MDedge Dermatology

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Monkeypox virus infections in children and adolescents in the United States are rare, and young patients with known infections have all recovered, according to a study from the Centers for Disease Control and Prevention.

In addition, evidence suggests that secondary transmission in schools or childcare facilities may be unlikely.

The study was the first comprehensive study on the impact of monkeypox on children during the 2022 outbreak, according to a statement emailed to this news organization from the California Department of Public Health, one of the state health departments that partnered with the CDC to share information.

News of low infection rates and relatively mild disease was welcome to clinicians, who had braced for severe findings on the basis of sparse prior data, according to Peter Chin-Hong, MD, a professor of medicine and an infectious diseases physician at the University of California, San Francisco.

“We were on heightened alert that kids may do poorly,” said Dr. Chin-Hong, who was not involved in the study but who cared for monkeypox patients during the outbreak. “I think this study is reassuring.

“The other silver lining about it is that most of the kids got infected in the household setting from ways that you would expect them to get [infected],” Dr. Chin-Hong said in an interview.

However, Black and Hispanic children were more likely to contract the disease, underscoring troubling inequities.

“Early on, individuals of color were much less likely to be able to successfully access vaccination,” said first author Ian Hennessee, PhD, MPH, an epidemic intelligence service officer with the CDC and a member of the Special Case Investigation Unit of the Multinational Monkeypox Response Team at the CDC. “We think those kinds of structural inequities really trickled down towards the children and adolescents that have been affected by this outbreak.”

The study was published  in Morbidity and Mortality Weekly Report.
 

A nationwide look at the data

The researchers discussed 83 children and adolescents with monkeypox who came to the CDC’s attention between May 17 and Sept. 24, 2022.

The 83 cases represent 0.3% of the 25,038 reported monkeypox cases in the United States over that period. Of the 28 children aged 12 years or younger, 18 (64%) were boys. Sixteen children were younger than 4 years.

Exposure data were available for 20 (71%) of those aged 0-12. In that group, 19 were exposed at home; 17 cases were due to routine skin-to-skin contact with a household caregiver; and one case was suspected to be caused by fomites (such as a shared towel). Exposure information was unavailable for the remaining case.

Most of the children experienced lesions on the trunk. No lesions were anogenital. Two patients in the youngest age group were hospitalized because of widespread rash that involved the eyelids, and a patient in the 5- to 12-year-old group was hospitalized because of periorbital cellulitis and conjunctivitis.

Among those aged 13-17, there were 55 cases. Of these patients, 89% were boys. Exposure data were available for 35 (64%). In 32 of these patients, the infection occurred from presumed sexual contact. Twenty-three of those adolescents reported male-to-male sexual contact. No case was found to be connected with sexual abuse.

Lesions in the adolescents were mostly truncal or anogenital. Six in this group were hospitalized, and all of them recovered. One adolescent was found to be HIV positive.

Black and Hispanic children accounted for 47% and 35% of all cases, respectively.

Eleven percent of all the children and adolescents were hospitalized, and none received intensive care.

Treatments, when given, included the antiviral drug tecovirimat, intravenous vaccinia immune globulin, and topical trifluridine. There were no deaths.

Ten symptomatic patients attended school or daycare. Among these patients, no secondary transmissions were found to have occurred. Some contacts were offered the JYNNEOS monkeypox vaccine as postexposure prophylaxis.

Limitations of the study included potentially overlooked cases. Data were collected through routine surveillance, children frequently experience rashes, and access to testing has been a challenge, Dr. Hennessee explained.

In addition, data on exposure characteristics were missing for some children.
 

Inequities and the risks of being judged

The outbreak in the United States has eased in recent months. However, though uncommon in children, monkeypox has affected some racial groups disproportionately.

“Especially in the later course of the outbreak, the majority of cases were among Black and Hispanic individuals,” said co-author Rachel E. Harold, MD, an infectious diseases specialist and supervisory medical officer with the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STDs, and TB Administration.

“Unfortunately, the pediatric cases do reflect the outbreak overall,” she told this news organization.

Dr. Harold noted there have been efforts in D.C. and other jurisdictions, as well as by the White House monkeypox response team, to reach populations at greatest risk and that they were “really trying to make vaccine available to people of color.”

Vaccination clinics often popped up in unexpected locations at short notice, and that made it hard for some people to get to them, Dr. Chin-Hong pointed out.

Another factor was “the public aspect of accessing diagnostics and vaccines and the way that that’s linked to potential judgment or sexual risk,” he added.

“Not everybody’s out,” Dr. Chin-Hong said, referring to members of the LGBTQ community. “In many communities of color, going to get a test or going to get a vaccine essentially means that you’re out.”

For clinicians who suspect monkeypox in a child, Dr. Harold suggests keeping a broad differential diagnosis, looking for an epidemiologic link, and contacting the CDC for assistance. Infected children should be encouraged to avoid touching their own eyes or mucous membranes, she added.

In addition, she said, tecovirimat is a reasonable treatment and is well tolerated by pediatric monkeypox patients with eczema, an underlying condition that could lead to severe disease.

For infected caregivers, Dr. Hennessee said, measures to prevent infecting children at home include isolation, contact precautions, and in some cases, postexposure prophylaxis via vaccination.

For sexually active adolescents, he advised that clinicians offer vaccination, education on sexual health, and testing for HIV and other sexually transmitted infections.

“It’s important to remember that adolescents may be sexually active, and clinicians should do a thorough and nonjudgmental sexual history,” Dr. Harold added. “That is always true, but especially if there is concern for [monkeypox].”

Dr. Hennessee, Dr. Chin-Hong, and Dr. Harold have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Diagnosis: Tuberous Xanthoma

The skin biopsy revealed a nodular collection of foam cells (quiz image [bottom]). Tuberous xanthoma was the most likely diagnosis based on the patient’s history as well as the clinical and histologic findings. Tuberous xanthomas are flat or elevated nodules in the dermis and subcutaneous tissue, commonly occurring on the skin over the joints.¹ Smaller nodules and papules often are referred to as tuberoeruptive xanthomas and exist on a continuum with the larger tuberous xanthomas. All xanthomas appear histologically similar, with collections of foam cells present within the dermis.² Foam cells form when serum lipoproteins diffuse through capillary walls, deposit in the skin or tendons, and are scavenged by monocytes.3 Tuberous xanthomas, along with tendinous, eruptive, and planar xanthomas, are the most likely to be associated with hyperlipidemia.⁴ They may indicate an underlying disorder of lipid metabolism, such as familial hypercholesterolemia.^1,3 This is the most common cause of inheritable cardiovascular disease, with a prevalence of approximately 1:250.² Premature cardiovascular disease risk increases 2 to 4 times in patients with familial hypercholesterolemia and tendinous xanthomas,¹ illustrating that recognition of cutaneous lesions can lead to earlier diagnosis and prevention of patient morbidity and mortality.

Juvenile xanthogranuloma typically presents as smooth yellow papules or nodules on the head and neck, with a characteristic “setting-sun” appearance (ie, yellow center with an erythematous halo) on dermoscopy.⁵ Histologically, juvenile xanthogranulomas are composed of foam cells and a mixed lymphohistiocytic infiltrate with eosinophils within the dermis. Giant cells with a ring of nuclei surrounded by cytoplasm containing lipid vacuoles (called Touton giant cells) are characteristic (Figure 1). In contrast to tuberous xanthomas, juvenile xanthogranulomas often present within the first year of life.⁶

Keloid scars are more prevalent in patients with skin of color. They are characterized by eosinophilic keloidal collagen with a whorled proliferation of fibroblasts on histology (Figure 2).⁷ They occur spontaneously or at sites of injury and present as bluish-red or flesh-colored firm papules or nodules.⁸ In our patient, keloid scars were an unlikely diagnosis due to the lack of trauma and the absence of keloidal collagen on histology.

Necrobiosis lipoidica diabeticorum typically presents as an erythematous, yellow-brown, circular plaque on the anterior lower leg in patients with diabetes mellitus; it rarely occurs in children.⁹ Microscopy shows palisaded granulomas surrounding necrobiotic collagen arranged horizontally in a layer cake–like fashion (Figure 3).^9,10 The etiology of necrobiosis lipoidica diabeticorum currently is unknown, though immune complex deposition may contribute to its pathology. It has been associated with type 1 diabetes mellitus, though severity of the lesions is not associated with extent of glycemic control.¹⁰

Rosai-Dorfman disease is an uncommon disorder characterized by a proliferation of histiocytes that most often presents as bilateral cervical lymphadenopathy in children and young adults but rarely can present with cutaneous lesions when extranodal involvement is present.^11,12 The cutaneous form most commonly presents as red papules or nodules. On histology, the lesions exhibit a nodular dermal proliferation of histiocytes and smaller lymphocytoid cells with a marbled or starry sky–like appearance on low power (Figure 4). On higher magnification, the characteristic finding of emperipolesis can be seen.11 On immunohistochemistry, the histiocytes stain positively for CD68 and S-100. Although the pathogenesis currently is unknown, evidence of clonality indicates the disease may be related to a neoplastic process.¹²

The Diagnosis: Tuberous Xanthoma

The skin biopsy revealed a nodular collection of foam cells (quiz image [bottom]). Tuberous xanthoma was the most likely diagnosis based on the patient’s history as well as the clinical and histologic findings. Tuberous xanthomas are flat or elevated nodules in the dermis and subcutaneous tissue, commonly occurring on the skin over the joints.¹ Smaller nodules and papules often are referred to as tuberoeruptive xanthomas and exist on a continuum with the larger tuberous xanthomas. All xanthomas appear histologically similar, with collections of foam cells present within the dermis.² Foam cells form when serum lipoproteins diffuse through capillary walls, deposit in the skin or tendons, and are scavenged by monocytes.3 Tuberous xanthomas, along with tendinous, eruptive, and planar xanthomas, are the most likely to be associated with hyperlipidemia.⁴ They may indicate an underlying disorder of lipid metabolism, such as familial hypercholesterolemia.^1,3 This is the most common cause of inheritable cardiovascular disease, with a prevalence of approximately 1:250.² Premature cardiovascular disease risk increases 2 to 4 times in patients with familial hypercholesterolemia and tendinous xanthomas,¹ illustrating that recognition of cutaneous lesions can lead to earlier diagnosis and prevention of patient morbidity and mortality.

Juvenile xanthogranuloma typically presents as smooth yellow papules or nodules on the head and neck, with a characteristic “setting-sun” appearance (ie, yellow center with an erythematous halo) on dermoscopy.⁵ Histologically, juvenile xanthogranulomas are composed of foam cells and a mixed lymphohistiocytic infiltrate with eosinophils within the dermis. Giant cells with a ring of nuclei surrounded by cytoplasm containing lipid vacuoles (called Touton giant cells) are characteristic (Figure 1). In contrast to tuberous xanthomas, juvenile xanthogranulomas often present within the first year of life.⁶

Keloid scars are more prevalent in patients with skin of color. They are characterized by eosinophilic keloidal collagen with a whorled proliferation of fibroblasts on histology (Figure 2).⁷ They occur spontaneously or at sites of injury and present as bluish-red or flesh-colored firm papules or nodules.⁸ In our patient, keloid scars were an unlikely diagnosis due to the lack of trauma and the absence of keloidal collagen on histology.

Necrobiosis lipoidica diabeticorum typically presents as an erythematous, yellow-brown, circular plaque on the anterior lower leg in patients with diabetes mellitus; it rarely occurs in children.⁹ Microscopy shows palisaded granulomas surrounding necrobiotic collagen arranged horizontally in a layer cake–like fashion (Figure 3).^9,10 The etiology of necrobiosis lipoidica diabeticorum currently is unknown, though immune complex deposition may contribute to its pathology. It has been associated with type 1 diabetes mellitus, though severity of the lesions is not associated with extent of glycemic control.¹⁰

Rosai-Dorfman disease is an uncommon disorder characterized by a proliferation of histiocytes that most often presents as bilateral cervical lymphadenopathy in children and young adults but rarely can present with cutaneous lesions when extranodal involvement is present.^11,12 The cutaneous form most commonly presents as red papules or nodules. On histology, the lesions exhibit a nodular dermal proliferation of histiocytes and smaller lymphocytoid cells with a marbled or starry sky–like appearance on low power (Figure 4). On higher magnification, the characteristic finding of emperipolesis can be seen.11 On immunohistochemistry, the histiocytes stain positively for CD68 and S-100. Although the pathogenesis currently is unknown, evidence of clonality indicates the disease may be related to a neoplastic process.¹²

The Diagnosis: Tuberous Xanthoma

The skin biopsy revealed a nodular collection of foam cells (quiz image [bottom]). Tuberous xanthoma was the most likely diagnosis based on the patient’s history as well as the clinical and histologic findings. Tuberous xanthomas are flat or elevated nodules in the dermis and subcutaneous tissue, commonly occurring on the skin over the joints.¹ Smaller nodules and papules often are referred to as tuberoeruptive xanthomas and exist on a continuum with the larger tuberous xanthomas. All xanthomas appear histologically similar, with collections of foam cells present within the dermis.² Foam cells form when serum lipoproteins diffuse through capillary walls, deposit in the skin or tendons, and are scavenged by monocytes.3 Tuberous xanthomas, along with tendinous, eruptive, and planar xanthomas, are the most likely to be associated with hyperlipidemia.⁴ They may indicate an underlying disorder of lipid metabolism, such as familial hypercholesterolemia.^1,3 This is the most common cause of inheritable cardiovascular disease, with a prevalence of approximately 1:250.² Premature cardiovascular disease risk increases 2 to 4 times in patients with familial hypercholesterolemia and tendinous xanthomas,¹ illustrating that recognition of cutaneous lesions can lead to earlier diagnosis and prevention of patient morbidity and mortality.

Juvenile xanthogranuloma typically presents as smooth yellow papules or nodules on the head and neck, with a characteristic “setting-sun” appearance (ie, yellow center with an erythematous halo) on dermoscopy.⁵ Histologically, juvenile xanthogranulomas are composed of foam cells and a mixed lymphohistiocytic infiltrate with eosinophils within the dermis. Giant cells with a ring of nuclei surrounded by cytoplasm containing lipid vacuoles (called Touton giant cells) are characteristic (Figure 1). In contrast to tuberous xanthomas, juvenile xanthogranulomas often present within the first year of life.⁶

Keloid scars are more prevalent in patients with skin of color. They are characterized by eosinophilic keloidal collagen with a whorled proliferation of fibroblasts on histology (Figure 2).⁷ They occur spontaneously or at sites of injury and present as bluish-red or flesh-colored firm papules or nodules.⁸ In our patient, keloid scars were an unlikely diagnosis due to the lack of trauma and the absence of keloidal collagen on histology.

Necrobiosis lipoidica diabeticorum typically presents as an erythematous, yellow-brown, circular plaque on the anterior lower leg in patients with diabetes mellitus; it rarely occurs in children.⁹ Microscopy shows palisaded granulomas surrounding necrobiotic collagen arranged horizontally in a layer cake–like fashion (Figure 3).^9,10 The etiology of necrobiosis lipoidica diabeticorum currently is unknown, though immune complex deposition may contribute to its pathology. It has been associated with type 1 diabetes mellitus, though severity of the lesions is not associated with extent of glycemic control.¹⁰

Rosai-Dorfman disease is an uncommon disorder characterized by a proliferation of histiocytes that most often presents as bilateral cervical lymphadenopathy in children and young adults but rarely can present with cutaneous lesions when extranodal involvement is present.^11,12 The cutaneous form most commonly presents as red papules or nodules. On histology, the lesions exhibit a nodular dermal proliferation of histiocytes and smaller lymphocytoid cells with a marbled or starry sky–like appearance on low power (Figure 4). On higher magnification, the characteristic finding of emperipolesis can be seen.11 On immunohistochemistry, the histiocytes stain positively for CD68 and S-100. Although the pathogenesis currently is unknown, evidence of clonality indicates the disease may be related to a neoplastic process.¹²

The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.

Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.¹ Contaminated fomites have been suggested as another source of infection.² The typical lesion appears dome-shaped, round, and pinkish-purple in color.¹ The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).^{3,4 A} giant atypical molluscum contagiosum is rarely seen in healthy individuals.
 

What’s on the differential?

The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.

Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.⁵ More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.

Comments from Dr. Eichenfield

This is a very hard diagnosis to make with the clinical findings and history.

Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.

Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.

References

1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.

2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).

3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.

4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.

5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.

The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.

Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.¹ Contaminated fomites have been suggested as another source of infection.² The typical lesion appears dome-shaped, round, and pinkish-purple in color.¹ The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).^{3,4 A} giant atypical molluscum contagiosum is rarely seen in healthy individuals.
 

What’s on the differential?

The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.

Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.⁵ More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.

Comments from Dr. Eichenfield

This is a very hard diagnosis to make with the clinical findings and history.

Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.

Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.

References

1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.

2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).

3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.

4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.

5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.

The correct answer is (D), molluscum contagiosum. Upon surgical excision, the pathology indicated the lesion was consistent with molluscum contagiosum.

Molluscum contagiosum is a benign skin disorder caused by a pox virus and is frequently seen in children. This disease is transmitted primarily through direct skin contact with an infected individual.¹ Contaminated fomites have been suggested as another source of infection.² The typical lesion appears dome-shaped, round, and pinkish-purple in color.¹ The incubation period ranges from 2 weeks to 6 months and is typically self-limited in immunocompetent hosts; however, in immunocompromised persons, molluscum contagiosum lesions may present atypically such that they are larger in size and/or resemble malignancies, such as basal cell carcinoma or keratoacanthoma (for single lesions), or other infectious diseases, such as cryptococcosis and histoplasmosis (for more numerous lesions).^{3,4 A} giant atypical molluscum contagiosum is rarely seen in healthy individuals.
 

What’s on the differential?

The recent episode of bleeding raises concern for other neoplastic processes of the skin including squamous cell carcinoma or basal cell carcinoma as well as cutaneous metastatic rhabdoid tumor, given the patient’s history.

Eruptive keratoacanthomas are also reported in patients taking nivolumab, an anti-PD-1 immunotherapy, which the patient has received for treatment of his recurrent metastatic rhabdoid tumor.⁵ More common entities such as a pyogenic granuloma or verruca are also included on the differential. The initial presentation of the lesion, however, is more consistent with the pearly umbilicated papules associated with molluscum contagiosum.

Comments from Dr. Eichenfield

This is a very hard diagnosis to make with the clinical findings and history.

Molluscum contagiosum infections are common, but with this patient’s medical history, biopsy and excision with pathologic examination was an appropriate approach to make a certain diagnosis.

Ms. Moyal is a research associate in the division of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Eichenfield is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego, and Rady Children’s Hospital, San Diego.

References

1. Brown J et al. Int J Dermatol. 2006 Feb;45(2):93-9.

2. Hanson D and Diven DG. Dermatol Online J. 2003 Mar;9(2).

3. Badri T and Gandhi GR. Molluscum contagiosum. 2022. In: StatPearls [Internet]. Treasure Island, Fla.: StatPearls Publishing.

4. Schwartz JJ and Myskowski PL. J Am Acad Dermatol. 1992 Oct 1;27(4):583-8.

5. Antonov NK et al. JAAD Case Rep. 2019 Apr 5;5(4):342-5.

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin, Madison, teaches patients how to breathe mindfully. So does Kathy Farah, MD, an integrative family physician who practices in Roberts, Wis.

Mindful breathing is the most basic mind-body skill and one that can help interrupt the itch-scratch cycle and relieve pain, stress, and distress often experienced by children, teens, and adults with dermatologic conditions, they said at the annual Integrative Dermatology Symposium.

“As with any integrative modality, if it’s safe and effective, then let’s use it,” Dr. Farah said in a presentation on the mind-body approach to pain and itch.

“A breathwork session can literally take 1 minute,” said Dr. Bodemer, associate professor of dermatology at the University of Wisconsin and director of an integrative dermatology clinic. Dr. Bodemer, who completed a fellowship in integrative medicine at the Andrew Weil Center for Integrative Medicine at the University of Arizona and sits on the American Board of Integrative Medicine, spoke on a mindfulness panel at the meeting.

Her favorite breathing practice is the “4-7-8” breath taught by Andrew Weil, MD, founder and director of the center. This involves inhaling through the nose for a count of 4, holding for 7, and exhaling through the mouth for a count of 8. “It doesn’t matter how slow or fast, it’s the tempo that matters ... On exhale, squeeze your abs in to engage your core and get air out of your lungs as much as you can,” she said, advising a cycle of three at a time.

A technique known as “square breathing” (breath in 4, hold for 4, breath out for 4, hold for 4) is another helpful technique to “reset the nervous system” said Dr. Farah, who worked for many years in a children’s hospital. With children, she said, “I often do five finger breathing.”

For five finger breathing, the children spread their fingers apart in front of them or on the ground and use the pointer finger of the opposite hand to trace each finger, inhaling while tracing upward, and exhaling while tracing down.

Dr. Farah, associate clinical director of The Center for Mind-Body Medicine in Washington, DC, said her commitment to mindfulness was influenced by a “seminal” study published over 20 years ago showing that patients with moderate to severe psoriasis who used a meditation-based, audiotape-guided stress reduction intervention during phototherapy sessions had more rapid resolution of psoriatic lesions than did patients who didn’t use the mindfulness exercise.

Among more recent findings: A cross-sectional study of 120 adult dermatology patients, published in the British Journal of Dermatology in 2016, assessed skin shame, social anxiety, anxiety, depression, dermatological quality of life, and levels of mindfulness, and found that higher levels of mindfulness were associated with lower levels of psychosocial distress.

Another cross-sectional questionnaire study looked at mindfulness and “itch catastrophizing” in 155 adult patients with atopic dermatitis. Higher levels of a specific facet of mindfulness termed “acting with awareness” were associated with lower levels of itch catastrophizing, the researchers found. “Catastrophizing is a negative way of thinking, this itching will never stop,” Dr. Farah explained. The study shows that “mindfulness can actually help reduce some of the automatic scratching and response to itch. So it’s a great adjunct to pharmaceuticals.”

Affirmations – phrases and statements that are repeated to oneself to help challenge negative thoughts – can also help reverse itch catastrophizing. Statements such as “I can breathe through this feeling of itching,” or “I can move to feel comfortable and relaxed” encourage positive change, she said.

“I teach [mindfulness skills like breathing] a lot, without any expectations. I’ll say ‘give it a try and see what you think.’ If patients feel even a micron better, then they’re invested” and can then find numerous tools online, Dr. Farah said. “Can I do this [in a busy schedule] with every patient? Absolutely not. But can I do it with every 10th patient? Maybe.”

Dr. Bodemer’s experience has shown her that “breathing with your patient builds rapport,” she said. “There’s something very powerful in that in terms of building trust. ... I’ll just do it [during a visit, to show them] and almost always, patients start breathing with me, with an invitation or without.”

For her own health, 4-7-8 breathing has “been a gateway to meditation and deeper practices,” she said. “But even without going very deep, it has a long history of being able to modulate the stress response. It’s the parasympathetic-sympathetic rebalancing I’m interested in.”

Mindful breathing and other mind-body practices also can be helpful for parents of children with eczema, she and Dr. Farah said.

Dr. Bodemer and Dr. Farah reported no financial relationships to disclose.

To better understand melasma, it is important for researchers to find groups of patients with confirmed disease for future clinical study. A recent research letter published in JAMA Dermatology suggests the ICD-10 code for melasma is a good identifier for patients with confirmed melasma, and might be a helpful tool for researchers interested in conducting retrospective studies of this patient population.

“Overall, our results support the validity of using the ICD-10 code for melasma to identify patients with a diagnosis of melasma for future studies,” Nicholas Theodosakis, MD, PhD, of the department of dermatology at Massachusetts General Hospital, Boston, and colleagues wrote in their research letter. “Despite some variability in diagnostic confidence, most patients were ultimately classified as moderately or highly likely to have a true diagnosis of melasma.”

Dr. Theodosakis and colleagues evaluated data from 5,322 adult patients in the Mass General Brigham Research Patient Data Registry between October 2015 and January 2021 who had an encounter that used the ICD-10 code for melasma (L81.1). The researchers then validated the ICD-10 code by examining the medical records of 300 patients (5.6%), confirming that melasma was the clinician’s favored diagnosis and that the patient met secondary diagnostic criteria. Confidence was rated in categories of “low confidence,” “moderate confidence,” “high confidence,” and “maximum confidence” based on secondary criteria such as hyperpigmentation of the face and upper body, hormone-related therapy exposure before diagnosis, pregnancy history, and dermatologist-confirmed diagnosis.

The patients who had their medical records examined for confirmed melasma were primarily women (285 patients; 95.0%) and were a mean 48.4 years old at diagnosis.

Of those in the validation cohort, melasma was the preferred diagnosis for clinicians of 291 patients (97.0%), while 274 patients (91.3%) had secondary diagnostic criteria of hyperpigmentation of the face and upper body and 252 patients (84.0%) had received a diagnosis from a dermatologist. Other less common secondary diagnostic criteria of the patient group were a history of having received hormone-related therapy before a melasma diagnosis (148 patients; 49.3%) and a history of pregnancy (168 patients; 56.0%). Based on identification of secondary diagnostic criteria, confidence in melasma diagnosis was high for 208 patients (69.3%), moderate for 61 patients (20.3%), and low for 31 patients (10.3%).

Dr. Theodosakis and colleagues noted their study was limited by its retrospective nature and the presence of a small validation cohort. “Despite these limitations, our findings provide a framework for identifying cohorts to evaluate the clinical course and treatment of melasma,” the authors concluded.

One of the authors reported relationships with companies including AbbVie, Acom, Boehringer Ingelheim, Concert, Digital Diagnostics, and Eli Lilly in the form of personal fees, equity, royalties and/or licensing, or medical advisory board positions outside the submitted work; another author reported being an advisory board member and consultant for and receiving honoraria from Incyte, Castle Biosciences, Galderma, and Sanofi outside the submitted work. The other authors reported no relevant conflicts of interest.

To better understand melasma, it is important for researchers to find groups of patients with confirmed disease for future clinical study. A recent research letter published in JAMA Dermatology suggests the ICD-10 code for melasma is a good identifier for patients with confirmed melasma, and might be a helpful tool for researchers interested in conducting retrospective studies of this patient population.

“Overall, our results support the validity of using the ICD-10 code for melasma to identify patients with a diagnosis of melasma for future studies,” Nicholas Theodosakis, MD, PhD, of the department of dermatology at Massachusetts General Hospital, Boston, and colleagues wrote in their research letter. “Despite some variability in diagnostic confidence, most patients were ultimately classified as moderately or highly likely to have a true diagnosis of melasma.”

Dr. Theodosakis and colleagues evaluated data from 5,322 adult patients in the Mass General Brigham Research Patient Data Registry between October 2015 and January 2021 who had an encounter that used the ICD-10 code for melasma (L81.1). The researchers then validated the ICD-10 code by examining the medical records of 300 patients (5.6%), confirming that melasma was the clinician’s favored diagnosis and that the patient met secondary diagnostic criteria. Confidence was rated in categories of “low confidence,” “moderate confidence,” “high confidence,” and “maximum confidence” based on secondary criteria such as hyperpigmentation of the face and upper body, hormone-related therapy exposure before diagnosis, pregnancy history, and dermatologist-confirmed diagnosis.

The patients who had their medical records examined for confirmed melasma were primarily women (285 patients; 95.0%) and were a mean 48.4 years old at diagnosis.

Of those in the validation cohort, melasma was the preferred diagnosis for clinicians of 291 patients (97.0%), while 274 patients (91.3%) had secondary diagnostic criteria of hyperpigmentation of the face and upper body and 252 patients (84.0%) had received a diagnosis from a dermatologist. Other less common secondary diagnostic criteria of the patient group were a history of having received hormone-related therapy before a melasma diagnosis (148 patients; 49.3%) and a history of pregnancy (168 patients; 56.0%). Based on identification of secondary diagnostic criteria, confidence in melasma diagnosis was high for 208 patients (69.3%), moderate for 61 patients (20.3%), and low for 31 patients (10.3%).

Dr. Theodosakis and colleagues noted their study was limited by its retrospective nature and the presence of a small validation cohort. “Despite these limitations, our findings provide a framework for identifying cohorts to evaluate the clinical course and treatment of melasma,” the authors concluded.

One of the authors reported relationships with companies including AbbVie, Acom, Boehringer Ingelheim, Concert, Digital Diagnostics, and Eli Lilly in the form of personal fees, equity, royalties and/or licensing, or medical advisory board positions outside the submitted work; another author reported being an advisory board member and consultant for and receiving honoraria from Incyte, Castle Biosciences, Galderma, and Sanofi outside the submitted work. The other authors reported no relevant conflicts of interest.

To better understand melasma, it is important for researchers to find groups of patients with confirmed disease for future clinical study. A recent research letter published in JAMA Dermatology suggests the ICD-10 code for melasma is a good identifier for patients with confirmed melasma, and might be a helpful tool for researchers interested in conducting retrospective studies of this patient population.

“Overall, our results support the validity of using the ICD-10 code for melasma to identify patients with a diagnosis of melasma for future studies,” Nicholas Theodosakis, MD, PhD, of the department of dermatology at Massachusetts General Hospital, Boston, and colleagues wrote in their research letter. “Despite some variability in diagnostic confidence, most patients were ultimately classified as moderately or highly likely to have a true diagnosis of melasma.”

Dr. Theodosakis and colleagues evaluated data from 5,322 adult patients in the Mass General Brigham Research Patient Data Registry between October 2015 and January 2021 who had an encounter that used the ICD-10 code for melasma (L81.1). The researchers then validated the ICD-10 code by examining the medical records of 300 patients (5.6%), confirming that melasma was the clinician’s favored diagnosis and that the patient met secondary diagnostic criteria. Confidence was rated in categories of “low confidence,” “moderate confidence,” “high confidence,” and “maximum confidence” based on secondary criteria such as hyperpigmentation of the face and upper body, hormone-related therapy exposure before diagnosis, pregnancy history, and dermatologist-confirmed diagnosis.

The patients who had their medical records examined for confirmed melasma were primarily women (285 patients; 95.0%) and were a mean 48.4 years old at diagnosis.

Of those in the validation cohort, melasma was the preferred diagnosis for clinicians of 291 patients (97.0%), while 274 patients (91.3%) had secondary diagnostic criteria of hyperpigmentation of the face and upper body and 252 patients (84.0%) had received a diagnosis from a dermatologist. Other less common secondary diagnostic criteria of the patient group were a history of having received hormone-related therapy before a melasma diagnosis (148 patients; 49.3%) and a history of pregnancy (168 patients; 56.0%). Based on identification of secondary diagnostic criteria, confidence in melasma diagnosis was high for 208 patients (69.3%), moderate for 61 patients (20.3%), and low for 31 patients (10.3%).

Dr. Theodosakis and colleagues noted their study was limited by its retrospective nature and the presence of a small validation cohort. “Despite these limitations, our findings provide a framework for identifying cohorts to evaluate the clinical course and treatment of melasma,” the authors concluded.

One of the authors reported relationships with companies including AbbVie, Acom, Boehringer Ingelheim, Concert, Digital Diagnostics, and Eli Lilly in the form of personal fees, equity, royalties and/or licensing, or medical advisory board positions outside the submitted work; another author reported being an advisory board member and consultant for and receiving honoraria from Incyte, Castle Biosciences, Galderma, and Sanofi outside the submitted work. The other authors reported no relevant conflicts of interest.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Monkeypox, though often mild, may be severe and even fatal in immunocompromised individuals, particularly those with untreated AIDS, according to a Centers for Disease Control and Prevention study in Morbidity and Mortality Weekly Report.

The study described a group of patients recently treated for severe monkeypox. The majority were Black, HIV positive, and not receiving treatment. Many were also facing homelessness.

The authors urged HIV testing for all sexually active individuals with suspected monkeypox. Early or prolonged monkeypox treatment may be necessary, they concluded.

Coauthor John T. Brooks, MD, called the study “a real call to action.”

“If we want to reduce cases of severe monkeypox, we need to reduce the number of persons with HIV who are undiagnosed and not treated,” said Dr. Brooks, a medical epidemiologist who is chief medical officer of CDC›s multinational monkeypox response. Dr. Brooks also leads the epidemiology research team in CDC’s division of HIV/AIDS prevention.

The article reflects long-existing health disparities, noted Richard Silvera, MD, MPH, CPH, who is associate program director of the infectious diseases fellowship and assistant professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York. He was not involved with the study.

“These patients really have not been served by the health care system,” Dr. Silvera said. “Monkeypox is just really taking advantage of that.”
 

How severe monkeypox can manifest

The authors reported on 57 adults hospitalized with severe monkeypox between Aug. 10 and Sept. 10, 2022, for whose care the providers sought CDC consultation.

The vast majority (95%) were men, their median age was 34 years, and 68% were Black. Nearly one in four were homeless (23%).

Overall, 47 (82%) were HIV positive, of whom just 4 had been receiving antiretroviral therapy (ART). Of 43 for whom CD4 counts were known, 71% had fewer than 50 CD4 cells/mm3.

Clinical signs included severe skin lesions in all patients and severe mucosal lesions in 68%. Other affected organ systems included lungs (21%), eyes (21%), and central nervous system (7%).

Treatments included oral or intravenous tecovirimat (93% and 65%, respectively), vaccinia immune globulin intravenous (VIGIV, 51%), and cidofovir (23%).

Nearly 1 in 3 patients (30%) received care in an ICU; 12 died (21%). Monkeypox was considered the cause or a contributing factor in five of the deaths and not a factor in one death; the remaining six deaths are under investigation.
 

Case studies

The report included details of three representative cases of the CDC consultations.

One was a Hispanic man in his 20s with a fever of 102.8° F, a rash including eschars, oral lesions, neck mass, and cervical lymphadenopathy. He had tested positive for monkeypox as an outpatient and upon admission was found to be HIV positive, with a CD4 count of 79 cells/mm³. He experienced a severe and ultimately fatal clinical course that included intubation, refractory hypotension, seizures, renal failure, and cardiac arrest. An autopsy revealed diffuse organ necrosis plus orthopoxvirus and cytomegalovirus.

The second was a Black man in his 30s with untreated AIDS and diffuse rash. He was tested and treated for gonorrhea, chlamydia, and syphilis before phimosis and urinary retention led to admission and a monkeypox diagnosis 4 weeks after his rash began. He was discharged with oral tecovirimat, but his skin lesions developed necrosis and he was readmitted twice, each time with new lesions. His clinical course included methicillin-resistant Staphylococcus aureus bacteremia, atrial fibrillation, eye and ear involvement, a suprapubic catheter, and progressive necrosis of his lesions. As of the CDC report, he was receiving ART and intravenous tecovirimat.

The third patient, a White man in his 40s with untreated AIDS, presented with diffuse rash. He was promptly diagnosed with monkeypox and admitted for pain control. He was discharged with oral tecovirimat and ART, but homelessness and food insecurity jeopardized the absorption of his tecovirimat (which depends on a full fatty meal), and the lesions worsened. Despite readmission and aggressive medical treatment, the patient required finger debridement and a toe amputation. After discharge, he was again readmitted for lesions and pain and, at report publication, remained hospitalized, taking oral tecovirimat and ART.

The patients in the study may not be typical of severe monkeypox cases, wrote the authors reported. Deaths after the study period were not counted.
 

Fewer cases, some severe

As of Nov. 7, the CDC has confirmed 28,709 monkeypox cases. These have trended downward since August. Most people with recent diagnoses are men who are gay, bisexual, same gender loving, or who have sex with men, and most are Black, according to Brooks.

Dr. Brooks urges clinicians to report suspected monkeypox cases – especially severe ones – to their health departments.

“We don’t have a good bead on exactly how many severe cases there are in the States because of complexities in our surveillance systems,” Dr. Brooks said.

For patients with suspected or confirmed monkeypox, Brooks recommends testing for sexually transmitted infections, including HIV if status is unknown. Patients with HIV should receive prompt ART. For those at risk for severe disease, the authors recommend early treatment for suspected monkeypox, even before results are back. Some patients may benefit from tecovirimat courses lasting beyond 14 days, plus additional antivirals (cidofovir or brincidofovir) and/or VIGIV.

“With severe cases, clinicians may want to consider the value of more than one drug to attack the virus at different stages of its replication cycle,” Dr. Brooks said.
 

Inequities matter

The authors called on providers to engage communities burdened by HIV and to ensure access to not only monkeypox vaccination, diagnosis, and treatment but also sustained HIV care.

Dr. Silvera added that providers need to tailor care plans to patients’ social determinants of health. For example, he explained, inpatient care for monkeypox could be appropriate for some patients facing homelessness and food insecurity – even if they are able to take tecovirimat orally.

He recommends tapping others’ expertise: “Our social work colleagues are well versed in this.”

“I don’t think these clinicians failed these patients. ... I think everyone made all the right choices medically,” Dr. Silvera added. “I think that the system failed these patients – and we as clinicians are part of those systems. So we also have the power to change those systems. And I think we just need to start opening our eyes to that and [start] to work together towards that goal to take better care of our patients.”

Dr. Brooks reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com.

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

Who watches the ED staff?

We heard a really great joke recently, one we simply have to share.

A man in Seattle went to a therapist. “I’m depressed,” he says. “Depressed, overworked, and lonely.”

Chinnapong/iStock/Getty Images

“Oh dear, that sounds quite serious,” the therapist replies. “Tell me all about it.”

“Life just seems so harsh and cruel,” the man explains. “The pandemic has caused 300,000 health care workers across the country to leave the industry.”

“Such as the doctor typically filling this role in the joke,” the therapist, who is not licensed to prescribe medicine, nods.

“Exactly! And with so many respiratory viruses circulating and COVID still hanging around, emergency departments all over the country are facing massive backups. People are waiting outside the hospital for hours, hoping a bed will open up. Things got so bad at a hospital near Seattle in October that a nurse called 911 on her own ED. Told the 911 operator to send the fire department to help out, since they were ‘drowning’ and ‘in dire straits.’ They had 45 patients waiting and only five nurses to take care of them.”

“That is quite serious,” the therapist says, scribbling down unseen notes.

“The fire chief did send a crew out, and they cleaned rooms, changed beds, and took vitals for 90 minutes until the crisis passed,” the man says. “But it’s only a matter of time before it happens again. The hospital president said they have 300 open positions, and literally no one has applied to work in the emergency department. Not one person.”

“And how does all this make you feel?” the therapist asks.

“I feel all alone,” the man says. “This world feels so threatening, like no one cares, and I have no idea what will come next. It’s so vague and uncertain.”

“Ah, I think I have a solution for you,” the therapist says. “Go to the emergency department at St. Michael Medical Center in Silverdale, near Seattle. They’ll get your bad mood all settled, and they’ll prescribe you the medicine you need to relax.”

The man bursts into tears. “You don’t understand,” he says. “I am the emergency department at St. Michael Medical Center.”

Good joke. Everybody laugh. Roll on snare drum. Curtains.

Myth buster: Supplements for cholesterol lowering

When it comes to that nasty low-density lipoprotein cholesterol, some people swear by supplements over statins as a holistic approach. Well, we’re busting the myth that those heart-healthy supplements are even effective in comparison.

Sally Kubetin/MDedge News

Which supplements are we talking about? These six are always on sale at the pharmacy: fish oil, cinnamon, garlic, turmeric, plant sterols, and red yeast rice.

In a study presented at the recent American Heart Association scientific sessions, researchers compared these supplements’ effectiveness in lowering LDL cholesterol with low-dose rosuvastatin or placebo among 199 adults aged 40-75 years who didn’t have a personal history of cardiovascular disease.

Participants who took the statin for 28 days had an average of 24% decrease in total cholesterol and a 38% reduction in LDL cholesterol, while 28 days’ worth of the supplements did no better than the placebo in either measure. Compared with placebo, the plant sterols supplement notably lowered HDL cholesterol and the garlic supplement notably increased LDL cholesterol.

Even though there are other studies showing the validity of plant sterols and red yeast rice to lower LDL cholesterol, author Luke J. Laffin, MD, of the Cleveland Clinic noted that this study shows how supplement results can vary and that more research is needed to see the effect they truly have on cholesterol over time.

So, should you stop taking or recommending supplements for heart health or healthy cholesterol levels? Well, we’re not going to come to your house and raid your medicine cabinet, but the authors of this study are definitely not saying that you should rely on them.

Consider this myth mostly busted.
 

COVID dept. of unintended consequences, part 2

The surveillance testing programs conducted in the first year of the pandemic were, in theory, meant to keep everyone safer. Someone, apparently, forgot to explain that to the students of the University of Wyoming and the University of Idaho.

Luis Alvarez/Getty Images

We’re all familiar with the drill: Students at the two schools had to undergo frequent COVID screening to keep the virus from spreading, thereby making everyone safer. Duck your head now, because here comes the unintended consequence.

The students who didn’t get COVID eventually, and perhaps not so surprisingly, “perceived that the mandatory testing policy decreased their risk of contracting COVID-19, and … this perception led to higher participation in COVID-risky events,” Chian Jones Ritten, PhD, and associates said in PNAS Nexus.

They surveyed 757 students from the Univ. of Washington and 517 from the Univ. of Idaho and found that those who were tested more frequently perceived that they were less likely to contract the virus. Those respondents also more frequently attended indoor gatherings, both small and large, and spent more time in restaurants and bars.

The investigators did not mince words: “From a public health standpoint, such behavior is problematic.”

Current parents/participants in the workforce might have other ideas about an appropriate response to COVID.

At this point, we probably should mention that appropriation is the second-most sincere form of flattery.

Who watches the ED staff?

We heard a really great joke recently, one we simply have to share.

A man in Seattle went to a therapist. “I’m depressed,” he says. “Depressed, overworked, and lonely.”

Chinnapong/iStock/Getty Images

“Oh dear, that sounds quite serious,” the therapist replies. “Tell me all about it.”

“Life just seems so harsh and cruel,” the man explains. “The pandemic has caused 300,000 health care workers across the country to leave the industry.”

“Such as the doctor typically filling this role in the joke,” the therapist, who is not licensed to prescribe medicine, nods.

“Exactly! And with so many respiratory viruses circulating and COVID still hanging around, emergency departments all over the country are facing massive backups. People are waiting outside the hospital for hours, hoping a bed will open up. Things got so bad at a hospital near Seattle in October that a nurse called 911 on her own ED. Told the 911 operator to send the fire department to help out, since they were ‘drowning’ and ‘in dire straits.’ They had 45 patients waiting and only five nurses to take care of them.”

“That is quite serious,” the therapist says, scribbling down unseen notes.

“The fire chief did send a crew out, and they cleaned rooms, changed beds, and took vitals for 90 minutes until the crisis passed,” the man says. “But it’s only a matter of time before it happens again. The hospital president said they have 300 open positions, and literally no one has applied to work in the emergency department. Not one person.”

“And how does all this make you feel?” the therapist asks.

“I feel all alone,” the man says. “This world feels so threatening, like no one cares, and I have no idea what will come next. It’s so vague and uncertain.”

“Ah, I think I have a solution for you,” the therapist says. “Go to the emergency department at St. Michael Medical Center in Silverdale, near Seattle. They’ll get your bad mood all settled, and they’ll prescribe you the medicine you need to relax.”

The man bursts into tears. “You don’t understand,” he says. “I am the emergency department at St. Michael Medical Center.”

Good joke. Everybody laugh. Roll on snare drum. Curtains.

Myth buster: Supplements for cholesterol lowering

When it comes to that nasty low-density lipoprotein cholesterol, some people swear by supplements over statins as a holistic approach. Well, we’re busting the myth that those heart-healthy supplements are even effective in comparison.

Sally Kubetin/MDedge News

Which supplements are we talking about? These six are always on sale at the pharmacy: fish oil, cinnamon, garlic, turmeric, plant sterols, and red yeast rice.

In a study presented at the recent American Heart Association scientific sessions, researchers compared these supplements’ effectiveness in lowering LDL cholesterol with low-dose rosuvastatin or placebo among 199 adults aged 40-75 years who didn’t have a personal history of cardiovascular disease.

Participants who took the statin for 28 days had an average of 24% decrease in total cholesterol and a 38% reduction in LDL cholesterol, while 28 days’ worth of the supplements did no better than the placebo in either measure. Compared with placebo, the plant sterols supplement notably lowered HDL cholesterol and the garlic supplement notably increased LDL cholesterol.

Even though there are other studies showing the validity of plant sterols and red yeast rice to lower LDL cholesterol, author Luke J. Laffin, MD, of the Cleveland Clinic noted that this study shows how supplement results can vary and that more research is needed to see the effect they truly have on cholesterol over time.

So, should you stop taking or recommending supplements for heart health or healthy cholesterol levels? Well, we’re not going to come to your house and raid your medicine cabinet, but the authors of this study are definitely not saying that you should rely on them.

Consider this myth mostly busted.
 

COVID dept. of unintended consequences, part 2

The surveillance testing programs conducted in the first year of the pandemic were, in theory, meant to keep everyone safer. Someone, apparently, forgot to explain that to the students of the University of Wyoming and the University of Idaho.

Luis Alvarez/Getty Images

We’re all familiar with the drill: Students at the two schools had to undergo frequent COVID screening to keep the virus from spreading, thereby making everyone safer. Duck your head now, because here comes the unintended consequence.

The students who didn’t get COVID eventually, and perhaps not so surprisingly, “perceived that the mandatory testing policy decreased their risk of contracting COVID-19, and … this perception led to higher participation in COVID-risky events,” Chian Jones Ritten, PhD, and associates said in PNAS Nexus.

They surveyed 757 students from the Univ. of Washington and 517 from the Univ. of Idaho and found that those who were tested more frequently perceived that they were less likely to contract the virus. Those respondents also more frequently attended indoor gatherings, both small and large, and spent more time in restaurants and bars.

The investigators did not mince words: “From a public health standpoint, such behavior is problematic.”

Current parents/participants in the workforce might have other ideas about an appropriate response to COVID.

At this point, we probably should mention that appropriation is the second-most sincere form of flattery.

Who watches the ED staff?

We heard a really great joke recently, one we simply have to share.

A man in Seattle went to a therapist. “I’m depressed,” he says. “Depressed, overworked, and lonely.”

Chinnapong/iStock/Getty Images

“Oh dear, that sounds quite serious,” the therapist replies. “Tell me all about it.”

“Life just seems so harsh and cruel,” the man explains. “The pandemic has caused 300,000 health care workers across the country to leave the industry.”

“Such as the doctor typically filling this role in the joke,” the therapist, who is not licensed to prescribe medicine, nods.

“Exactly! And with so many respiratory viruses circulating and COVID still hanging around, emergency departments all over the country are facing massive backups. People are waiting outside the hospital for hours, hoping a bed will open up. Things got so bad at a hospital near Seattle in October that a nurse called 911 on her own ED. Told the 911 operator to send the fire department to help out, since they were ‘drowning’ and ‘in dire straits.’ They had 45 patients waiting and only five nurses to take care of them.”

“That is quite serious,” the therapist says, scribbling down unseen notes.

“The fire chief did send a crew out, and they cleaned rooms, changed beds, and took vitals for 90 minutes until the crisis passed,” the man says. “But it’s only a matter of time before it happens again. The hospital president said they have 300 open positions, and literally no one has applied to work in the emergency department. Not one person.”

“And how does all this make you feel?” the therapist asks.

“I feel all alone,” the man says. “This world feels so threatening, like no one cares, and I have no idea what will come next. It’s so vague and uncertain.”

“Ah, I think I have a solution for you,” the therapist says. “Go to the emergency department at St. Michael Medical Center in Silverdale, near Seattle. They’ll get your bad mood all settled, and they’ll prescribe you the medicine you need to relax.”

The man bursts into tears. “You don’t understand,” he says. “I am the emergency department at St. Michael Medical Center.”

Good joke. Everybody laugh. Roll on snare drum. Curtains.

Myth buster: Supplements for cholesterol lowering

When it comes to that nasty low-density lipoprotein cholesterol, some people swear by supplements over statins as a holistic approach. Well, we’re busting the myth that those heart-healthy supplements are even effective in comparison.

Sally Kubetin/MDedge News

Which supplements are we talking about? These six are always on sale at the pharmacy: fish oil, cinnamon, garlic, turmeric, plant sterols, and red yeast rice.

In a study presented at the recent American Heart Association scientific sessions, researchers compared these supplements’ effectiveness in lowering LDL cholesterol with low-dose rosuvastatin or placebo among 199 adults aged 40-75 years who didn’t have a personal history of cardiovascular disease.

Participants who took the statin for 28 days had an average of 24% decrease in total cholesterol and a 38% reduction in LDL cholesterol, while 28 days’ worth of the supplements did no better than the placebo in either measure. Compared with placebo, the plant sterols supplement notably lowered HDL cholesterol and the garlic supplement notably increased LDL cholesterol.

Even though there are other studies showing the validity of plant sterols and red yeast rice to lower LDL cholesterol, author Luke J. Laffin, MD, of the Cleveland Clinic noted that this study shows how supplement results can vary and that more research is needed to see the effect they truly have on cholesterol over time.

So, should you stop taking or recommending supplements for heart health or healthy cholesterol levels? Well, we’re not going to come to your house and raid your medicine cabinet, but the authors of this study are definitely not saying that you should rely on them.

Consider this myth mostly busted.
 

COVID dept. of unintended consequences, part 2

The surveillance testing programs conducted in the first year of the pandemic were, in theory, meant to keep everyone safer. Someone, apparently, forgot to explain that to the students of the University of Wyoming and the University of Idaho.

Luis Alvarez/Getty Images

We’re all familiar with the drill: Students at the two schools had to undergo frequent COVID screening to keep the virus from spreading, thereby making everyone safer. Duck your head now, because here comes the unintended consequence.

The students who didn’t get COVID eventually, and perhaps not so surprisingly, “perceived that the mandatory testing policy decreased their risk of contracting COVID-19, and … this perception led to higher participation in COVID-risky events,” Chian Jones Ritten, PhD, and associates said in PNAS Nexus.

They surveyed 757 students from the Univ. of Washington and 517 from the Univ. of Idaho and found that those who were tested more frequently perceived that they were less likely to contract the virus. Those respondents also more frequently attended indoor gatherings, both small and large, and spent more time in restaurants and bars.

The investigators did not mince words: “From a public health standpoint, such behavior is problematic.”

Current parents/participants in the workforce might have other ideas about an appropriate response to COVID.

At this point, we probably should mention that appropriation is the second-most sincere form of flattery.

A majority of states cover human papillomavirus vaccination through age 45 years with no need for prior authorization, which has implications for adults with certain dermatologic diseases, according to the authors of a review of Medicaid policies across all 50 states.

The human papillomavirus (HPV) vaccine is approved for people aged 9-45 years, for preventing genital, cervical, anal, and oropharyngeal cancers, and genital warts. And the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends routine vaccination with the HPV vaccine for individuals aged 9-26 years, with “shared clinical decision-making” recommended for vaccination of those aged 27-45 years, wrote Nathaniel Goldman of New York Medical College, Valhalla, and coauthors, from the University of Missouri–Kansas City and Harvard Medical School, Boston.

xrender/Thinkstock

Vaccine discussions are important in dermatology

“Dermatologists care for patients who may be an increased risk of vaccine-preventable illnesses, either from a skin disease or a dermatology medication,” corresponding author Megan H. Noe, MD, a dermatologist at Brigham and Women’s Hospital, and assistant professor of dermatology, Harvard Medical School, Boston, said in an interview. “Over the last several years, we have seen that all physicians, whether they provide vaccinations or not, can play an important role in discussing vaccines with their patients,” she said.  

“Vaccines can be cost-prohibitive for patients without insurance coverage, so we hope that dermatologists will be more likely to recommend the HPV vaccine to patients 27-45 years of age if they know that it is likely covered by insurance,” Dr. Noe noted.

Vaccine discussions

“I think it’s great that many Medicaid plans are covering HPV vaccination,” said Karl Saardi, MD, of the department of dermatology, George Washington University, Washington, who was asked to comment on the study. “I routinely recommend [vaccination] for patients who have viral warts, since it does lead to improvement in some cases,” Dr. Saardi, who was not involved in the current study, said in an interview. “Although we don’t have the HPV vaccines in our clinic for administration, my experience has been that patients are very open to discussing it with their primary care doctors.”

Although the upper age range continues to rise, “I think getting younger people vaccinated will also prove to be important,” said Dr. Saardi, director of the inpatient dermatology service at the George Washington University Hospital.

The point made in the current study about the importance of HPV vaccination in patients with hidradenitis suppurativa is also crucial, he added. “Since chronic skin inflammation in hidradenitis drives squamous cell carcinoma, reducing the impact of HPV on such cancers makes perfect sense.”

The study received no outside funding. Dr. Noe disclosed grants from Boehringer Ingelheim unrelated to the current study. Dr. Saardi had no financial conflicts to disclose.

A majority of states cover human papillomavirus vaccination through age 45 years with no need for prior authorization, which has implications for adults with certain dermatologic diseases, according to the authors of a review of Medicaid policies across all 50 states.

The human papillomavirus (HPV) vaccine is approved for people aged 9-45 years, for preventing genital, cervical, anal, and oropharyngeal cancers, and genital warts. And the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends routine vaccination with the HPV vaccine for individuals aged 9-26 years, with “shared clinical decision-making” recommended for vaccination of those aged 27-45 years, wrote Nathaniel Goldman of New York Medical College, Valhalla, and coauthors, from the University of Missouri–Kansas City and Harvard Medical School, Boston.

xrender/Thinkstock

Vaccine discussions are important in dermatology

“Dermatologists care for patients who may be an increased risk of vaccine-preventable illnesses, either from a skin disease or a dermatology medication,” corresponding author Megan H. Noe, MD, a dermatologist at Brigham and Women’s Hospital, and assistant professor of dermatology, Harvard Medical School, Boston, said in an interview. “Over the last several years, we have seen that all physicians, whether they provide vaccinations or not, can play an important role in discussing vaccines with their patients,” she said.  

“Vaccines can be cost-prohibitive for patients without insurance coverage, so we hope that dermatologists will be more likely to recommend the HPV vaccine to patients 27-45 years of age if they know that it is likely covered by insurance,” Dr. Noe noted.

Vaccine discussions

“I think it’s great that many Medicaid plans are covering HPV vaccination,” said Karl Saardi, MD, of the department of dermatology, George Washington University, Washington, who was asked to comment on the study. “I routinely recommend [vaccination] for patients who have viral warts, since it does lead to improvement in some cases,” Dr. Saardi, who was not involved in the current study, said in an interview. “Although we don’t have the HPV vaccines in our clinic for administration, my experience has been that patients are very open to discussing it with their primary care doctors.”

Although the upper age range continues to rise, “I think getting younger people vaccinated will also prove to be important,” said Dr. Saardi, director of the inpatient dermatology service at the George Washington University Hospital.

The point made in the current study about the importance of HPV vaccination in patients with hidradenitis suppurativa is also crucial, he added. “Since chronic skin inflammation in hidradenitis drives squamous cell carcinoma, reducing the impact of HPV on such cancers makes perfect sense.”

The study received no outside funding. Dr. Noe disclosed grants from Boehringer Ingelheim unrelated to the current study. Dr. Saardi had no financial conflicts to disclose.

A majority of states cover human papillomavirus vaccination through age 45 years with no need for prior authorization, which has implications for adults with certain dermatologic diseases, according to the authors of a review of Medicaid policies across all 50 states.

The human papillomavirus (HPV) vaccine is approved for people aged 9-45 years, for preventing genital, cervical, anal, and oropharyngeal cancers, and genital warts. And the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends routine vaccination with the HPV vaccine for individuals aged 9-26 years, with “shared clinical decision-making” recommended for vaccination of those aged 27-45 years, wrote Nathaniel Goldman of New York Medical College, Valhalla, and coauthors, from the University of Missouri–Kansas City and Harvard Medical School, Boston.

xrender/Thinkstock

Vaccine discussions are important in dermatology

“Dermatologists care for patients who may be an increased risk of vaccine-preventable illnesses, either from a skin disease or a dermatology medication,” corresponding author Megan H. Noe, MD, a dermatologist at Brigham and Women’s Hospital, and assistant professor of dermatology, Harvard Medical School, Boston, said in an interview. “Over the last several years, we have seen that all physicians, whether they provide vaccinations or not, can play an important role in discussing vaccines with their patients,” she said.  

“Vaccines can be cost-prohibitive for patients without insurance coverage, so we hope that dermatologists will be more likely to recommend the HPV vaccine to patients 27-45 years of age if they know that it is likely covered by insurance,” Dr. Noe noted.

Vaccine discussions

“I think it’s great that many Medicaid plans are covering HPV vaccination,” said Karl Saardi, MD, of the department of dermatology, George Washington University, Washington, who was asked to comment on the study. “I routinely recommend [vaccination] for patients who have viral warts, since it does lead to improvement in some cases,” Dr. Saardi, who was not involved in the current study, said in an interview. “Although we don’t have the HPV vaccines in our clinic for administration, my experience has been that patients are very open to discussing it with their primary care doctors.”

Although the upper age range continues to rise, “I think getting younger people vaccinated will also prove to be important,” said Dr. Saardi, director of the inpatient dermatology service at the George Washington University Hospital.

The point made in the current study about the importance of HPV vaccination in patients with hidradenitis suppurativa is also crucial, he added. “Since chronic skin inflammation in hidradenitis drives squamous cell carcinoma, reducing the impact of HPV on such cancers makes perfect sense.”

The study received no outside funding. Dr. Noe disclosed grants from Boehringer Ingelheim unrelated to the current study. Dr. Saardi had no financial conflicts to disclose.

This year Medscape surveyed more than 2,300 physicians about how they prioritized various social issues. Around half of them rated climate change among their five most important issues. Slightly lower percentages of doctors prioritized domestic violence and immigration/refugee policies that highly, and about 40% did so regarding reproductive rights in the United States.

Survey responses and comments left on the Physicians’ Views on Today’s Divisive Social Issues 2022 report provide insights into doctors’ attitudes and thinking about these four social challenges.
 

Relevance of climate change to health care

In the Medscape report, 61% of physicians described themselves as “very concerned” or “concerned” about climate change, and about 7 in 10 agreed with the statement that it should be a top worldwide priority. “Climate change is the most pressing issue of this century,” a psychiatrist respondent wrote.

What about direct effects on patients’ health? An internist worried that rising temperatures will cause “pathogens to spread and infect disadvantaged people who do not have health access and have immunocompromised conditions.” A family medicine physician predicted “more weather disasters, more asthma, more hormonal changes, and more obesity.”

However, physician viewpoints ran the gamut with an issue that has become politically and emotionally charged. Descriptions such as “overblown,” “hysteria,” “hoax,” and “farce” were used. “Climate change is a natural phenomenon under God’s purview,” an emergency medicine physician said.

And there was some middle-ground thinking. “It’s overstated but quite real,” a pediatrician respondent wrote. Added an ophthalmologist: “It has gone on for ages. We must work to decrease man-made conditions that affect climate change, but it must be done in an intelligent fashion.”
 

Domestic violence: What physicians can do

About 7 in 10 physicians surveyed by Medscape said they don’t think the United States is adequately tackling domestic violence. “It is underrecognized and ignored,” a psychiatrist respondent argued. The problem is “rampant and unacceptable, pushed into a closet and normalized, with associated shame,” an emergency medicine doctor wrote.

Many respondents noted that physicians are under a mandate to report abuse of or a suspicious injury to a patient. Some shared anecdotes about how they reported action they had taken when they suspected it. “I’ve told patients who may be in dangerous situations that I’m a safe person and provide a safe space,” a radiologist added. An internist said, “I’ve recently started to ask about safety at home during triage on every patient.”

Other doctors bemoaned a lack of adequate education on detecting and managing domestic violence and abuse. “Domestic violence is often not recognized by health care providers,” a psychiatrist respondent observed.
 

Expanding legal immigration

In the Medscape report, 34% of physicians felt U.S. immigration/refugee policies need to be tougher, while 28% said they are too restrictive, and about a fifth saw them as appropriate.

“As an immigrant, I can tell you that the system is flawed and needs a complete overhaul, which will take a bipartisan effort,” an endocrinologist respondent wrote.

A number of respondents argued that it’s critical to simplify the process of obtaining U.S. citizenship so that fewer will feel forced to enter the country illegally. “For a country that relies very heavily on immigrants to sustain our health care system, we behave like idiots in denying safe harbor,” a nephrologist asserted.

A neurologist concurred. “Legal immigration needs to be encouraged. It should be easier to exchange visitor or student visa to immigrant visa in order to retain talent in the health care and technology fields, which would alleviate the shortage of workers in health care.”
 

Reproductive rights: No easy answers

Medscape’s survey was conducted before the U.S. Supreme Court in June reversed Roe v. Wade. In the report, 71% of physicians described themselves as very to somewhat concerned about women’s reproductive rights, but their viewpoints became nuanced after that. “There is a big disparity among physicians on this topic,” an oncologist respondent wrote.

At one end of the spectrum, 3% of doctors felt that abortions should never be permitted. “The human baby in the womb is an independent person with the right to life,” a pathologist said. At the other end, nearly one-fourth of physicians believed abortion should be accessible under all circumstances, regardless of trimester or reason. “I am just here to support the woman and make her decision a reality,” an internist said.

While saying an abortion should be granted after “fetal viability” only “in extenuating circumstances,” an ob.gyn. respondent said she is “extremely concerned” about attacks on abortion rights. “Some of us are old enough to remember women coming to the ER in extremis after illegal procedures, prior to Roe v. Wade.”

A version of this article first appeared on Medscape.com.

This year Medscape surveyed more than 2,300 physicians about how they prioritized various social issues. Around half of them rated climate change among their five most important issues. Slightly lower percentages of doctors prioritized domestic violence and immigration/refugee policies that highly, and about 40% did so regarding reproductive rights in the United States.

Survey responses and comments left on the Physicians’ Views on Today’s Divisive Social Issues 2022 report provide insights into doctors’ attitudes and thinking about these four social challenges.
 

Relevance of climate change to health care

In the Medscape report, 61% of physicians described themselves as “very concerned” or “concerned” about climate change, and about 7 in 10 agreed with the statement that it should be a top worldwide priority. “Climate change is the most pressing issue of this century,” a psychiatrist respondent wrote.

What about direct effects on patients’ health? An internist worried that rising temperatures will cause “pathogens to spread and infect disadvantaged people who do not have health access and have immunocompromised conditions.” A family medicine physician predicted “more weather disasters, more asthma, more hormonal changes, and more obesity.”

However, physician viewpoints ran the gamut with an issue that has become politically and emotionally charged. Descriptions such as “overblown,” “hysteria,” “hoax,” and “farce” were used. “Climate change is a natural phenomenon under God’s purview,” an emergency medicine physician said.

And there was some middle-ground thinking. “It’s overstated but quite real,” a pediatrician respondent wrote. Added an ophthalmologist: “It has gone on for ages. We must work to decrease man-made conditions that affect climate change, but it must be done in an intelligent fashion.”
 

Domestic violence: What physicians can do

About 7 in 10 physicians surveyed by Medscape said they don’t think the United States is adequately tackling domestic violence. “It is underrecognized and ignored,” a psychiatrist respondent argued. The problem is “rampant and unacceptable, pushed into a closet and normalized, with associated shame,” an emergency medicine doctor wrote.

Many respondents noted that physicians are under a mandate to report abuse of or a suspicious injury to a patient. Some shared anecdotes about how they reported action they had taken when they suspected it. “I’ve told patients who may be in dangerous situations that I’m a safe person and provide a safe space,” a radiologist added. An internist said, “I’ve recently started to ask about safety at home during triage on every patient.”

Other doctors bemoaned a lack of adequate education on detecting and managing domestic violence and abuse. “Domestic violence is often not recognized by health care providers,” a psychiatrist respondent observed.
 

Expanding legal immigration

In the Medscape report, 34% of physicians felt U.S. immigration/refugee policies need to be tougher, while 28% said they are too restrictive, and about a fifth saw them as appropriate.

“As an immigrant, I can tell you that the system is flawed and needs a complete overhaul, which will take a bipartisan effort,” an endocrinologist respondent wrote.

A number of respondents argued that it’s critical to simplify the process of obtaining U.S. citizenship so that fewer will feel forced to enter the country illegally. “For a country that relies very heavily on immigrants to sustain our health care system, we behave like idiots in denying safe harbor,” a nephrologist asserted.

A neurologist concurred. “Legal immigration needs to be encouraged. It should be easier to exchange visitor or student visa to immigrant visa in order to retain talent in the health care and technology fields, which would alleviate the shortage of workers in health care.”
 

Reproductive rights: No easy answers

Medscape’s survey was conducted before the U.S. Supreme Court in June reversed Roe v. Wade. In the report, 71% of physicians described themselves as very to somewhat concerned about women’s reproductive rights, but their viewpoints became nuanced after that. “There is a big disparity among physicians on this topic,” an oncologist respondent wrote.

At one end of the spectrum, 3% of doctors felt that abortions should never be permitted. “The human baby in the womb is an independent person with the right to life,” a pathologist said. At the other end, nearly one-fourth of physicians believed abortion should be accessible under all circumstances, regardless of trimester or reason. “I am just here to support the woman and make her decision a reality,” an internist said.

While saying an abortion should be granted after “fetal viability” only “in extenuating circumstances,” an ob.gyn. respondent said she is “extremely concerned” about attacks on abortion rights. “Some of us are old enough to remember women coming to the ER in extremis after illegal procedures, prior to Roe v. Wade.”

A version of this article first appeared on Medscape.com.

This year Medscape surveyed more than 2,300 physicians about how they prioritized various social issues. Around half of them rated climate change among their five most important issues. Slightly lower percentages of doctors prioritized domestic violence and immigration/refugee policies that highly, and about 40% did so regarding reproductive rights in the United States.

Survey responses and comments left on the Physicians’ Views on Today’s Divisive Social Issues 2022 report provide insights into doctors’ attitudes and thinking about these four social challenges.
 

Relevance of climate change to health care

In the Medscape report, 61% of physicians described themselves as “very concerned” or “concerned” about climate change, and about 7 in 10 agreed with the statement that it should be a top worldwide priority. “Climate change is the most pressing issue of this century,” a psychiatrist respondent wrote.

What about direct effects on patients’ health? An internist worried that rising temperatures will cause “pathogens to spread and infect disadvantaged people who do not have health access and have immunocompromised conditions.” A family medicine physician predicted “more weather disasters, more asthma, more hormonal changes, and more obesity.”

However, physician viewpoints ran the gamut with an issue that has become politically and emotionally charged. Descriptions such as “overblown,” “hysteria,” “hoax,” and “farce” were used. “Climate change is a natural phenomenon under God’s purview,” an emergency medicine physician said.

And there was some middle-ground thinking. “It’s overstated but quite real,” a pediatrician respondent wrote. Added an ophthalmologist: “It has gone on for ages. We must work to decrease man-made conditions that affect climate change, but it must be done in an intelligent fashion.”
 

Domestic violence: What physicians can do

About 7 in 10 physicians surveyed by Medscape said they don’t think the United States is adequately tackling domestic violence. “It is underrecognized and ignored,” a psychiatrist respondent argued. The problem is “rampant and unacceptable, pushed into a closet and normalized, with associated shame,” an emergency medicine doctor wrote.

Many respondents noted that physicians are under a mandate to report abuse of or a suspicious injury to a patient. Some shared anecdotes about how they reported action they had taken when they suspected it. “I’ve told patients who may be in dangerous situations that I’m a safe person and provide a safe space,” a radiologist added. An internist said, “I’ve recently started to ask about safety at home during triage on every patient.”

Other doctors bemoaned a lack of adequate education on detecting and managing domestic violence and abuse. “Domestic violence is often not recognized by health care providers,” a psychiatrist respondent observed.
 

Expanding legal immigration

In the Medscape report, 34% of physicians felt U.S. immigration/refugee policies need to be tougher, while 28% said they are too restrictive, and about a fifth saw them as appropriate.

“As an immigrant, I can tell you that the system is flawed and needs a complete overhaul, which will take a bipartisan effort,” an endocrinologist respondent wrote.

A number of respondents argued that it’s critical to simplify the process of obtaining U.S. citizenship so that fewer will feel forced to enter the country illegally. “For a country that relies very heavily on immigrants to sustain our health care system, we behave like idiots in denying safe harbor,” a nephrologist asserted.

A neurologist concurred. “Legal immigration needs to be encouraged. It should be easier to exchange visitor or student visa to immigrant visa in order to retain talent in the health care and technology fields, which would alleviate the shortage of workers in health care.”
 

Reproductive rights: No easy answers

Medscape’s survey was conducted before the U.S. Supreme Court in June reversed Roe v. Wade. In the report, 71% of physicians described themselves as very to somewhat concerned about women’s reproductive rights, but their viewpoints became nuanced after that. “There is a big disparity among physicians on this topic,” an oncologist respondent wrote.

At one end of the spectrum, 3% of doctors felt that abortions should never be permitted. “The human baby in the womb is an independent person with the right to life,” a pathologist said. At the other end, nearly one-fourth of physicians believed abortion should be accessible under all circumstances, regardless of trimester or reason. “I am just here to support the woman and make her decision a reality,” an internist said.

While saying an abortion should be granted after “fetal viability” only “in extenuating circumstances,” an ob.gyn. respondent said she is “extremely concerned” about attacks on abortion rights. “Some of us are old enough to remember women coming to the ER in extremis after illegal procedures, prior to Roe v. Wade.”

A version of this article first appeared on Medscape.com.