, serology, direct immunofluorescence assay, polymerase chain reaction, or Tzanck smear because other conditions such as plugged lactiferous ducts, candidal mastitis, or bacterial mastitis may mimic HSV. Rapid and accurate diagnosis of the breastfeeding woman with HSV of the nipple can help identify children with herpetic gingivostomatitis that is not readily apparent.