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Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12


Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18

Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24

Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32

Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12


Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18

Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24

Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32

Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
Mohs micrographic surgery (MMS)—developed by Dr. Frederic Mohs in the 1930s—is the gold standard for treating various cutaneous malignancies. It provides maximal conservation of uninvolved tissues while producing higher cure rates compared to wide local excision.1,2
We sought to assess the various characteristics that impact patient satisfaction to help Mohs surgeons incorporate relatively simple yet clinically significant practices into their patient encounters. We conducted a systematic literature search of peer-reviewed PubMed articles indexed for MEDLINE from database inception through November 2023 using the terms Mohs micrographic surgery and patient satisfaction. Among the inclusion criteria were studies involving participants having undergone MMS, with objective assessments on patient-reported satisfaction or preferences related to patient education, communication, anxiety-alleviating measures, or QOL in MMS. Studies were excluded if they failed to meet these criteria, were outdated and no longer clinically relevant, or measured unalterable factors with no significant impact on how Mohs surgeons could change clinical practice. Of the 157 nonreplicated studies identified, 34 met inclusion criteria.
Perioperative Patient Communication and Education Techniques
Perioperative Patient Communication—Many studies have evaluated the impact of perioperative patient-provider communication and education on patient satisfaction in those undergoing MMS. Studies focusing on preoperative and postoperative telephone calls, patient consultation formats, and patient-perceived impact of such communication modalities have been well documented (Table 1).3-8 The importance of the patient follow-up after MMS was further supported by a retrospective study concluding that 88.7% (86/97) of patients regarded follow-up visits as important, and 80% (77/97) desired additional follow-up 3 months after MMS.9 Additional studies have highlighted the importance of thorough and open perioperative patient-provider communication during MMS (Table 2).10-12


Patient-Education Techniques—Many studies have assessed the use of visual models to aid in patient education on MMS, specifically the preprocedural consent process (Table 3).13-16 Additionally, 2 randomized controlled trials assessing the use of at-home and same-day in-office preoperative educational videos concluded that these interventions increased patient knowledge and confidence regarding procedural risks and benefits, with no statistically significant differences in patient anxiety or satisfaction.17,18

Despite the availability of these educational videos, many patients often turn to online resources for self-education, which is problematic if reader literacy is incongruent with online readability. One study assessing readability of online MMS resources concluded that the most accessed articles exceeded the recommended reading level for adequate patient comprehension.19 A survey studying a wide range of variables related to patient satisfaction (eg, demographics, socioeconomics, health status) in 339 MMS patients found that those who considered themselves more involved in the decision-making process were more satisfied in the short-term, and married patients had even higher long-term satisfaction. Interestingly, this study also concluded that undergoing 3 or more MMS stages was associated with higher short- and long-term satisfaction, likely secondary to perceived effects of increased overall care, medical attention, and time spent with the provider.20
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding patient education and communication13-20:
- Preoperative and same-day postoperative telephone follow-up (TFU) do not show statistically significant impacts on patient satisfaction; however, TFU allows for identification of postoperative concerns and inadequate pain management, which may have downstream effects on long-term perception of the overall patient experience.
- The use of video-assisted consent yields improved patient satisfaction and knowledge, while video content—traditional or didactic—has no impact on satisfaction in new MMS patients.
- The use of at-home or same-day in-office preoperative educational videos can improve procedural knowledge and risk-benefit understanding of MMS while having no impact on satisfaction.
- Bedside manner and effective in-person communication by the provider often takes precedence in the patient experience; however, implementation of additional educational modalities should be considered.
Patient Anxiety and QOL
Reducing Patient Anxiety—The use of perioperative distractors to reduce patient anxiety may play an integral role when patients undergo MMS, as there often are prolonged waiting periods between stages when patients may feel increasingly vulnerable or anxious. Table 4 reviews studies on perioperative distractors that showed a statistically significant reduction in MMS patient anxiety.21-24

Although not statistically significant, additional studies evaluating the use of intraoperative anxiety-reduction methods in MMS have demonstrated a downtrend in patient anxiety with the following interventions: engaging in small talk with clinic staff, bringing a guest, eating, watching television, communicating surgical expectations with the provider, handholding, use of a stress ball, and use of 3-dimensional educational MMS models.25-27 Similarly, a survey of 73 patients undergoing MMS found that patients tended to enjoy complimentary beverages preprocedurally in the waiting room, reading, speaking with their guest, watching television, or using their telephone during wait times.28 Table 5 lists additional perioperative factors encompassing specific patient and surgical characteristics that help reduce patient anxiety.29-32

Patient QOL—Many methods aimed at decreasing MMS-related patient anxiety often show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience. A prospective observational study of MMS patients noted a statistically significant improvement in patient QOL scores 3 months postsurgery (P=.0007), demonstrating that MMS generally results in positive patient outcomes despite preprocedural anxiety.33 An additional prospective study in MMS patients with nonmelanoma skin cancer concluded that sex, age, and closure type—factors often shown to affect anxiety levels—did not significantly impact patient satisfaction.34 Similarly, high satisfaction levels can be expected among MMS patients undergoing treatment of melanoma in situ, with more than 90% of patients rating their treatment experience a 4 (agree) or 5 (strongly agree) out of 5 in short- and long-term satisfaction assessments (38/41 and 40/42, respectively).35 This assessment, conducted 3 months postoperatively, asked patients to score the statement, “I am completely satisfied with the treatment of my skin problem,” on a scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Lastly, patient perception of their surgeon’s skill may contribute to levels of patient satisfaction. Although suture spacing has not been shown to affect surgical outcomes, it has been demonstrated to impact the patient’s perception of surgical skill and is further supported by a study concluding that closures with 2-mm spacing were ranked significantly lower by patients compared with closures with either 4- or 6-mm spacing (P=.005 and P=.012, respectively).36
Synthesis of this information with emphasis on the higher evidence-based studies—including systematic reviews, meta-analyses, and randomized controlled trials—yields the following beneficial interventions regarding anxiety-reducing measures and patient-perceived QOL21-36:
- Factors shown to decrease patient anxiety include patient personalized music, virtual-reality experience, perioperative informational videos, and 3-dimensional–printed MMS models.
- Many methods aimed at decreasing MMS-related patient anxiety show no direct impact on patient satisfaction, likely due to the multifactorial nature of the patient-perceived experience.
- Higher anxiety can be associated with worse QOL scores in MMS patients, and additional factors that may have a negative impact on anxiety include female sex, younger age, and tumor location on the face.
Conclusion
Many factors affect patient satisfaction in MMS. Increased awareness and acknowledgement of these factors can foster improved clinical practice and patient experience, which can have downstream effects on patient compliance and overall psychosocial and medical well-being. With the movement toward value-based health care, patient satisfaction ratings are likely to play an increasingly important role in physician reimbursement. Adapting one’s practice to include high-quality, time-efficient, patient-centered care goes hand in hand with increasing MMS patient satisfaction. Careful evaluation and scrutiny of one’s current practices while remaining cognizant of patient population, resource availability, and clinical limitations often reveal opportunities for small adjustments that can have a great impact on patient satisfaction. This thorough assessment and review of the published literature aims to assist MMS surgeons in understanding the role that certain factors—(1) perioperative patient communication and education techniques and (2) patient anxiety, QOL, and additional considerations—have on overall satisfaction with MMS. Specific consideration should be placed on the fact that patient satisfaction is multifactorial, and many different interventions can have a positive impact on the overall patient experience.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
- Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011; 29:135-139, vii. doi:10.1016/j.det.2011.01.010
- Leslie DF, Greenway HT. Mohs micrographic surgery for skin cancer. Australas J Dermatol. 1991;32:159-164. doi:10.1111/j.1440 -0960.1991.tb01783.x
- Sobanko JF, Da Silva D, Chiesa Fuxench ZC, et al. Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery. J Am Acad Dermatol. 2017;76:519-526. doi:10.1016/j.jaad.2016.09.027
- Sharon VR, Armstrong AW, Jim On SC, et al. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. doi:10.1111/dsu.12083
- Knackstedt TJ, Samie FH. Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery. J Am Acad Dermatol. 2015;72:340-344. doi:10.1016/j.jaad.2014.10.022
- Vance S, Fontecilla N, Samie FH, et al. Effect of postoperative telephone calls on patient satisfaction and scar satisfaction after Mohs micrographic surgery. Dermatol Surg. 2019;45:1459-1464. doi:10.1097/DSS.0000000000001913
- Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167:570-574. doi:10.1111 /j.1365-2133.2012.11011.x
- Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2021;85:220-221. doi:10.1016 /j.jaad.2020.07.106
- Sharon VR, Armstrong AW, Jim-On S, et al. Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice. Dermatol Surg. 2013;39:773-778. doi:10.1111/dsu.12136
- Xu S, Atanelov Z, Bhatia AC. Online patient-reported reviews of Mohs micrographic surgery: qualitative analysis of positive and negative experiences. Cutis. 2017;99:E25-E29.
- Golda N, Beeson S, Kohli N, et al. Recommendations for improving the patient experience in specialty encounters. J Am Acad Dermatol. 2018;78:653-659. doi:10.1016/j.jaad.2017.05.040
- Patel P, Malik K, Khachemoune A. Patient education in Mohs surgery: a review and critical evaluation of techniques. Arch Dermatol Res. 2021;313:217-224. doi:10.1007/s00403-020-02119-5
- Migden M, Chavez-Frazier A, Nguyen T. The use of high definition video modules for delivery of informed consent and wound care education in the Mohs surgery unit. Semin Cutan Med Surg. 2008;27:89-93. doi:10.1016/j.sder.2008.02.001
- Newsom E, Lee E, Rossi A, et al. Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018;44:778-784. doi:10.1097/DSS.0000000000001473
- West L, Srivastava D, Goldberg LH, et al. Multimedia technology used to supplement patient consent for Mohs micrographic surgery. Dermatol Surg. 2020;46:586-590. doi:10.1097/DSS.0000000000002134
- Miao Y, Venning VL, Mallitt KA, et al. A randomized controlled trial comparing video-assisted informed consent with standard consent for Mohs micrographic surgery. JAAD Int. 2020;1:13-20. doi:10.1016 /j.jdin.2020.03.005
- Mann J, Li L, Kulakov E, et al. Home viewing of educational video improves patient understanding of Mohs micrographic surgery. Clin Exp Dermatol. 2022;47:93-97. doi:10.1111/ced.14845
- Delcambre M, Haynes D, Hajar T, et al. Using a multimedia tool for informed consent in Mohs surgery: a randomized trial measuring effects on patient anxiety, knowledge, and satisfaction. Dermatol Surg. 2020;46:591-598. doi:10.1097/DSS.0000000000002213
- Vargas CR, DePry J, Lee BT, et al. The readability of online patient information about Mohs micrographic surgery. Dermatol Surg. 2016;42:1135-1141. doi:10.1097/DSS.0000000000000866
- Asgari MM, Warton EM, Neugebauer R, et al. Predictors of patient satisfaction with Mohs surgery: analysis of preoperative, intraoperative, and postoperative factors in a prospective cohort. Arch Dermatol. 2011;147:1387-1394.
- Vachiramon V, Sobanko JF, Rattanaumpawan P, et al. Music reduces patient anxiety during Mohs surgery: an open-label randomized controlled trial. Dermatol Surg. 2013;39:298-305. doi:10.1111/dsu.12047
- Hawkins SD, Koch SB, Williford PM, et al. Web app- and text message-based patient education in Mohs micrographic surgery-a randomized controlled trial. Dermatol Surg. 2018;44:924-932. doi:10.1097/DSS.0000000000001489
- Higgins S, Feinstein S, Hawkins M, et al. Virtual reality to improve the experience of the Mohs patient-a prospective interventional study. Dermatol Surg. 2019;45:1009-1018. doi:10.1097 /DSS.0000000000001854
- Guo D, Zloty DM, Kossintseva I. Efficacy and safety of anxiolytics in Mohs micrographic surgery: a randomized, double-blinded, placebo-controlled trial. Dermatol Surg. 2023;49:989-994. doi:10.1097 /DSS.0000000000003905
- Locke MC, Wilkerson EC, Mistur RL, et al. 2015 Arte Poster Competition first place winner: assessing the correlation between patient anxiety and satisfaction for Mohs surgery. J Drugs Dermatol. 2015;14:1070-1072.
- Yanes AF, Weil A, Furlan KC, et al. Effect of stress ball use or hand-holding on anxiety during skin cancer excision: a randomized clinical trial. JAMA Dermatol. 2018;154:1045-1049. doi:10.1001 /jamadermatol.2018.1783
- Biro M, Kim I, Huynh A, et al. The use of 3-dimensionally printed models to optimize patient education and alleviate perioperative anxiety in Mohs micrographic surgery: a randomized controlled trial. J Am Acad Dermatol. 2019;81:1339-1345. doi:10.1016/j.jaad.2019.05.085
- Ali FR, Al-Niaimi F, Craythorne EE, et al. Patient satisfaction and the waiting room in Mohs surgery: appropriate prewarning may abrogate boredom. J Eur Acad Dermatol Venereol. 2017;31:e337-e338.
- Kossintseva I, Zloty D. Determinants and timeline of perioperative anxiety in Mohs surgery. Dermatol Surg. 2017;43:1029-1035.
- Kruchevsky D, Hirth J, Capucha T, et al. Triggers of preoperative anxiety in patients undergoing Mohs micrographic surgery. Dermatol Surg. 2021;47:1110-1112.
- Kokoska RE, Szeto MD, Steadman L, et al. Analysis of factors contributing to perioperative Mohs micrographic surgery anxiety: patient survey study at an academic center. Dermatol Surg. 2022;48:1279-1282.
- Long J, Rajabi-Estarabadi A, Levin A, et al. Perioperative anxiety associated with Mohs micrographic surgery: a survey-based study. Dermatol Surg. 2022;48:711-715.
- Zhang J, Miller CJ, O’Malley V, et al. Patient quality of life fluctuates before and after Mohs micrographic surgery: a longitudinal assessment of the patient experience. J Am Acad Dermatol. 2018;78:1060-1067.
- Lee EB, Ford A, Clarey D, et al. Patient outcomes and satisfaction after Mohs micrographic surgery in patients with nonmelanoma skin cancer. Dermatol Sur. 2021;47:1190-1194.
- Condie D, West L, Hynan LS, et al. Patient satisfaction with Mohs surgery for melanoma in situ. Dermatol Surg. 2021;47:288-290.
- Arshanapalli A, Tra n JM, Aylward JL, et al. The effect of suture spacing on patient perception of surgical skill. J Am Acad Dermatol. 2021;84:735-736.
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
Enhancing Patient Satisfaction and Quality of Life With Mohs Micrographic Surgery: A Systematic Review of Patient Education, Communication, and Anxiety Management
PRACTICE POINTS
- When patients are treated with Mohs micrographic surgery (MMS), thorough in-person dialogue augmented by pre- and same-day telephone follow-ups can help them feel heard and better supported, even though follow-up calls alone may not drive satisfaction scores.
- Increased awareness and implementation of the various factors influencing patient satisfaction and quality of life in MMS can enhance clinical practice and improve patient experiences, with potential impacts on compliance, psychosocial well-being, medical outcomes, and physician reimbursement.
- Patient satisfaction and procedural understanding can be improved with video and visual-based education. Anxiety-reducing methods help lower perioperative stress.
How to Foster Camaraderie in Dermatology Residency
Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another.1 Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.
Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.2 The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.
Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?
Establish a Social Committee
As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.
Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.
Utilize Social Media
Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.
Encourage Local and National Conference Attendance
All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.
In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.
Repair Conflicts and Build a Climate of Collaboration
Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.
It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.
Final Thoughts
Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.
- Kouzes JM, Posner BZ. Foster collaboration. In: Kouzes JM, Posner BZ, eds. The Leadership Challenge. 6th ed. John Wiley & Sons, Inc; 2017:195-217.
- Cooper J, Shao K, Feng H. Racial/ethnic health disparities in dermatology in the United States, part 1: overview of contributing factors and management strategies [published online February 7, 2022]. J Am Acad Dermatol. 2022;87:723-730. doi:10.1016/j.jaad.2021.12.061
Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another.1 Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.
Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.2 The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.
Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?
Establish a Social Committee
As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.
Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.
Utilize Social Media
Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.
Encourage Local and National Conference Attendance
All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.
In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.
Repair Conflicts and Build a Climate of Collaboration
Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.
It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.
Final Thoughts
Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.
Change is inevitable in residency as well as in life. Every year on July 1, the atmosphere and social structure of residencies change with the new postgraduate year 2 class. Each class brings a unique perspective and energy. Residents come together from different backgrounds and life situations. Some residents are single, some are engaged or married, and some are starting or expanding their families. Some residents will have prior careers, others will have graduate degrees or expertise in various fields. They will have different ethnic backgrounds, religious and/or spiritual beliefs, familial upbringings, personalities, and methods of communicating. These differences all are important to consider when developing a mindset of inclusion and camaraderie. As residents start their journey together, it is important to remember that residency is a team endeavor. The principles of teamwork apply directly to residents and are founded on creating a climate of trust and building strong relationships with one another.1 Trust is the foundation of good relationships in the workplace; it allows people to communicate freely and foster the belief that everyone is working for each other’s best interests. Being open and sharing knowledge about networking opportunities, scholarships, and research projects is one way to foster collaboration and trust in residency.
Diversity, equity, and inclusion in dermatology is a work in progress. In the 2020-2021 dermatology application cycle, only 4.8% of applicants identified as Hispanic or Latino, and 7.8% identified as Black or African American.2 The American Academy of Dermatology took an active role in promoting diversity by creating a task force in 2018 to increase the exposure and recruitment into dermatology of medical students who are underrepresented in medicine.2 As standards for diversity are met in dermatology, we will have the wonderful opportunity to welcome even more diversity into our lives.
Listening, showing curiosity about your co-residents’ lives outside of work, and asking questions can help build respect, friendships, and camaraderie. Ask your co-residents what makes them happy and what their goals are in residency. Finding common goals and cultivating the mindset that you all work together to achieve your goals is key to the success of a residency class. Now that we discussed accepting and welcoming differences, how do you foster camaraderie in a social setting?
Establish a Social Committee
As a class, consider 1 or 2 residents who are always excited to try new activities such as attend restaurant openings, exercise classes, concerts, or movie nights. Consider nominating these co-residents along with one attending to be social chairs of your residency. The social chairs should meet and establish at least 1 social event per season, with 4 total for the academic year. There are only 2 rules with social events: (1) they must be held outside of clinic, and (2) everyone should try their best to attend.
Social chairs should try to prioritize a location-specific event that allows the residents who are not from the area to experience something local, which can be anything from apple picking at an orchard in the fall to beach volleyball in the summer. Planning these parties gives everyone an event to look forward to and a chance to spend time together and grow closer. The memories and inside jokes that arise from these outings are invaluable and increase joy inside and outside of clinic.
Utilize Social Media
Another project can be developing a social media account for your program with the approval of your faculty. @unmcdermatology, @uwderm, and @gwdermres can help foster social relationships by establishing a lighthearted space to celebrate the residency’s achievements, new publications, volunteer events, or social gatherings.
Encourage Local and National Conference Attendance
All residents should be encouraged to submit abstracts to local and national conferences and attend with their co-residents. Conferences are peak opportunities to foster camaraderie within residency classes, as they involve a sense of togetherness in the specialty along with the excitement of traveling to a new city and meeting other like-minded individuals. Conferences allow collaboration within the specialty on a national level and foster relationships between residency programs.
In addition, national groups such as the Women’s Dermatologic Society, the Skin of Color Society, and the American Academy of Dermatology Diversity, Equity, and Inclusion task force meet at the national conferences and discuss their next initiatives and projects. Joining a society of your interest can lead to many new networks and relationships you may not have had before. Even if you are not interested in specializing after general dermatology, consider attending a surgery, dermatopathology, or pediatric or cosmetic dermatology conference to learn more about the field from the experts.
Repair Conflicts and Build a Climate of Collaboration
Conflicts and disagreements unfortunately are inevitable during residency. Whether they involve planning vacation times or coordinating call schedules, everyone will not agree on every decision. Learning how to handle and approach conflict with co-residents is of utmost importance to maintaining the hard work you have put in to create trust, camaraderie, and a good social atmosphere. If you are having an issue with a circumstance involving a co-resident, holding a grudge will only sour your experience and the experience of others. Talking to your co-resident directly about your concerns before escalating the issue to a chief resident or faculty member is a great start. Consider asking them about their thought process and show concern for their point of view. Listen to them openly before going into your preferences. It is important to remember that working as a team requires sacrifices, and sometimes you will not be satisfied with the outcome of a conflict.
It also is important to remember that feelings change, and an issue you feel you must address immediately can wait to be addressed at a better time when you have calmed down. You may even find that you decide not to address it at all. At the end of the day, if a conflict cannot be worked out between those involved, consider confiding in a chief resident or a faculty mentor for advice on the next steps to take to resolve the problem. Ultimately, having a good foundation of respect and strong bonds with your residents will help tremendously when conflicts arise.
Final Thoughts
Fostering camaraderie in residency will improve the overall experience and lives of the residents, as well as the experience of the faculty, staff, and patients by the trickle-down effect. Creating a cheerful and fun atmosphere filled with inside jokes and excitement regarding upcoming social events or conferences will certainly result in a time you will cherish for the rest of your life.
- Kouzes JM, Posner BZ. Foster collaboration. In: Kouzes JM, Posner BZ, eds. The Leadership Challenge. 6th ed. John Wiley & Sons, Inc; 2017:195-217.
- Cooper J, Shao K, Feng H. Racial/ethnic health disparities in dermatology in the United States, part 1: overview of contributing factors and management strategies [published online February 7, 2022]. J Am Acad Dermatol. 2022;87:723-730. doi:10.1016/j.jaad.2021.12.061
- Kouzes JM, Posner BZ. Foster collaboration. In: Kouzes JM, Posner BZ, eds. The Leadership Challenge. 6th ed. John Wiley & Sons, Inc; 2017:195-217.
- Cooper J, Shao K, Feng H. Racial/ethnic health disparities in dermatology in the United States, part 1: overview of contributing factors and management strategies [published online February 7, 2022]. J Am Acad Dermatol. 2022;87:723-730. doi:10.1016/j.jaad.2021.12.061
Resident Pearls
- Camaraderie in residency is a special dynamic that can be enhanced and fostered in many different ways.
- The relationships among residents should be treated with importance, as some of the friends you make will last a career and/or a lifetime.
- Conflicts inevitably will arise and learning how to handle them effectively can improve the residency experience.
Nail Salon Safety: From Nail Dystrophy to Acrylate Contact Allergies
As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.
Nail Polish Application Process
The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.1 Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.
Contact Dermatitis
Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.2 Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.3 Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.3
Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.4 Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.5 Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.
Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.6 It is important to note that sensitization may develop months to years after using artificial nails.
Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.
Common Onychodystrophies
Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.5 One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.8 Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.6 One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.9
Infections
In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.1 Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.10
Final Thoughts
Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.
- Reinecke JK, Hinshaw MA. Nail health in women. Int J Womens Dermatol. 2020;6:73-79. doi:10.1016/j.ijwd.2020.01.006
- Warshaw EM, Voller LM, Silverberg JI, et al. Contact dermatitis associated with nail care products: retrospective analysis of North American Contact Dermatitis Group data, 2001-2016. Dermatitis. 2020;31:191-201. doi:10.1097/DER.0000000000000583
- Militello M, Hu S, Laughter M, et al. American Contact Dermatitis Society allergens of the year 2000 to 2020 [published online April 25, 2020]. Dermatol Clin. 2020;38:309-320. doi:10.1016/j.det.2020.02.011
- Kucharczyk M, Słowik-Rylska M, Cyran-Stemplewska S, et al. Acrylates as a significant cause of allergic contact dermatitis: new sources of exposure. Postepy Dermatol Alergol. 2021;38:555-560. doi:10.5114/ada.2020.95848
- Draelos ZD. Cosmetics and cosmeceuticals. In: Bolognia J, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Elsevier; 2018:2587-2588.
- Iorizzo M, Piraccini BM, Tosti A. Nail cosmetics in nail disorders.J Cosmet Dermatol. 2007;6:53-58. doi:10.1111/j.1473-2165.2007.00290.x
- Maio P, Carvalho R, Amaro C, et al. Letter: allergic contact dermatitis from sculptured acrylic nails: special presentation with a possible airborne pattern. Dermatol Online J. 2012;18:13.
- Chen AF, Chimento SM, Hu S, et al. Nail damage from gel polish manicure. J Cosmet Dermatol. 2012;11:27-29. doi:10.1111/j.1473-2165.2011.00595.x
- Cervantes J, Sanchez M, Eber AE, et al. Pterygium inversum unguis secondary to gel polish [published online October 16, 2017]. J Eur Acad Dermatol Venereol. 2018;32:160-163. doi:10.1111/jdv.14603
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.
Nail Polish Application Process
The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.1 Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.
Contact Dermatitis
Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.2 Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.3 Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.3
Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.4 Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.5 Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.
Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.6 It is important to note that sensitization may develop months to years after using artificial nails.
Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.
Common Onychodystrophies
Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.5 One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.8 Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.6 One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.9
Infections
In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.1 Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.10
Final Thoughts
Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.
As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.
Nail Polish Application Process
The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.1 Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.
Contact Dermatitis
Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.2 Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.3 Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.3
Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.4 Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.5 Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.
Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.6 It is important to note that sensitization may develop months to years after using artificial nails.
Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.
Common Onychodystrophies
Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.5 One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.8 Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.6 One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.9
Infections
In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.1 Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.10
Final Thoughts
Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.
- Reinecke JK, Hinshaw MA. Nail health in women. Int J Womens Dermatol. 2020;6:73-79. doi:10.1016/j.ijwd.2020.01.006
- Warshaw EM, Voller LM, Silverberg JI, et al. Contact dermatitis associated with nail care products: retrospective analysis of North American Contact Dermatitis Group data, 2001-2016. Dermatitis. 2020;31:191-201. doi:10.1097/DER.0000000000000583
- Militello M, Hu S, Laughter M, et al. American Contact Dermatitis Society allergens of the year 2000 to 2020 [published online April 25, 2020]. Dermatol Clin. 2020;38:309-320. doi:10.1016/j.det.2020.02.011
- Kucharczyk M, Słowik-Rylska M, Cyran-Stemplewska S, et al. Acrylates as a significant cause of allergic contact dermatitis: new sources of exposure. Postepy Dermatol Alergol. 2021;38:555-560. doi:10.5114/ada.2020.95848
- Draelos ZD. Cosmetics and cosmeceuticals. In: Bolognia J, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Elsevier; 2018:2587-2588.
- Iorizzo M, Piraccini BM, Tosti A. Nail cosmetics in nail disorders.J Cosmet Dermatol. 2007;6:53-58. doi:10.1111/j.1473-2165.2007.00290.x
- Maio P, Carvalho R, Amaro C, et al. Letter: allergic contact dermatitis from sculptured acrylic nails: special presentation with a possible airborne pattern. Dermatol Online J. 2012;18:13.
- Chen AF, Chimento SM, Hu S, et al. Nail damage from gel polish manicure. J Cosmet Dermatol. 2012;11:27-29. doi:10.1111/j.1473-2165.2011.00595.x
- Cervantes J, Sanchez M, Eber AE, et al. Pterygium inversum unguis secondary to gel polish [published online October 16, 2017]. J Eur Acad Dermatol Venereol. 2018;32:160-163. doi:10.1111/jdv.14603
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
- Reinecke JK, Hinshaw MA. Nail health in women. Int J Womens Dermatol. 2020;6:73-79. doi:10.1016/j.ijwd.2020.01.006
- Warshaw EM, Voller LM, Silverberg JI, et al. Contact dermatitis associated with nail care products: retrospective analysis of North American Contact Dermatitis Group data, 2001-2016. Dermatitis. 2020;31:191-201. doi:10.1097/DER.0000000000000583
- Militello M, Hu S, Laughter M, et al. American Contact Dermatitis Society allergens of the year 2000 to 2020 [published online April 25, 2020]. Dermatol Clin. 2020;38:309-320. doi:10.1016/j.det.2020.02.011
- Kucharczyk M, Słowik-Rylska M, Cyran-Stemplewska S, et al. Acrylates as a significant cause of allergic contact dermatitis: new sources of exposure. Postepy Dermatol Alergol. 2021;38:555-560. doi:10.5114/ada.2020.95848
- Draelos ZD. Cosmetics and cosmeceuticals. In: Bolognia J, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Elsevier; 2018:2587-2588.
- Iorizzo M, Piraccini BM, Tosti A. Nail cosmetics in nail disorders.J Cosmet Dermatol. 2007;6:53-58. doi:10.1111/j.1473-2165.2007.00290.x
- Maio P, Carvalho R, Amaro C, et al. Letter: allergic contact dermatitis from sculptured acrylic nails: special presentation with a possible airborne pattern. Dermatol Online J. 2012;18:13.
- Chen AF, Chimento SM, Hu S, et al. Nail damage from gel polish manicure. J Cosmet Dermatol. 2012;11:27-29. doi:10.1111/j.1473-2165.2011.00595.x
- Cervantes J, Sanchez M, Eber AE, et al. Pterygium inversum unguis secondary to gel polish [published online October 16, 2017]. J Eur Acad Dermatol Venereol. 2018;32:160-163. doi:10.1111/jdv.14603
- Vugia DJ, Jang Y, Zizek C, et al. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11:616-618. doi:10.3201/eid1104.040936
Resident Pearls
- Every step of the nail manicuring process presents opportunities for nail trauma, infections, and contact dermatitis.
- As residents, it is important to be aware of the hazards associated with nail salons and educate our patients accordingly.
- Nail health is essential to optimizing everyday work for our patients—whether it entails taking care of children, typing, or other hands-on activities.
Removal of Isotretinoin Gender-Based Guidelines: Inclusivity Takes Precedence
Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.
Developing Inclusive iPLEDGE Categories
In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.1,2
As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.3
As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.4 The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.
On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.
Impact of iPLEDGE Categories on Transgender Patients
These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.
Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?
Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.5 In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.4 Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.
Inclusive Language in iPLEDGE Categories
It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”3
Sanchez et al6 provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.
Final Thoughts
The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.
- Yeung H, Luk KM, Chen SC, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80:591-602. doi:10.1016/j.jaad.2018.02.045
- Flores AR, Herman JL, Gates GJ, et al. How many adults identify as transgender in the United States? UCLA Williams Institute website. Published June 2016. Accessed March 1, 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
- Doheny K. FDA OKs iPLEDGE change for gender-neutral language. Dermatology News. October 13, 2021. Accessed March 3, 2022. https://www.mdedge.com/dermatology/article/247352/acne/fda-oks-ipledge-change-gender-neutral-language/page/0/1
- Doheny K. iPLEDGE rollout described as a failure, chaotic, and a disaster. Medscape. December 16, 2021. Accessed March 1, 2022. https://www.medscape.com/viewarticle/964925?uac=423615MG
- Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11:222-229.
- Sanchez DP, Brownstone N, Thibodeaux Q, et al. Prescribing isotretinoin for transgender patients: a call to action and recommendations. J Drugs Dermatol. 2021;20:106-108.
Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.
Developing Inclusive iPLEDGE Categories
In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.1,2
As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.3
As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.4 The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.
On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.
Impact of iPLEDGE Categories on Transgender Patients
These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.
Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?
Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.5 In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.4 Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.
Inclusive Language in iPLEDGE Categories
It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”3
Sanchez et al6 provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.
Final Thoughts
The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.
Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.
Developing Inclusive iPLEDGE Categories
In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.1,2
As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.3
As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.4 The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.
On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.
Impact of iPLEDGE Categories on Transgender Patients
These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.
Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?
Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.5 In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.4 Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.
Inclusive Language in iPLEDGE Categories
It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”3
Sanchez et al6 provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.
Final Thoughts
The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.
- Yeung H, Luk KM, Chen SC, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80:591-602. doi:10.1016/j.jaad.2018.02.045
- Flores AR, Herman JL, Gates GJ, et al. How many adults identify as transgender in the United States? UCLA Williams Institute website. Published June 2016. Accessed March 1, 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
- Doheny K. FDA OKs iPLEDGE change for gender-neutral language. Dermatology News. October 13, 2021. Accessed March 3, 2022. https://www.mdedge.com/dermatology/article/247352/acne/fda-oks-ipledge-change-gender-neutral-language/page/0/1
- Doheny K. iPLEDGE rollout described as a failure, chaotic, and a disaster. Medscape. December 16, 2021. Accessed March 1, 2022. https://www.medscape.com/viewarticle/964925?uac=423615MG
- Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11:222-229.
- Sanchez DP, Brownstone N, Thibodeaux Q, et al. Prescribing isotretinoin for transgender patients: a call to action and recommendations. J Drugs Dermatol. 2021;20:106-108.
- Yeung H, Luk KM, Chen SC, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80:591-602. doi:10.1016/j.jaad.2018.02.045
- Flores AR, Herman JL, Gates GJ, et al. How many adults identify as transgender in the United States? UCLA Williams Institute website. Published June 2016. Accessed March 1, 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
- Doheny K. FDA OKs iPLEDGE change for gender-neutral language. Dermatology News. October 13, 2021. Accessed March 3, 2022. https://www.mdedge.com/dermatology/article/247352/acne/fda-oks-ipledge-change-gender-neutral-language/page/0/1
- Doheny K. iPLEDGE rollout described as a failure, chaotic, and a disaster. Medscape. December 16, 2021. Accessed March 1, 2022. https://www.medscape.com/viewarticle/964925?uac=423615MG
- Wierckx K, Van de Peer F, Verhaeghe E, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11:222-229.
- Sanchez DP, Brownstone N, Thibodeaux Q, et al. Prescribing isotretinoin for transgender patients: a call to action and recommendations. J Drugs Dermatol. 2021;20:106-108.
Resident Pearls
- Major changes in the iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) system recently took place, including simplifying registration categories while making the process more inclusive for patients.
- It is important to practice culturally sensitive language when discussing subjects regarding gender identification and sexual practices. Sample questions have been provided to help familiarize practitioners with optimal ways to approach these patient encounters.
- There likely will be more changes with iPLEDGE REMS in the future as the American Academy of Dermatology Association continues to work on solutions regarding decreasing monthly qualifications for patients who cannot get pregnant and possible removal of patient attestation requirements.