Shari R. Lipner, MD, PhD

Health care–specific (eg, Healthgrades, Zocdoc, Vitals, WebMD) and general consumer websites (eg, Google, Yelp) are popular platforms for patients to find physicians, schedule appointments, and review physician experiences. Patients find ratings on these websites more trustworthy than standardized surveys distributed by hospitals, but many physicians do not trust the reviews on these sites. For example, in a survey of both physicians (n=828) and patients (n=494), 36% of physicians trusted online reviews compared to 57% of patients.¹ The objective of this study was to determine if health care–specific or general consumer websites more accurately reflect overall patient sentiment. This knowledge can help physicians who are seeking to improve the patient experience understand which websites have more accurate and trustworthy reviews.

Methods

A list of dermatologists from the top 10 most and least dermatologist–dense areas in the United States was compiled to examine different physician populations.² Equal numbers of male and female dermatologists were randomly selected from the most dense areas. All physicians were included from the least dense areas because of limited sample size. Ratings were collected from websites most likely to appear on the first page of a Google search for a physician name, as these are most likely to be seen by patients. Descriptive statistics were generated to describe the study population; mean and median physician rating (using a scale of 1–5); SD; and minimum, maximum, and interquartile ranges. Spearman correlation coefficients were generated to examine the strength of association between ratings from website pairs. P<.05 was considered statistically significant, with analyses performed in R (3.6.2) for Windows (the R Foundation).

Results

A total of 167 representative physicians were included in this analysis; 141 from the most dense areas, and 26 from the least dense areas. The lowest average ratings for the entire sample and most dermatologist–dense areas were found on Yelp (3.61 and 3.60, respectively), and the lowest ratings in the least dermatologist–dense areas were found on Google (3.45)(Table 1). Correlation coefficient values were lowest for Zocdoc and Healthgrades (0.263) and highest for Vitals and WebMD (0.963)(Table 2). The health care–specific sites were closer to the overall average (4.06) than the general consumer sites (eFigure).

Comment

Although dermatologist ratings on each site had a broad range, we found that patients typically expressed negative interactions on general consumer websites rather than health care–specific websites. When comparing the ratings of the same group of dermatologists across different sites, ratings on health care–specific sites had a higher degree of correlation, with physician ratings more similar between 2 health care–specific sites and less similar between a health care–specific and a general consumer website. This pattern was consistent in both dermatologist-dense and dermatologist-poor areas, despite patients having varying levels of access to dermatologic care and medical resources and potentially different regional preferences of consumer websites. Taken together, these findings imply that health care–specific websites more consistently reflect overall patient sentiment.

Although one 2016 study comparing reviews of dermatology practices on Zocdoc and Yelp also demonstrated lower average ratings on Yelp,³ our study suggests that this trend is not isolated to these 2 sites but can be seen when comparing many health care–specific sites vs general consumer sites.

Our study compared ratings of dermatologists among popular websites to understand those that are most representative of patient attitudes toward physicians. These findings are important because online reviews reflect the entire patient experience, not just the patient-physician interaction, which may explain why physician scores on standardized questionnaires, such as Press Ganey surveys, do not correlate well with their online reviews.⁴ In a study comparing 98 physicians with negative online ratings to 82 physicians in similar departments with positive ratings, there was no significant difference in scores on patient-physician interaction questions on the Press Ganey survey.⁵ However, physicians who received negative online reviews scored lower on Press Ganey questions related to nonphysician interactions (eg, office cleanliness, interactions with staff).

The current study was subject to several limitations. Our analysis included all physicians in our random selection without accounting for those physicians with a greater online presence who might be more cognizant of these ratings and try to manipulate them through a reputation-management company or public relations consultant.

Conclusion

Our study suggests that consumer websites are not primarily used by disgruntled patients wishing to express grievances; instead, on average, most physicians received positive reviews. Furthermore, health care–specific websites show a higher degree of concordance than and may more accurately reflect overall patient attitudes toward their physicians than general consumer sites. Reviews from these health care–specific sites may be more helpful than general consumer websites in allowing physicians to understand patient sentiment and improve patient experiences.

Health care–specific (eg, Healthgrades, Zocdoc, Vitals, WebMD) and general consumer websites (eg, Google, Yelp) are popular platforms for patients to find physicians, schedule appointments, and review physician experiences. Patients find ratings on these websites more trustworthy than standardized surveys distributed by hospitals, but many physicians do not trust the reviews on these sites. For example, in a survey of both physicians (n=828) and patients (n=494), 36% of physicians trusted online reviews compared to 57% of patients.¹ The objective of this study was to determine if health care–specific or general consumer websites more accurately reflect overall patient sentiment. This knowledge can help physicians who are seeking to improve the patient experience understand which websites have more accurate and trustworthy reviews.

Methods

A list of dermatologists from the top 10 most and least dermatologist–dense areas in the United States was compiled to examine different physician populations.² Equal numbers of male and female dermatologists were randomly selected from the most dense areas. All physicians were included from the least dense areas because of limited sample size. Ratings were collected from websites most likely to appear on the first page of a Google search for a physician name, as these are most likely to be seen by patients. Descriptive statistics were generated to describe the study population; mean and median physician rating (using a scale of 1–5); SD; and minimum, maximum, and interquartile ranges. Spearman correlation coefficients were generated to examine the strength of association between ratings from website pairs. P<.05 was considered statistically significant, with analyses performed in R (3.6.2) for Windows (the R Foundation).

Results

A total of 167 representative physicians were included in this analysis; 141 from the most dense areas, and 26 from the least dense areas. The lowest average ratings for the entire sample and most dermatologist–dense areas were found on Yelp (3.61 and 3.60, respectively), and the lowest ratings in the least dermatologist–dense areas were found on Google (3.45)(Table 1). Correlation coefficient values were lowest for Zocdoc and Healthgrades (0.263) and highest for Vitals and WebMD (0.963)(Table 2). The health care–specific sites were closer to the overall average (4.06) than the general consumer sites (eFigure).

Comment

Although dermatologist ratings on each site had a broad range, we found that patients typically expressed negative interactions on general consumer websites rather than health care–specific websites. When comparing the ratings of the same group of dermatologists across different sites, ratings on health care–specific sites had a higher degree of correlation, with physician ratings more similar between 2 health care–specific sites and less similar between a health care–specific and a general consumer website. This pattern was consistent in both dermatologist-dense and dermatologist-poor areas, despite patients having varying levels of access to dermatologic care and medical resources and potentially different regional preferences of consumer websites. Taken together, these findings imply that health care–specific websites more consistently reflect overall patient sentiment.

Although one 2016 study comparing reviews of dermatology practices on Zocdoc and Yelp also demonstrated lower average ratings on Yelp,³ our study suggests that this trend is not isolated to these 2 sites but can be seen when comparing many health care–specific sites vs general consumer sites.

Our study compared ratings of dermatologists among popular websites to understand those that are most representative of patient attitudes toward physicians. These findings are important because online reviews reflect the entire patient experience, not just the patient-physician interaction, which may explain why physician scores on standardized questionnaires, such as Press Ganey surveys, do not correlate well with their online reviews.⁴ In a study comparing 98 physicians with negative online ratings to 82 physicians in similar departments with positive ratings, there was no significant difference in scores on patient-physician interaction questions on the Press Ganey survey.⁵ However, physicians who received negative online reviews scored lower on Press Ganey questions related to nonphysician interactions (eg, office cleanliness, interactions with staff).

The current study was subject to several limitations. Our analysis included all physicians in our random selection without accounting for those physicians with a greater online presence who might be more cognizant of these ratings and try to manipulate them through a reputation-management company or public relations consultant.

Conclusion

Our study suggests that consumer websites are not primarily used by disgruntled patients wishing to express grievances; instead, on average, most physicians received positive reviews. Furthermore, health care–specific websites show a higher degree of concordance than and may more accurately reflect overall patient attitudes toward their physicians than general consumer sites. Reviews from these health care–specific sites may be more helpful than general consumer websites in allowing physicians to understand patient sentiment and improve patient experiences.

Health care–specific (eg, Healthgrades, Zocdoc, Vitals, WebMD) and general consumer websites (eg, Google, Yelp) are popular platforms for patients to find physicians, schedule appointments, and review physician experiences. Patients find ratings on these websites more trustworthy than standardized surveys distributed by hospitals, but many physicians do not trust the reviews on these sites. For example, in a survey of both physicians (n=828) and patients (n=494), 36% of physicians trusted online reviews compared to 57% of patients.¹ The objective of this study was to determine if health care–specific or general consumer websites more accurately reflect overall patient sentiment. This knowledge can help physicians who are seeking to improve the patient experience understand which websites have more accurate and trustworthy reviews.

Methods

A list of dermatologists from the top 10 most and least dermatologist–dense areas in the United States was compiled to examine different physician populations.² Equal numbers of male and female dermatologists were randomly selected from the most dense areas. All physicians were included from the least dense areas because of limited sample size. Ratings were collected from websites most likely to appear on the first page of a Google search for a physician name, as these are most likely to be seen by patients. Descriptive statistics were generated to describe the study population; mean and median physician rating (using a scale of 1–5); SD; and minimum, maximum, and interquartile ranges. Spearman correlation coefficients were generated to examine the strength of association between ratings from website pairs. P<.05 was considered statistically significant, with analyses performed in R (3.6.2) for Windows (the R Foundation).

Results

A total of 167 representative physicians were included in this analysis; 141 from the most dense areas, and 26 from the least dense areas. The lowest average ratings for the entire sample and most dermatologist–dense areas were found on Yelp (3.61 and 3.60, respectively), and the lowest ratings in the least dermatologist–dense areas were found on Google (3.45)(Table 1). Correlation coefficient values were lowest for Zocdoc and Healthgrades (0.263) and highest for Vitals and WebMD (0.963)(Table 2). The health care–specific sites were closer to the overall average (4.06) than the general consumer sites (eFigure).

Comment

Although dermatologist ratings on each site had a broad range, we found that patients typically expressed negative interactions on general consumer websites rather than health care–specific websites. When comparing the ratings of the same group of dermatologists across different sites, ratings on health care–specific sites had a higher degree of correlation, with physician ratings more similar between 2 health care–specific sites and less similar between a health care–specific and a general consumer website. This pattern was consistent in both dermatologist-dense and dermatologist-poor areas, despite patients having varying levels of access to dermatologic care and medical resources and potentially different regional preferences of consumer websites. Taken together, these findings imply that health care–specific websites more consistently reflect overall patient sentiment.

Although one 2016 study comparing reviews of dermatology practices on Zocdoc and Yelp also demonstrated lower average ratings on Yelp,³ our study suggests that this trend is not isolated to these 2 sites but can be seen when comparing many health care–specific sites vs general consumer sites.

Our study compared ratings of dermatologists among popular websites to understand those that are most representative of patient attitudes toward physicians. These findings are important because online reviews reflect the entire patient experience, not just the patient-physician interaction, which may explain why physician scores on standardized questionnaires, such as Press Ganey surveys, do not correlate well with their online reviews.⁴ In a study comparing 98 physicians with negative online ratings to 82 physicians in similar departments with positive ratings, there was no significant difference in scores on patient-physician interaction questions on the Press Ganey survey.⁵ However, physicians who received negative online reviews scored lower on Press Ganey questions related to nonphysician interactions (eg, office cleanliness, interactions with staff).

The current study was subject to several limitations. Our analysis included all physicians in our random selection without accounting for those physicians with a greater online presence who might be more cognizant of these ratings and try to manipulate them through a reputation-management company or public relations consultant.

Conclusion

Our study suggests that consumer websites are not primarily used by disgruntled patients wishing to express grievances; instead, on average, most physicians received positive reviews. Furthermore, health care–specific websites show a higher degree of concordance than and may more accurately reflect overall patient attitudes toward their physicians than general consumer sites. Reviews from these health care–specific sites may be more helpful than general consumer websites in allowing physicians to understand patient sentiment and improve patient experiences.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

To the Editor:

Onychomycosis is the most common nail disorder, affecting approximately 5.5% of the world’s population.¹ There are a limited number of topical and systemic therapies approved by the US Food and Drug Administration (FDA), but no consensus guidelines exist for the management of onychomycosis. Therefore, we hypothesized that prescribing patterns would vary among different groups.

We examined data from the Centers for Medicare & Medicaid Services’ Part D Prescriber Public Use Files for 2013 to 2016.² Prescribing patterns were assessed for dermatologists, nurse practitioners, physician assistants, and podiatrists prescribing systemic (ie, terbinafine, itraconazole) or topical (ie, efinaconazole, tavaborole, ciclopirox) therapies. A cut-off of systemic therapy lasting 84 days or more (reflecting FDA-approved treatment regimens for toenail onychomycosis) was used to exclude prescriptions for other fungal conditions that require shorter treatment courses. Statistical analysis with χ² tests identified differences among specialties’ prescribing patterns.

Overall, onychomycosis medications accounted for $85.4 million in expenditures from 2013 to 2016, with spending increasing at a rate of 21.2% annually (Table 1). The greatest single-year increase was observed from 2014 to 2015, with a 40.6% surge in overall expenditures for onychomycosis medications—increasing from $17.8 million to $25.0 million in spending. Dermatologists’ prescriptions accounted for 14.8% of all claims for onychomycosis medications and 18.3% of total expenditures during the study period, totaling $15.7 million in costs. Dermatologists’ claims increased at a rate of 7.4% annually, while expenditures increased at 15.4% annually. A greater proportion of dermatologists (96.4%) prescribed topicals for onychomycosis relative to nurse practitioners (90.2%) and podiatrists (91.3%)(P<.01)(Table 2). No significant difference was observed in the prescribing patterns of dermatologists and physician assistants (P=.99).

Ciclopirox is the most commonly prescribed therapy for onychomycosis across all groups, prescribed by more than 88% of prescribers in all studied specialties. Although ciclopirox is one of the least expensive treatment options available for onychomycosis, it has the lowest relative cure rate.⁵ Onychomycosis management requires understanding of drug efficacy and disease severity.⁶ Inappropriate treatment selection may result in prolonged treatment courses and increased costs. Consensus guidelines for onychomycosis therapies across specialties may yield more cost-effective treatment for this common nail condition.

Acknowledgment
The authors thank Paul J. Christos, DrPH, MS (New York, New York), for his advisement regarding statistical analysis for this manuscript.

To the Editor:

Onychomycosis is the most common nail disorder, affecting approximately 5.5% of the world’s population.¹ There are a limited number of topical and systemic therapies approved by the US Food and Drug Administration (FDA), but no consensus guidelines exist for the management of onychomycosis. Therefore, we hypothesized that prescribing patterns would vary among different groups.

We examined data from the Centers for Medicare & Medicaid Services’ Part D Prescriber Public Use Files for 2013 to 2016.² Prescribing patterns were assessed for dermatologists, nurse practitioners, physician assistants, and podiatrists prescribing systemic (ie, terbinafine, itraconazole) or topical (ie, efinaconazole, tavaborole, ciclopirox) therapies. A cut-off of systemic therapy lasting 84 days or more (reflecting FDA-approved treatment regimens for toenail onychomycosis) was used to exclude prescriptions for other fungal conditions that require shorter treatment courses. Statistical analysis with χ² tests identified differences among specialties’ prescribing patterns.

Overall, onychomycosis medications accounted for $85.4 million in expenditures from 2013 to 2016, with spending increasing at a rate of 21.2% annually (Table 1). The greatest single-year increase was observed from 2014 to 2015, with a 40.6% surge in overall expenditures for onychomycosis medications—increasing from $17.8 million to $25.0 million in spending. Dermatologists’ prescriptions accounted for 14.8% of all claims for onychomycosis medications and 18.3% of total expenditures during the study period, totaling $15.7 million in costs. Dermatologists’ claims increased at a rate of 7.4% annually, while expenditures increased at 15.4% annually. A greater proportion of dermatologists (96.4%) prescribed topicals for onychomycosis relative to nurse practitioners (90.2%) and podiatrists (91.3%)(P<.01)(Table 2). No significant difference was observed in the prescribing patterns of dermatologists and physician assistants (P=.99).

Ciclopirox is the most commonly prescribed therapy for onychomycosis across all groups, prescribed by more than 88% of prescribers in all studied specialties. Although ciclopirox is one of the least expensive treatment options available for onychomycosis, it has the lowest relative cure rate.⁵ Onychomycosis management requires understanding of drug efficacy and disease severity.⁶ Inappropriate treatment selection may result in prolonged treatment courses and increased costs. Consensus guidelines for onychomycosis therapies across specialties may yield more cost-effective treatment for this common nail condition.

Acknowledgment
The authors thank Paul J. Christos, DrPH, MS (New York, New York), for his advisement regarding statistical analysis for this manuscript.

To the Editor:

Onychomycosis is the most common nail disorder, affecting approximately 5.5% of the world’s population.¹ There are a limited number of topical and systemic therapies approved by the US Food and Drug Administration (FDA), but no consensus guidelines exist for the management of onychomycosis. Therefore, we hypothesized that prescribing patterns would vary among different groups.

We examined data from the Centers for Medicare & Medicaid Services’ Part D Prescriber Public Use Files for 2013 to 2016.² Prescribing patterns were assessed for dermatologists, nurse practitioners, physician assistants, and podiatrists prescribing systemic (ie, terbinafine, itraconazole) or topical (ie, efinaconazole, tavaborole, ciclopirox) therapies. A cut-off of systemic therapy lasting 84 days or more (reflecting FDA-approved treatment regimens for toenail onychomycosis) was used to exclude prescriptions for other fungal conditions that require shorter treatment courses. Statistical analysis with χ² tests identified differences among specialties’ prescribing patterns.

Overall, onychomycosis medications accounted for $85.4 million in expenditures from 2013 to 2016, with spending increasing at a rate of 21.2% annually (Table 1). The greatest single-year increase was observed from 2014 to 2015, with a 40.6% surge in overall expenditures for onychomycosis medications—increasing from $17.8 million to $25.0 million in spending. Dermatologists’ prescriptions accounted for 14.8% of all claims for onychomycosis medications and 18.3% of total expenditures during the study period, totaling $15.7 million in costs. Dermatologists’ claims increased at a rate of 7.4% annually, while expenditures increased at 15.4% annually. A greater proportion of dermatologists (96.4%) prescribed topicals for onychomycosis relative to nurse practitioners (90.2%) and podiatrists (91.3%)(P<.01)(Table 2). No significant difference was observed in the prescribing patterns of dermatologists and physician assistants (P=.99).

Ciclopirox is the most commonly prescribed therapy for onychomycosis across all groups, prescribed by more than 88% of prescribers in all studied specialties. Although ciclopirox is one of the least expensive treatment options available for onychomycosis, it has the lowest relative cure rate.⁵ Onychomycosis management requires understanding of drug efficacy and disease severity.⁶ Inappropriate treatment selection may result in prolonged treatment courses and increased costs. Consensus guidelines for onychomycosis therapies across specialties may yield more cost-effective treatment for this common nail condition.

Acknowledgment
The authors thank Paul J. Christos, DrPH, MS (New York, New York), for his advisement regarding statistical analysis for this manuscript.

Coronavirus disease 2019 (COVID-19) has spread across all 7 continents, including 185 countries, and infected more than 21.9 million individuals worldwide as of August 18, 2020, according to the Johns Hopkins Coronavirus Resource Center. It has strained our health care system and affected all specialties, including dermatology. Dermatologists have taken important safety measures by canceling/deferring elective and nonemergency procedures and diagnosing/treating patients via telemedicine. Many residents and attending dermatologists have volunteered to care for COVID-19 inpatients and donated personal protective equipment (PPE) to hospitals reporting shortages.¹ As we prepare to treat increasing numbers of in-office patients, there will be a critical need for PPE. We highlight the use of 3-dimensional (3D) imaging and printing technologies as it applies to the dermatology outpatient setting.

N95 masks are necessary during the COVID-19 pandemic because they effectively filter at least 95% of 0.3-μm airborne particles and provide adequate face seals.¹ 3-Dimensional imaging integrated with 3D printers can be used to scan precise facial parameters (eg, jawline, nose) and account for facial hair density and length to produce comfortable tailored N95 masks and face seals.^1,2 3-Dimensional printing utilizes robotics and computer-aided design systems to layer and deposit biomaterials, thereby creating cost-effective, customizable, mechanically stable, and biocompatible constructs.^1,3 An ideal 3D-printed N95 mask would be printed via fused deposition modeling, consisting of a combination of lightweight and fatigue-resistant biomaterials, including electrostatic nonwoven polypropylene and styrene-(ethylene-butylene)-styrene.^1,4 The resulting masks, made from industrial-grade raw materials, are practical alternatives for dermatology practices with insufficient supplies.

Face shields offer an additional layer of safety for the face and mucosae and also may provide longevity for N95 masks. Using synthetic polymers such as polycarbonate and polyethylene, 3D printers can be used to construct face shields via fused deposition modeling.¹ These face shields may be worn over N95 masks and then can be sanitized and reused.

Mohs surgeons and staff may be at particularly high risk for COVID-19 infection due to their close proximity to the face during surgery, use of cautery, and prolonged time spent with patients while taking layers and suturing. Multispectral optoacoustic tomography is a noninvasive imaging tool that can map skin tumors via optical contrast with accuracy comparable to histologic measurements.⁵ 3-Dimensional facial imaging and printing can be used to calculate tumor surface area for customized masks, leaving sufficient skin for excision and reconstruction. Patient face coverings would cover the nose and mouth, only expose relevant areas near the excision site, and include adjustable/removable ear loops for tumors localized to the ears. A schematic of how 3D technologies can be applied for Mohs micrographic surgery is provided in the Figure.

Coronavirus disease 2019 (COVID-19) has spread across all 7 continents, including 185 countries, and infected more than 21.9 million individuals worldwide as of August 18, 2020, according to the Johns Hopkins Coronavirus Resource Center. It has strained our health care system and affected all specialties, including dermatology. Dermatologists have taken important safety measures by canceling/deferring elective and nonemergency procedures and diagnosing/treating patients via telemedicine. Many residents and attending dermatologists have volunteered to care for COVID-19 inpatients and donated personal protective equipment (PPE) to hospitals reporting shortages.¹ As we prepare to treat increasing numbers of in-office patients, there will be a critical need for PPE. We highlight the use of 3-dimensional (3D) imaging and printing technologies as it applies to the dermatology outpatient setting.

N95 masks are necessary during the COVID-19 pandemic because they effectively filter at least 95% of 0.3-μm airborne particles and provide adequate face seals.¹ 3-Dimensional imaging integrated with 3D printers can be used to scan precise facial parameters (eg, jawline, nose) and account for facial hair density and length to produce comfortable tailored N95 masks and face seals.^1,2 3-Dimensional printing utilizes robotics and computer-aided design systems to layer and deposit biomaterials, thereby creating cost-effective, customizable, mechanically stable, and biocompatible constructs.^1,3 An ideal 3D-printed N95 mask would be printed via fused deposition modeling, consisting of a combination of lightweight and fatigue-resistant biomaterials, including electrostatic nonwoven polypropylene and styrene-(ethylene-butylene)-styrene.^1,4 The resulting masks, made from industrial-grade raw materials, are practical alternatives for dermatology practices with insufficient supplies.

Face shields offer an additional layer of safety for the face and mucosae and also may provide longevity for N95 masks. Using synthetic polymers such as polycarbonate and polyethylene, 3D printers can be used to construct face shields via fused deposition modeling.¹ These face shields may be worn over N95 masks and then can be sanitized and reused.

Mohs surgeons and staff may be at particularly high risk for COVID-19 infection due to their close proximity to the face during surgery, use of cautery, and prolonged time spent with patients while taking layers and suturing. Multispectral optoacoustic tomography is a noninvasive imaging tool that can map skin tumors via optical contrast with accuracy comparable to histologic measurements.⁵ 3-Dimensional facial imaging and printing can be used to calculate tumor surface area for customized masks, leaving sufficient skin for excision and reconstruction. Patient face coverings would cover the nose and mouth, only expose relevant areas near the excision site, and include adjustable/removable ear loops for tumors localized to the ears. A schematic of how 3D technologies can be applied for Mohs micrographic surgery is provided in the Figure.

Coronavirus disease 2019 (COVID-19) has spread across all 7 continents, including 185 countries, and infected more than 21.9 million individuals worldwide as of August 18, 2020, according to the Johns Hopkins Coronavirus Resource Center. It has strained our health care system and affected all specialties, including dermatology. Dermatologists have taken important safety measures by canceling/deferring elective and nonemergency procedures and diagnosing/treating patients via telemedicine. Many residents and attending dermatologists have volunteered to care for COVID-19 inpatients and donated personal protective equipment (PPE) to hospitals reporting shortages.¹ As we prepare to treat increasing numbers of in-office patients, there will be a critical need for PPE. We highlight the use of 3-dimensional (3D) imaging and printing technologies as it applies to the dermatology outpatient setting.

N95 masks are necessary during the COVID-19 pandemic because they effectively filter at least 95% of 0.3-μm airborne particles and provide adequate face seals.¹ 3-Dimensional imaging integrated with 3D printers can be used to scan precise facial parameters (eg, jawline, nose) and account for facial hair density and length to produce comfortable tailored N95 masks and face seals.^1,2 3-Dimensional printing utilizes robotics and computer-aided design systems to layer and deposit biomaterials, thereby creating cost-effective, customizable, mechanically stable, and biocompatible constructs.^1,3 An ideal 3D-printed N95 mask would be printed via fused deposition modeling, consisting of a combination of lightweight and fatigue-resistant biomaterials, including electrostatic nonwoven polypropylene and styrene-(ethylene-butylene)-styrene.^1,4 The resulting masks, made from industrial-grade raw materials, are practical alternatives for dermatology practices with insufficient supplies.

Face shields offer an additional layer of safety for the face and mucosae and also may provide longevity for N95 masks. Using synthetic polymers such as polycarbonate and polyethylene, 3D printers can be used to construct face shields via fused deposition modeling.¹ These face shields may be worn over N95 masks and then can be sanitized and reused.

Mohs surgeons and staff may be at particularly high risk for COVID-19 infection due to their close proximity to the face during surgery, use of cautery, and prolonged time spent with patients while taking layers and suturing. Multispectral optoacoustic tomography is a noninvasive imaging tool that can map skin tumors via optical contrast with accuracy comparable to histologic measurements.⁵ 3-Dimensional facial imaging and printing can be used to calculate tumor surface area for customized masks, leaving sufficient skin for excision and reconstruction. Patient face coverings would cover the nose and mouth, only expose relevant areas near the excision site, and include adjustable/removable ear loops for tumors localized to the ears. A schematic of how 3D technologies can be applied for Mohs micrographic surgery is provided in the Figure.

Practice Gap

The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.¹ Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.

The Technique

Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.² The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.

Practice Implications

The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.

Practice Gap

The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.¹ Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.

The Technique

Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.² The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.

Practice Implications

The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.

Practice Gap

The Centers for Disease Control and Prevention recommends handwashing with soap and water or using alcohol-based hand sanitizers to prevent transmission of coronavirus disease 2019. Five steps are delineated for effective handwashing: wetting, lathering, scrubbing, rinsing, and drying. Although alcohol-based sanitizers may be perceived as more damaging to the skin, they are less likely to cause dermatitis than handwashing with soap and water.¹ Instructions are precise for handwashing, while there are no recommendations for effective use of alcohol-based hand sanitizers. A common inquiry regarding alcohol-based hand sanitizers is the volume needed for efficacy without causing skin irritation.

The Technique

Approximately 1 mL of alcohol-based hand sanitizer is recommended by some manufacturers. However, abundant evidence refutes this recommendation, including a study that tested the microbial efficacy of alcohol-based sanitizers by volume. A volume of 2 mL was necessary to achieve the 2.0 log reduction of contaminants as required by the US Food and Drug Administration for antimicrobial efficacy.² The precise measurement of hand sanitizer using a calibrated syringe before each use is impractical. Thus, we recommend using a screw-top toothpaste cap to assist in approximating the necessary volume (Figure). The cap holds approximately 1 mL of liquid as measured using a syringe; therefore, 2 caps filled with sanitizer should be used.

Practice Implications

The general public may be underutilizing hand sanitizer due to fear of excessive skin irritation or supply shortages, which will reduce efficacy. Patients and physicians can use this simple visual approximation to ensure adequate use of hand sanitizer volume.

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

To the Editor:

Patients with skin, hair, or nail concerns often utilize online resources to self-diagnose or learn more about physician-diagnosed conditions. The American Academy of Dermatology (AAD) website offers the public access to informational pages categorized by disease or treatment (https://www.aad.org/public). We sought to evaluate the nail content by searching the Patients and Public section of the AAD website to qualitatively and quantitatively describe mentions of nail conditions. Psoriasis, psoriatic arthritis, atopic dermatitis, and ringworm content also were analyzed and compared to nail content. The analysis was performed on September 7, 2019.

Of the 73 topics listed in the Diseases and Treatments section of the site, 17 (23%) specifically mentioned nail symptoms or pathology (Table). Three additional topics—atopic dermatitis, cellulitis, and neurodermatitis—recommended keeping nails short to prevent injury from scratching. There was 1 mention of obtaining fungal cultures, 2 of nail scraping microscopy, 2 of nail clippings, and 2 of nail-related cancers. There were no mentions of nail biopsies. The total number of unique clinical images across all sections was 300, with 12 of nails. The video library contained 84 videos, of which 6 focused on nail health.

Many of the included images were not representative of common clinical findings. The nail lichen planus image showed pitting instead of more typical findings of nail plate atrophy and pterygium. The nail melanoma image showed thickened yellow toenails and the fifth toenail with a thin gray-brown band instead of an isolated wide black band. The nail fungus section included images of superficial onychomycosis and severe onychodystrophy instead of showing more common changes such as distal onycholysis with subungual hyperkeratosis, which is typical of the most common subtype, distal lateral subungual onychomycosis.⁵ Onychomycosis was referenced again in the ringworm section with 1 image repeated from the nail fungus section and another image that appeared to be a subungual hematoma.

The AAD website offers important patient education resources; however, nail content is underrepresented on this platform. Dermatologists are experts on nail disease, and increased efforts are needed to educate the public about frequently encountered nail signs and symptoms that could signify a serious underlying condition.

After our original search and analysis, new nail topics, images, and videos have been added; therefore, there has been a positive trend toward new nail content being added to site, which will greatly benefit patients.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Residency application is an arduous experience for many medical students. The National Resident Matching Program reported that US medical school seniors who matched into dermatology applied to a median of 90 programs and attended 9 interviews in 2019.¹ High application and interview travel costs are a disadvantage for applicants from lower socioeconomic backgrounds. We propose that the coronavirus disease 2019 (COVID-19) pandemic should serve as a call to action for dermatology to update and promote a more equitable, time-effective, and cost-efficient residency interview process.

In light of COVID-19, dermatology residency program directors have recommended a holistic application review process, taking into consideration “disparities in strength of applications due to lack of opportunity for students with smaller home programs or in areas more affected by this crisis.”² However, in a 2018 survey of 180 dermatology faculty members, 80% stated that time spent reviewing residency applications was already excessive.³ The Association of American Medical Colleges reported that for medical student applicants with US Medical Licensing Examination Step 1 scores lower than 237 or higher than 251, the value added by submitting one additional application beyond means of 43 (95% confidence interval [CI], 34-53) and 34 (95% CI, 28-41), respectively, is reduced relative to the value added by each application before reaching the point of diminishing returns.⁴ Therefore, we suggest limiting the number of applications per applicant to the upper bounds of the CI for the lower US Medical Licensing Examination Step 1 score (53), facilitating a more detailed review of fewer applications by each program and limiting student expenses.

On May 7, 2020, the Association of American Medical Colleges made a statement strongly encouraging medical school and teaching hospital faculty to conduct interviews through videoconferencing.⁵ Videoconferencing interviews (VCIs) minimize travel-associated health risks, providing a more equitable structure for applicants and programs in areas disproportionately impacted by the pandemic. In the 2018 survey of dermatology faculty members, only 11% believed that applicants interviewing virtually received equal consideration to those interviewing in person; a solution to this problem would be to mandate that all applicants use VCIs during the COVID-19 pandemic.³ This coming year, residency programs may elect to replace in-person interviews with VCIs, or they may utilize VCIs as screening tools to narrow down the applicant pool and for students to rank their preferred programs prior to an in-person interview. By inviting fewer applicants for in-person interviews, travel-associated health risks, financial costs, and missed educational activities would be minimized. Given that many medical students have had academic activities cancelled or postponed due to COVID-19, student opportunities for live clinical experiences should be maximized.

As programs plan for future application cycles beyond COVID-19, they must work to balance competing interests. Videoconferencing interviews allow for improved access to interviewing for applicants of lower socioeconomic classes, improved geographic mobility of applicants, and increased flexibility in accommodating faculty schedules with reduced time away from patient care and research; however, with VCIs one may lose the personal element that comes from the in-person interview, including interactions among applicants, faculty, current residents, and staff on the day of interview, as well as the departmental tour. Additionally, the quality of VCIs may be diminished by technical difficulties and the possibility of distractions, making standardization of the interview experience for applicants challenging.

The COVID-19 pandemic will surely leave its mark on the residency application cycle. We must take time now to collaborate and brainstorm creative solutions to maximize the equity and efficiency of the application process for both residency programs and students. We welcome reader feedback on these ideas and other possible solutions in the form of Letters to the Editor.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.

Case Report

A 92-year-old Eastern European woman presented to our nail clinic with a history of onychodystrophy and arthralgia of the digits of several months’ duration. Her dermatologic history was notable for irritant hand dermatitis. A prior nail plate clipping with histopathologic examination was negative for fungal elements. Physical examination revealed onychorrhexis of all fingernails as well as onycholysis and subungual hyperkeratosis of the right fourth fingernail. Blue-green staining was incidentally noted on the right second and third fingernails and nail folds (Figure 1). Contact dermoscopy using ultrasound gel revealed translucent areas with sparse pigment, though denser areas had a fine branching pattern (Figure 2). When questioned, the patient reported use of “zelyonka,” a brilliant green solution, to self-treat the nails. Histopathology on repeat nail clippings showed parakeratosis and serum, which was most consistent with her known history of irritant hand dermatitis. Radiographs of the hands revealed osteoarthritis that was most prominent at the distal interphalangeal joints.

Comment

Brilliant green is a triphenylmethane dye commonly used in Eastern Europe and other regions for the treatment of superficial skin infections and onychomycosis.¹ Its use as an antiseptic and wound healing agent has been investigated in the scientific literature since at least the early 20th century.² Brilliant green typically is applied in a 0.1% to 2% ethanol solution.¹ The dye has bactericidal activity against gram-positive organisms, particularly staphylococci and streptococci.^2,3 It has been used for the treatment of fungal skin and nail infections since at least the early 20th century, with anecdotal success.⁴ Although there have been no studies investigating use of brilliant green alone for the treatment of onychomycosis, it is sometimes used in combination with conventional oral agents for this purpose.⁵ Because of its availability, safety, ease of use, and low cost, brilliant green has been promoted as an antiseptic in resource-poor settings.³ The revival of brilliant green and other antiseptic dyes in these settings has been suggested as an alternative to oral antibiotic agents, to which resistance is rising, and as a potential cancer therapy.^6,7 Although brilliant green’s mechanism of action in treating skin infections is unclear, it has been shown to form covalent adducts with thioredoxin reductase 2, a protein conserved from bacteria to humans with an essential function for cellular activity.⁷

Early case studies suggested that brilliant green was beneficial in treating wounds²; however, this indication is controversial. In a guinea pig study, brilliant green was shown to inhibit wound healing and the formation of granulation tissue.⁸ It also should be noted that when used topically, brilliant green may cause skin sensitization, necrotic skin reactions, and permanent staining of clothing. It has no known anti-inflammatory properties and also may cause skin irritation.⁸ Brilliant green may cause blindness if it comes in contact with the eyes.¹

Brilliant green has other potential dermatologic indications. For example, a combination of brilliant green and gentian violet, a related dye, has demonstrated efficacy in the treatment of cutaneous hemangiomas in mouse models by blocking expression of angiopoietin-2.⁷

Dermatologists should be familiar with brilliant green and its common uses as well as adverse effects. Brilliant green is commercially available for a low cost ($5 to $20) in specialty pharmacies or online (eg, Amazon). It is sold alone or in combination with gentian violet and proflavine hemisulfate, and a prescription is not required. Due to its low cost and accessibility, patients may use brilliant green to self-treat dermatologic conditions. Green nails due to staining with brilliant green dye must be distinguished from other etiologies causing green nail discoloration, such as infection with Pseudomonas aeruginosa or Aspergillus, bullous disorders, jaundice, “old” hematomas, nail polish, and other exogenous pigments.