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New guidance for those fully vaccinated against COVID-19
As has been dominating the headlines, the Centers for Disease Control and Prevention recently released updated public health guidance for those who are fully vaccinated against COVID-19.
This new guidance applies to those who are fully vaccinated as indicated by 2 weeks after the second dose in a 2-dose series or 2 weeks after a single-dose vaccine. Those who meet these criteria no longer need to wear a mask or physically distance themselves from others in both indoor and outdoor settings. For those not fully vaccinated, masking and social distancing should continue to be practiced.
The new guidance indicates that quarantine after a known exposure is no longer necessary.
Unless required by local, state, or territorial health authorities, testing is no longer required following domestic travel for fully vaccinated individuals. A negative test is still required prior to boarding an international flight to the United States and testing 3-5 days after arrival is still recommended. Self-quarantine is no longer required after international travel for fully vaccinated individuals.
The new guidance recommends that individuals who are fully vaccinated not participate in routine screening programs when feasible. Finally, if an individual has tested positive for COVID-19, regardless of vaccination status, that person should isolate and not visit public or private settings for a minimum of ten days.1
Updated guidance for health care facilities
In addition to changes for the general public in all settings, the CDC updated guidance for health care facilities on April 27, 2021. These updated guidelines allow for communal dining and visitation for fully vaccinated patients and their visitors. The guidelines indicate that fully vaccinated health care personnel (HCP) do not require quarantine after exposure to patients who have tested positive for COVID-19 as long as the HCP remains asymptomatic. They should, however, continue to utilize personal protective equipment as previously recommended. HCPs are able to be in break and meeting rooms unmasked if all HCPs are vaccinated.2
There are some important caveats to these updated guidelines. They do not apply to those who have immunocompromising conditions, including those using immunosuppressant agents. They also do not apply to locations subject to federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.
Those who work or reside in correction or detention facilities and homeless shelters are also still required to test after known exposures. Masking is still required by all travelers on all forms of public transportation into and within the United States.
Most importantly, the guidelines apply only to those who are fully vaccinated. Finally, no vaccine is perfect. As such, anyone who experiences symptoms indicative of COVID-19, regardless of vaccination status, should obtain viral testing and isolate themselves from others.1,2
Pros and cons to new guidance
Both sets of updated guidelines are a great example of public health guidance that is changing as the evidence is gathered and changes. This guidance is also a welcome encouragement that the vaccines are effective at decreasing transmission of this virus that has upended our world.
These guidelines leave room for change as evidence is gathered on emerging novel variants. There are, however, a few remaining concerns.
My first concern is for those who are not yet able to be vaccinated, including children under the age of 12. For families with members who are not fully vaccinated, they may have first heard the headlines of “you do not have to mask” to then read the fine print that remains. When truly following these guidelines, many social situations in both the public and private setting should still include both masking and social distancing.
There is no clarity on how these guidelines are enforced. Within the guidance, it is clear that individuals’ privacy is of utmost importance. In the absence of knowledge, that means that the assumption should be that all are not yet vaccinated. Unless there is a way to reliably demonstrate vaccination status, it would likely still be safer to assume that there are individuals who are not fully vaccinated within the setting.
Finally, although this is great news surrounding the efficacy of the vaccine, some are concerned that local mask mandates that have already started to be lifted will be completely removed. As there is still a large portion of the population not yet fully vaccinated, it seems premature for local, state, and territorial authorities to lift these mandates.
How to continue exercising caution
With the outstanding concerns, I will continue to mask in settings, particularly indoors, where I do not definitely know that everyone is vaccinated. I will continue to do this to protect my children and my patients who are not yet vaccinated, and my patients who are immunosuppressed for whom we do not yet have enough information.
I will continue to advise my patients to be thoughtful about the risk for themselves and their families as well.
There has been more benefit to these public health measures then just decreased transmission of COVID-19. I hope that this year has reinforced within us the benefits of masking and self-isolation in the cases of any contagious illnesses.
Although I am looking forward to the opportunities to interact in person with more colleagues and friends, I think we should continue to do this with caution and thoughtfulness. We must be prepared for the possibility of vaccines having decreased efficacy against novel variants as well as eventually the possibility of waning immunity. If these should occur, we need to be prepared for additional recommendation changes and tightening of restrictions.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. Centers for Disease Control and Prevention. Interim Public Health Recommendations for Fully Vaccinated People. U.S. Department of Health & Human Services, May 13, 2021.
2. Centers for Disease Control and Prevention. Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination. U.S. Department of Health and Human Services, April 27, 2021.
As has been dominating the headlines, the Centers for Disease Control and Prevention recently released updated public health guidance for those who are fully vaccinated against COVID-19.
This new guidance applies to those who are fully vaccinated as indicated by 2 weeks after the second dose in a 2-dose series or 2 weeks after a single-dose vaccine. Those who meet these criteria no longer need to wear a mask or physically distance themselves from others in both indoor and outdoor settings. For those not fully vaccinated, masking and social distancing should continue to be practiced.
The new guidance indicates that quarantine after a known exposure is no longer necessary.
Unless required by local, state, or territorial health authorities, testing is no longer required following domestic travel for fully vaccinated individuals. A negative test is still required prior to boarding an international flight to the United States and testing 3-5 days after arrival is still recommended. Self-quarantine is no longer required after international travel for fully vaccinated individuals.
The new guidance recommends that individuals who are fully vaccinated not participate in routine screening programs when feasible. Finally, if an individual has tested positive for COVID-19, regardless of vaccination status, that person should isolate and not visit public or private settings for a minimum of ten days.1
Updated guidance for health care facilities
In addition to changes for the general public in all settings, the CDC updated guidance for health care facilities on April 27, 2021. These updated guidelines allow for communal dining and visitation for fully vaccinated patients and their visitors. The guidelines indicate that fully vaccinated health care personnel (HCP) do not require quarantine after exposure to patients who have tested positive for COVID-19 as long as the HCP remains asymptomatic. They should, however, continue to utilize personal protective equipment as previously recommended. HCPs are able to be in break and meeting rooms unmasked if all HCPs are vaccinated.2
There are some important caveats to these updated guidelines. They do not apply to those who have immunocompromising conditions, including those using immunosuppressant agents. They also do not apply to locations subject to federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.
Those who work or reside in correction or detention facilities and homeless shelters are also still required to test after known exposures. Masking is still required by all travelers on all forms of public transportation into and within the United States.
Most importantly, the guidelines apply only to those who are fully vaccinated. Finally, no vaccine is perfect. As such, anyone who experiences symptoms indicative of COVID-19, regardless of vaccination status, should obtain viral testing and isolate themselves from others.1,2
Pros and cons to new guidance
Both sets of updated guidelines are a great example of public health guidance that is changing as the evidence is gathered and changes. This guidance is also a welcome encouragement that the vaccines are effective at decreasing transmission of this virus that has upended our world.
These guidelines leave room for change as evidence is gathered on emerging novel variants. There are, however, a few remaining concerns.
My first concern is for those who are not yet able to be vaccinated, including children under the age of 12. For families with members who are not fully vaccinated, they may have first heard the headlines of “you do not have to mask” to then read the fine print that remains. When truly following these guidelines, many social situations in both the public and private setting should still include both masking and social distancing.
There is no clarity on how these guidelines are enforced. Within the guidance, it is clear that individuals’ privacy is of utmost importance. In the absence of knowledge, that means that the assumption should be that all are not yet vaccinated. Unless there is a way to reliably demonstrate vaccination status, it would likely still be safer to assume that there are individuals who are not fully vaccinated within the setting.
Finally, although this is great news surrounding the efficacy of the vaccine, some are concerned that local mask mandates that have already started to be lifted will be completely removed. As there is still a large portion of the population not yet fully vaccinated, it seems premature for local, state, and territorial authorities to lift these mandates.
How to continue exercising caution
With the outstanding concerns, I will continue to mask in settings, particularly indoors, where I do not definitely know that everyone is vaccinated. I will continue to do this to protect my children and my patients who are not yet vaccinated, and my patients who are immunosuppressed for whom we do not yet have enough information.
I will continue to advise my patients to be thoughtful about the risk for themselves and their families as well.
There has been more benefit to these public health measures then just decreased transmission of COVID-19. I hope that this year has reinforced within us the benefits of masking and self-isolation in the cases of any contagious illnesses.
Although I am looking forward to the opportunities to interact in person with more colleagues and friends, I think we should continue to do this with caution and thoughtfulness. We must be prepared for the possibility of vaccines having decreased efficacy against novel variants as well as eventually the possibility of waning immunity. If these should occur, we need to be prepared for additional recommendation changes and tightening of restrictions.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. Centers for Disease Control and Prevention. Interim Public Health Recommendations for Fully Vaccinated People. U.S. Department of Health & Human Services, May 13, 2021.
2. Centers for Disease Control and Prevention. Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination. U.S. Department of Health and Human Services, April 27, 2021.
As has been dominating the headlines, the Centers for Disease Control and Prevention recently released updated public health guidance for those who are fully vaccinated against COVID-19.
This new guidance applies to those who are fully vaccinated as indicated by 2 weeks after the second dose in a 2-dose series or 2 weeks after a single-dose vaccine. Those who meet these criteria no longer need to wear a mask or physically distance themselves from others in both indoor and outdoor settings. For those not fully vaccinated, masking and social distancing should continue to be practiced.
The new guidance indicates that quarantine after a known exposure is no longer necessary.
Unless required by local, state, or territorial health authorities, testing is no longer required following domestic travel for fully vaccinated individuals. A negative test is still required prior to boarding an international flight to the United States and testing 3-5 days after arrival is still recommended. Self-quarantine is no longer required after international travel for fully vaccinated individuals.
The new guidance recommends that individuals who are fully vaccinated not participate in routine screening programs when feasible. Finally, if an individual has tested positive for COVID-19, regardless of vaccination status, that person should isolate and not visit public or private settings for a minimum of ten days.1
Updated guidance for health care facilities
In addition to changes for the general public in all settings, the CDC updated guidance for health care facilities on April 27, 2021. These updated guidelines allow for communal dining and visitation for fully vaccinated patients and their visitors. The guidelines indicate that fully vaccinated health care personnel (HCP) do not require quarantine after exposure to patients who have tested positive for COVID-19 as long as the HCP remains asymptomatic. They should, however, continue to utilize personal protective equipment as previously recommended. HCPs are able to be in break and meeting rooms unmasked if all HCPs are vaccinated.2
There are some important caveats to these updated guidelines. They do not apply to those who have immunocompromising conditions, including those using immunosuppressant agents. They also do not apply to locations subject to federal, state, local, tribal, or territorial laws, rules, and regulations, including local business and workplace guidance.
Those who work or reside in correction or detention facilities and homeless shelters are also still required to test after known exposures. Masking is still required by all travelers on all forms of public transportation into and within the United States.
Most importantly, the guidelines apply only to those who are fully vaccinated. Finally, no vaccine is perfect. As such, anyone who experiences symptoms indicative of COVID-19, regardless of vaccination status, should obtain viral testing and isolate themselves from others.1,2
Pros and cons to new guidance
Both sets of updated guidelines are a great example of public health guidance that is changing as the evidence is gathered and changes. This guidance is also a welcome encouragement that the vaccines are effective at decreasing transmission of this virus that has upended our world.
These guidelines leave room for change as evidence is gathered on emerging novel variants. There are, however, a few remaining concerns.
My first concern is for those who are not yet able to be vaccinated, including children under the age of 12. For families with members who are not fully vaccinated, they may have first heard the headlines of “you do not have to mask” to then read the fine print that remains. When truly following these guidelines, many social situations in both the public and private setting should still include both masking and social distancing.
There is no clarity on how these guidelines are enforced. Within the guidance, it is clear that individuals’ privacy is of utmost importance. In the absence of knowledge, that means that the assumption should be that all are not yet vaccinated. Unless there is a way to reliably demonstrate vaccination status, it would likely still be safer to assume that there are individuals who are not fully vaccinated within the setting.
Finally, although this is great news surrounding the efficacy of the vaccine, some are concerned that local mask mandates that have already started to be lifted will be completely removed. As there is still a large portion of the population not yet fully vaccinated, it seems premature for local, state, and territorial authorities to lift these mandates.
How to continue exercising caution
With the outstanding concerns, I will continue to mask in settings, particularly indoors, where I do not definitely know that everyone is vaccinated. I will continue to do this to protect my children and my patients who are not yet vaccinated, and my patients who are immunosuppressed for whom we do not yet have enough information.
I will continue to advise my patients to be thoughtful about the risk for themselves and their families as well.
There has been more benefit to these public health measures then just decreased transmission of COVID-19. I hope that this year has reinforced within us the benefits of masking and self-isolation in the cases of any contagious illnesses.
Although I am looking forward to the opportunities to interact in person with more colleagues and friends, I think we should continue to do this with caution and thoughtfulness. We must be prepared for the possibility of vaccines having decreased efficacy against novel variants as well as eventually the possibility of waning immunity. If these should occur, we need to be prepared for additional recommendation changes and tightening of restrictions.
Dr. Wheat is a family physician at Erie Family Health Center in Chicago. She is program director of Northwestern’s McGaw Family Medicine residency program at Humboldt Park, Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].
References
1. Centers for Disease Control and Prevention. Interim Public Health Recommendations for Fully Vaccinated People. U.S. Department of Health & Human Services, May 13, 2021.
2. Centers for Disease Control and Prevention. Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination. U.S. Department of Health and Human Services, April 27, 2021.
Use your court awareness to go faster in practice
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
A woman with scaling, and painful, crusted, erythematous papules and pustules on her face
Biopsy for this patient revealed folliculitis with Demodex mites visualized on histology. Direct immunofluorescence was negative. A KOH preparation was performed and was positive for large numbers of Demodex. Bacterial cultures were negative. The patient was started on a course of submicrobial doxycycline and ivermectin and showed marked improvement 1 month following treatment.
Demodex folliculorum and Demodex brevis (collectively referred to as Demodex) are microscopic parasitic mites that commonly live on human skin.1 Typically, the mite remains asymptomatic. However, in higher numbers, the infestation may cause dermatoses, called demodicosis. Lesions often present as itchy papules, pustules, and erythematous scaling on the face, ears, and scalp. Blepharitis may be present. Demodex folliculitis is more common in immunocompromised patients.2
Demodex may have a causative role in rosacea and present similarly, with a key difference being that Demodex-type rosacea is more scaly/dry and pustular than common rosacea.1 In Demodex folliculitis, bacterial cultures are often negative. A skin scraping for KOH will reveal increased mite colonization. The Demodex mite may also be seen in histologic slides.
Treatment of Demodex folliculitis includes crotamiton cream, permethrin cream, oral tetracyclines, topical or systemic metronidazole, and topical or oral ivermectin.
This case and photos were submitted by Susannah McClain, MD, Three Rivers Dermatology, Pittsburgh.
References
1. Rather PA and Hassan I. Indian J Dermatol. 2014 Jan;59(1):60-6.
2. Bachmeyer C and Moreno-Sabater A. CMAJ. 2017 Jun 26;189(25):E865.
Biopsy for this patient revealed folliculitis with Demodex mites visualized on histology. Direct immunofluorescence was negative. A KOH preparation was performed and was positive for large numbers of Demodex. Bacterial cultures were negative. The patient was started on a course of submicrobial doxycycline and ivermectin and showed marked improvement 1 month following treatment.
Demodex folliculorum and Demodex brevis (collectively referred to as Demodex) are microscopic parasitic mites that commonly live on human skin.1 Typically, the mite remains asymptomatic. However, in higher numbers, the infestation may cause dermatoses, called demodicosis. Lesions often present as itchy papules, pustules, and erythematous scaling on the face, ears, and scalp. Blepharitis may be present. Demodex folliculitis is more common in immunocompromised patients.2
Demodex may have a causative role in rosacea and present similarly, with a key difference being that Demodex-type rosacea is more scaly/dry and pustular than common rosacea.1 In Demodex folliculitis, bacterial cultures are often negative. A skin scraping for KOH will reveal increased mite colonization. The Demodex mite may also be seen in histologic slides.
Treatment of Demodex folliculitis includes crotamiton cream, permethrin cream, oral tetracyclines, topical or systemic metronidazole, and topical or oral ivermectin.
This case and photos were submitted by Susannah McClain, MD, Three Rivers Dermatology, Pittsburgh.
References
1. Rather PA and Hassan I. Indian J Dermatol. 2014 Jan;59(1):60-6.
2. Bachmeyer C and Moreno-Sabater A. CMAJ. 2017 Jun 26;189(25):E865.
Biopsy for this patient revealed folliculitis with Demodex mites visualized on histology. Direct immunofluorescence was negative. A KOH preparation was performed and was positive for large numbers of Demodex. Bacterial cultures were negative. The patient was started on a course of submicrobial doxycycline and ivermectin and showed marked improvement 1 month following treatment.
Demodex folliculorum and Demodex brevis (collectively referred to as Demodex) are microscopic parasitic mites that commonly live on human skin.1 Typically, the mite remains asymptomatic. However, in higher numbers, the infestation may cause dermatoses, called demodicosis. Lesions often present as itchy papules, pustules, and erythematous scaling on the face, ears, and scalp. Blepharitis may be present. Demodex folliculitis is more common in immunocompromised patients.2
Demodex may have a causative role in rosacea and present similarly, with a key difference being that Demodex-type rosacea is more scaly/dry and pustular than common rosacea.1 In Demodex folliculitis, bacterial cultures are often negative. A skin scraping for KOH will reveal increased mite colonization. The Demodex mite may also be seen in histologic slides.
Treatment of Demodex folliculitis includes crotamiton cream, permethrin cream, oral tetracyclines, topical or systemic metronidazole, and topical or oral ivermectin.
This case and photos were submitted by Susannah McClain, MD, Three Rivers Dermatology, Pittsburgh.
References
1. Rather PA and Hassan I. Indian J Dermatol. 2014 Jan;59(1):60-6.
2. Bachmeyer C and Moreno-Sabater A. CMAJ. 2017 Jun 26;189(25):E865.
Dr. Fauci: Extraordinary challenges, scientific triumphs with COVID-19
“Vaccines have been the bright light of this extraordinary challenge that we’ve gone through,” said Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.
In an address for the opening ceremony of the American Thoracic Society’s virtual international conference, Dr. Fauci emphasized the role of basic and clinical research and government support for science in helping turn the tide of the COVID-19 pandemic.
“A few weeks ago, I wrote an editorial in Science, because there was some misunderstanding about how and why we were able to go from a realization of a new pathogen in January of 2020, to getting doses of vaccines in the arms of individuals – a highly efficacious vaccine – 11 months later. Truly, an unprecedented accomplishment,” he said.
“But as I said in the editorial, the speed and efficiency with which these highly efficacious vaccines were developed, and their potential for saving millions of lives, are due to an extraordinary multidisciplinary effort, involving basic, preclinical, and clinical science that had been underway – out of the spotlight – for decades and decades before the unfolding of the COVID-19 pandemic, a fact that very few people really appreciate: namely, the importance of investment in biomedical research.”
The general addresses the troops
Perhaps no other audience is so well suited to receive Dr. Fauci’s speech as those who are currently attending (virtually) the ATS conference, including researchers who scrutinize the virus from every angle to describe its workings and identify its vulnerabilities, epidemiologists who study viral transmission and look for ways to thwart it, public health workers who fan out to communities across the country to push vaccine acceptance, and clinicians who specialize in critical care and pulmonary medicine, many of whom staff the respiratory floors and intensive care units where the most severely ill patients are treated.
Speaking about the lessons learned and challenges remaining from the COVID-19 pandemic, Dr. Fauci briefly reviewed the epidemiology, virology and transmission, diagnostics, and clinical course of SARS-CoV-2 infections and the therapeutics and vaccines for COVID-19.
Epidemiology
The pandemic began in December 2019 with recognition of a novel type of pneumonia in the Wuhan District of Central China, Dr. Fauci noted.
“Very quickly thereafter, in the first week of January 2020, the Chinese identified a new strain of coronavirus as [the] source of the outbreak. Fast forward to where we are right now: We have experienced and are experiencing the most devastating pandemic of a respiratory illness in the last 102 years, with already approximately 160 million individuals having been infected – and this is clearly a gross undercounting – and also 3.3 million deaths, again, very likely an undercounting,” he said.
According to the Centers for Disease Control and Prevention, as of May 9, 2021, there were approximately 32.5 million cases of COVID-19 and 578,520 deaths in the United States. Those cases and deaths occurred largely in three surges in the United States, in early spring, early summer, and late fall of 2020.
Virology and transmission
SARS-CoV-2 is a beta-coronavirus in the same subgenus as SARS-CoV-1 and some bat coronaviruses, Dr. Fauci explained. The viral genome is large, about 30,000 kilobases, and it has four structural proteins, most importantly the S or “spike” protein that allows the virus to attach to and fuse with cell membranes by binding to the ACE2 receptor on tissues in the upper and lower respiratory tract, gastrointestinal tract, cardiovascular system, and other organ systems.
The virus is transmitted mainly through exposure to respiratory droplets within 6 feet of an infected person, or sometimes through droplets or particles that remain in the air over time and various distances.
Contact with contaminated surfaces, once feared as a means of transmission, is now understood to be less common.
The virus has been detected in stool, blood, semen, and ocular secretions, although the role of transmission through these sources is still unknown.
“Some very interesting characteristics of this virus, really quite unique compared to other viruses, certainly other respiratory viruses, is [that] about a third to 40% of people who are infected never develop any symptoms,” Dr. Fauci said. “Importantly, and very problematic to what we do to contain it – particularly with regard to identification, isolation, and contract tracing – between 50% and 60% of the transmissions occur either from someone who will never develop symptoms, or someone in the presymptomatic phase of disease.”
The fundamentals of preventing acquisition and transmission are as familiar to most Americans now as the Pledge of Allegiance: universal mask wearing, physical distancing, avoiding crowds and congregate settings, preference for outdoor over indoor settings, and frequent hand washing, he noted.
Diagnostics
Tests for SARS-CoV-2 infection fall into three basic categories: molecular tests such as polymerase chain reaction (PCR) that are highly specific and highly sensitive for actual infections, antigen tests that detect the viral protein rather than the nucleic acids, and antibody tests to detect serum proteins made in response to viral infection.
Antigen testing is used largely for broader surveillance of groups of individuals to detect viral penetrance within that group, Dr. Fauci noted.
Clinical course
The clinical course of COVID-19 has some interesting characteristics but is not substantially different from a flu-like syndrome, Dr. Fauci said.
Symptoms and signs common to both types of infections include fever, cough, fatigue, anorexia, dyspnea, and myalgias, but the loss of smell and/or taste preceding the onset of respiratory symptoms is a unique feature of COVID-19.
Dr. Fauci cited data on more than 44,000 individuals with confirmed COVID-19 in China that showed that a large majority (81%) of cases were mild or moderate in nature, but 14% of patients experienced severe disease, and 5% were critically ill. The case-fatality rate in this study was 2.3%.
People at increased risk for severe disease include older adults and those of any age with certain comorbidities.
Manifestations of severe COVID-19 infections in adults can include neurological disorders, hyperinflammation, acute respiratory distress syndrome, cardiac dysfunction, hypercoagulability, and acute kidney injury.
In children, COVID-19 has been associated with a multisystem inflammatory syndrome (MIS-C) similar to Kawasaki disease.
In a substantial number of cases, the effects of COVID-19 can linger for 6 months or longer, Dr. Fauci said, pointing to a study from the University of Washington in Seattle.
Investigators there found that approximately 30% of patients enrolled at their center reported persistent symptoms for as long as 9 months after the initial illness, with fatigue as the most commonly reported symptom. One-third of outpatients with mild disease also reported persistent symptoms.
Therapeutics
Therapeutics that are either approved by the Food and Drug Administration, have emergency use authorization, or are in clinical trials for early or moderate disease include remdesivir (Veklury, Gilead Sciences), monoclonal antibodies, convalescent plasma, antiviral agents, hyperimmune globulin, anticoagulants, and immunomodulators.
Options for moderate to severe to advanced disease include dexamethasone, baricitinib (Olumiant, Eli Lilly and Company) plus remdesivir, and immunomodulators such as infliximab (Remicade, Janssen Biotech), and biosimilars.
Vaccines
Finally, Dr. Fauci reviewed the current state of vaccines, including the three with emergency use authorization from the FDA as of this writing: two nucleic acid, messenger RNA-based (mRNA) vaccines from Moderna and Pfizer/BioNTech, and an adenoviral vector-based vaccine from Johnson & Johnson.
Other vaccines in development or in use elsewhere in the world include recombinant protein and adjuvant approaches by GlaxoSmithKline and Sanofi (in a phase 2 clinical trial launched in February 2021) and by Novavax.
The three vaccines in use in the United States were highly efficacious in both clinical trials, with efficacy of about 95% for the mRNA vaccines and 67% for the Johnson & Johnson vaccine.
The real-world performance of these vaccines has been even more impressive, however.
For example, the Johnson & Johnson vaccine had 72% efficacy at preventing moderate to severe COVID 19 in the United States, 68% in Brazil, and 64% in South Africa, and 85% efficacy against severe disease across all regions studied, Dr. Fauci said.
He cited a study of 22,234 employees of the University of Texas Southwestern Medical Center in Dallas who were vaccinated under a program started on Dec. 15, 2020. The COVID-19 infection rate among these vaccinated employees was 0.05%.
Dr. Fauci recounted the experience in Israel, where the highly transmissible B.1.1.7 strain of SARS-CoV-2 is predominant. A chart of the progress shows clearly that as the vaccine doses delivered steadily increased, the number of COVID-19 cases began a precipitous decline.
Horse race
Fittingly for a speech presented on the day that the Preakness Stakes – the second leg in thoroughbred racing’s Triple Crown – was run, Dr. Fauci closed with a cartoon showing two racehorses, labeled “SARS-CoV-2” and “Vaccines,” nearly neck-and-neck, but with vaccines having a slight lead.
“We are in a race against the virus. The vaccines, and the virus: If we vaccinate the overwhelming proportion of our population, we will without a doubt be able to crush the outbreak in the same way as we have done with other viral-borne diseases like measles, smallpox, and polio.
“So, the message is: Get vaccinated,” he concluded.
“Vaccines have been the bright light of this extraordinary challenge that we’ve gone through,” said Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.
In an address for the opening ceremony of the American Thoracic Society’s virtual international conference, Dr. Fauci emphasized the role of basic and clinical research and government support for science in helping turn the tide of the COVID-19 pandemic.
“A few weeks ago, I wrote an editorial in Science, because there was some misunderstanding about how and why we were able to go from a realization of a new pathogen in January of 2020, to getting doses of vaccines in the arms of individuals – a highly efficacious vaccine – 11 months later. Truly, an unprecedented accomplishment,” he said.
“But as I said in the editorial, the speed and efficiency with which these highly efficacious vaccines were developed, and their potential for saving millions of lives, are due to an extraordinary multidisciplinary effort, involving basic, preclinical, and clinical science that had been underway – out of the spotlight – for decades and decades before the unfolding of the COVID-19 pandemic, a fact that very few people really appreciate: namely, the importance of investment in biomedical research.”
The general addresses the troops
Perhaps no other audience is so well suited to receive Dr. Fauci’s speech as those who are currently attending (virtually) the ATS conference, including researchers who scrutinize the virus from every angle to describe its workings and identify its vulnerabilities, epidemiologists who study viral transmission and look for ways to thwart it, public health workers who fan out to communities across the country to push vaccine acceptance, and clinicians who specialize in critical care and pulmonary medicine, many of whom staff the respiratory floors and intensive care units where the most severely ill patients are treated.
Speaking about the lessons learned and challenges remaining from the COVID-19 pandemic, Dr. Fauci briefly reviewed the epidemiology, virology and transmission, diagnostics, and clinical course of SARS-CoV-2 infections and the therapeutics and vaccines for COVID-19.
Epidemiology
The pandemic began in December 2019 with recognition of a novel type of pneumonia in the Wuhan District of Central China, Dr. Fauci noted.
“Very quickly thereafter, in the first week of January 2020, the Chinese identified a new strain of coronavirus as [the] source of the outbreak. Fast forward to where we are right now: We have experienced and are experiencing the most devastating pandemic of a respiratory illness in the last 102 years, with already approximately 160 million individuals having been infected – and this is clearly a gross undercounting – and also 3.3 million deaths, again, very likely an undercounting,” he said.
According to the Centers for Disease Control and Prevention, as of May 9, 2021, there were approximately 32.5 million cases of COVID-19 and 578,520 deaths in the United States. Those cases and deaths occurred largely in three surges in the United States, in early spring, early summer, and late fall of 2020.
Virology and transmission
SARS-CoV-2 is a beta-coronavirus in the same subgenus as SARS-CoV-1 and some bat coronaviruses, Dr. Fauci explained. The viral genome is large, about 30,000 kilobases, and it has four structural proteins, most importantly the S or “spike” protein that allows the virus to attach to and fuse with cell membranes by binding to the ACE2 receptor on tissues in the upper and lower respiratory tract, gastrointestinal tract, cardiovascular system, and other organ systems.
The virus is transmitted mainly through exposure to respiratory droplets within 6 feet of an infected person, or sometimes through droplets or particles that remain in the air over time and various distances.
Contact with contaminated surfaces, once feared as a means of transmission, is now understood to be less common.
The virus has been detected in stool, blood, semen, and ocular secretions, although the role of transmission through these sources is still unknown.
“Some very interesting characteristics of this virus, really quite unique compared to other viruses, certainly other respiratory viruses, is [that] about a third to 40% of people who are infected never develop any symptoms,” Dr. Fauci said. “Importantly, and very problematic to what we do to contain it – particularly with regard to identification, isolation, and contract tracing – between 50% and 60% of the transmissions occur either from someone who will never develop symptoms, or someone in the presymptomatic phase of disease.”
The fundamentals of preventing acquisition and transmission are as familiar to most Americans now as the Pledge of Allegiance: universal mask wearing, physical distancing, avoiding crowds and congregate settings, preference for outdoor over indoor settings, and frequent hand washing, he noted.
Diagnostics
Tests for SARS-CoV-2 infection fall into three basic categories: molecular tests such as polymerase chain reaction (PCR) that are highly specific and highly sensitive for actual infections, antigen tests that detect the viral protein rather than the nucleic acids, and antibody tests to detect serum proteins made in response to viral infection.
Antigen testing is used largely for broader surveillance of groups of individuals to detect viral penetrance within that group, Dr. Fauci noted.
Clinical course
The clinical course of COVID-19 has some interesting characteristics but is not substantially different from a flu-like syndrome, Dr. Fauci said.
Symptoms and signs common to both types of infections include fever, cough, fatigue, anorexia, dyspnea, and myalgias, but the loss of smell and/or taste preceding the onset of respiratory symptoms is a unique feature of COVID-19.
Dr. Fauci cited data on more than 44,000 individuals with confirmed COVID-19 in China that showed that a large majority (81%) of cases were mild or moderate in nature, but 14% of patients experienced severe disease, and 5% were critically ill. The case-fatality rate in this study was 2.3%.
People at increased risk for severe disease include older adults and those of any age with certain comorbidities.
Manifestations of severe COVID-19 infections in adults can include neurological disorders, hyperinflammation, acute respiratory distress syndrome, cardiac dysfunction, hypercoagulability, and acute kidney injury.
In children, COVID-19 has been associated with a multisystem inflammatory syndrome (MIS-C) similar to Kawasaki disease.
In a substantial number of cases, the effects of COVID-19 can linger for 6 months or longer, Dr. Fauci said, pointing to a study from the University of Washington in Seattle.
Investigators there found that approximately 30% of patients enrolled at their center reported persistent symptoms for as long as 9 months after the initial illness, with fatigue as the most commonly reported symptom. One-third of outpatients with mild disease also reported persistent symptoms.
Therapeutics
Therapeutics that are either approved by the Food and Drug Administration, have emergency use authorization, or are in clinical trials for early or moderate disease include remdesivir (Veklury, Gilead Sciences), monoclonal antibodies, convalescent plasma, antiviral agents, hyperimmune globulin, anticoagulants, and immunomodulators.
Options for moderate to severe to advanced disease include dexamethasone, baricitinib (Olumiant, Eli Lilly and Company) plus remdesivir, and immunomodulators such as infliximab (Remicade, Janssen Biotech), and biosimilars.
Vaccines
Finally, Dr. Fauci reviewed the current state of vaccines, including the three with emergency use authorization from the FDA as of this writing: two nucleic acid, messenger RNA-based (mRNA) vaccines from Moderna and Pfizer/BioNTech, and an adenoviral vector-based vaccine from Johnson & Johnson.
Other vaccines in development or in use elsewhere in the world include recombinant protein and adjuvant approaches by GlaxoSmithKline and Sanofi (in a phase 2 clinical trial launched in February 2021) and by Novavax.
The three vaccines in use in the United States were highly efficacious in both clinical trials, with efficacy of about 95% for the mRNA vaccines and 67% for the Johnson & Johnson vaccine.
The real-world performance of these vaccines has been even more impressive, however.
For example, the Johnson & Johnson vaccine had 72% efficacy at preventing moderate to severe COVID 19 in the United States, 68% in Brazil, and 64% in South Africa, and 85% efficacy against severe disease across all regions studied, Dr. Fauci said.
He cited a study of 22,234 employees of the University of Texas Southwestern Medical Center in Dallas who were vaccinated under a program started on Dec. 15, 2020. The COVID-19 infection rate among these vaccinated employees was 0.05%.
Dr. Fauci recounted the experience in Israel, where the highly transmissible B.1.1.7 strain of SARS-CoV-2 is predominant. A chart of the progress shows clearly that as the vaccine doses delivered steadily increased, the number of COVID-19 cases began a precipitous decline.
Horse race
Fittingly for a speech presented on the day that the Preakness Stakes – the second leg in thoroughbred racing’s Triple Crown – was run, Dr. Fauci closed with a cartoon showing two racehorses, labeled “SARS-CoV-2” and “Vaccines,” nearly neck-and-neck, but with vaccines having a slight lead.
“We are in a race against the virus. The vaccines, and the virus: If we vaccinate the overwhelming proportion of our population, we will without a doubt be able to crush the outbreak in the same way as we have done with other viral-borne diseases like measles, smallpox, and polio.
“So, the message is: Get vaccinated,” he concluded.
“Vaccines have been the bright light of this extraordinary challenge that we’ve gone through,” said Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases.
In an address for the opening ceremony of the American Thoracic Society’s virtual international conference, Dr. Fauci emphasized the role of basic and clinical research and government support for science in helping turn the tide of the COVID-19 pandemic.
“A few weeks ago, I wrote an editorial in Science, because there was some misunderstanding about how and why we were able to go from a realization of a new pathogen in January of 2020, to getting doses of vaccines in the arms of individuals – a highly efficacious vaccine – 11 months later. Truly, an unprecedented accomplishment,” he said.
“But as I said in the editorial, the speed and efficiency with which these highly efficacious vaccines were developed, and their potential for saving millions of lives, are due to an extraordinary multidisciplinary effort, involving basic, preclinical, and clinical science that had been underway – out of the spotlight – for decades and decades before the unfolding of the COVID-19 pandemic, a fact that very few people really appreciate: namely, the importance of investment in biomedical research.”
The general addresses the troops
Perhaps no other audience is so well suited to receive Dr. Fauci’s speech as those who are currently attending (virtually) the ATS conference, including researchers who scrutinize the virus from every angle to describe its workings and identify its vulnerabilities, epidemiologists who study viral transmission and look for ways to thwart it, public health workers who fan out to communities across the country to push vaccine acceptance, and clinicians who specialize in critical care and pulmonary medicine, many of whom staff the respiratory floors and intensive care units where the most severely ill patients are treated.
Speaking about the lessons learned and challenges remaining from the COVID-19 pandemic, Dr. Fauci briefly reviewed the epidemiology, virology and transmission, diagnostics, and clinical course of SARS-CoV-2 infections and the therapeutics and vaccines for COVID-19.
Epidemiology
The pandemic began in December 2019 with recognition of a novel type of pneumonia in the Wuhan District of Central China, Dr. Fauci noted.
“Very quickly thereafter, in the first week of January 2020, the Chinese identified a new strain of coronavirus as [the] source of the outbreak. Fast forward to where we are right now: We have experienced and are experiencing the most devastating pandemic of a respiratory illness in the last 102 years, with already approximately 160 million individuals having been infected – and this is clearly a gross undercounting – and also 3.3 million deaths, again, very likely an undercounting,” he said.
According to the Centers for Disease Control and Prevention, as of May 9, 2021, there were approximately 32.5 million cases of COVID-19 and 578,520 deaths in the United States. Those cases and deaths occurred largely in three surges in the United States, in early spring, early summer, and late fall of 2020.
Virology and transmission
SARS-CoV-2 is a beta-coronavirus in the same subgenus as SARS-CoV-1 and some bat coronaviruses, Dr. Fauci explained. The viral genome is large, about 30,000 kilobases, and it has four structural proteins, most importantly the S or “spike” protein that allows the virus to attach to and fuse with cell membranes by binding to the ACE2 receptor on tissues in the upper and lower respiratory tract, gastrointestinal tract, cardiovascular system, and other organ systems.
The virus is transmitted mainly through exposure to respiratory droplets within 6 feet of an infected person, or sometimes through droplets or particles that remain in the air over time and various distances.
Contact with contaminated surfaces, once feared as a means of transmission, is now understood to be less common.
The virus has been detected in stool, blood, semen, and ocular secretions, although the role of transmission through these sources is still unknown.
“Some very interesting characteristics of this virus, really quite unique compared to other viruses, certainly other respiratory viruses, is [that] about a third to 40% of people who are infected never develop any symptoms,” Dr. Fauci said. “Importantly, and very problematic to what we do to contain it – particularly with regard to identification, isolation, and contract tracing – between 50% and 60% of the transmissions occur either from someone who will never develop symptoms, or someone in the presymptomatic phase of disease.”
The fundamentals of preventing acquisition and transmission are as familiar to most Americans now as the Pledge of Allegiance: universal mask wearing, physical distancing, avoiding crowds and congregate settings, preference for outdoor over indoor settings, and frequent hand washing, he noted.
Diagnostics
Tests for SARS-CoV-2 infection fall into three basic categories: molecular tests such as polymerase chain reaction (PCR) that are highly specific and highly sensitive for actual infections, antigen tests that detect the viral protein rather than the nucleic acids, and antibody tests to detect serum proteins made in response to viral infection.
Antigen testing is used largely for broader surveillance of groups of individuals to detect viral penetrance within that group, Dr. Fauci noted.
Clinical course
The clinical course of COVID-19 has some interesting characteristics but is not substantially different from a flu-like syndrome, Dr. Fauci said.
Symptoms and signs common to both types of infections include fever, cough, fatigue, anorexia, dyspnea, and myalgias, but the loss of smell and/or taste preceding the onset of respiratory symptoms is a unique feature of COVID-19.
Dr. Fauci cited data on more than 44,000 individuals with confirmed COVID-19 in China that showed that a large majority (81%) of cases were mild or moderate in nature, but 14% of patients experienced severe disease, and 5% were critically ill. The case-fatality rate in this study was 2.3%.
People at increased risk for severe disease include older adults and those of any age with certain comorbidities.
Manifestations of severe COVID-19 infections in adults can include neurological disorders, hyperinflammation, acute respiratory distress syndrome, cardiac dysfunction, hypercoagulability, and acute kidney injury.
In children, COVID-19 has been associated with a multisystem inflammatory syndrome (MIS-C) similar to Kawasaki disease.
In a substantial number of cases, the effects of COVID-19 can linger for 6 months or longer, Dr. Fauci said, pointing to a study from the University of Washington in Seattle.
Investigators there found that approximately 30% of patients enrolled at their center reported persistent symptoms for as long as 9 months after the initial illness, with fatigue as the most commonly reported symptom. One-third of outpatients with mild disease also reported persistent symptoms.
Therapeutics
Therapeutics that are either approved by the Food and Drug Administration, have emergency use authorization, or are in clinical trials for early or moderate disease include remdesivir (Veklury, Gilead Sciences), monoclonal antibodies, convalescent plasma, antiviral agents, hyperimmune globulin, anticoagulants, and immunomodulators.
Options for moderate to severe to advanced disease include dexamethasone, baricitinib (Olumiant, Eli Lilly and Company) plus remdesivir, and immunomodulators such as infliximab (Remicade, Janssen Biotech), and biosimilars.
Vaccines
Finally, Dr. Fauci reviewed the current state of vaccines, including the three with emergency use authorization from the FDA as of this writing: two nucleic acid, messenger RNA-based (mRNA) vaccines from Moderna and Pfizer/BioNTech, and an adenoviral vector-based vaccine from Johnson & Johnson.
Other vaccines in development or in use elsewhere in the world include recombinant protein and adjuvant approaches by GlaxoSmithKline and Sanofi (in a phase 2 clinical trial launched in February 2021) and by Novavax.
The three vaccines in use in the United States were highly efficacious in both clinical trials, with efficacy of about 95% for the mRNA vaccines and 67% for the Johnson & Johnson vaccine.
The real-world performance of these vaccines has been even more impressive, however.
For example, the Johnson & Johnson vaccine had 72% efficacy at preventing moderate to severe COVID 19 in the United States, 68% in Brazil, and 64% in South Africa, and 85% efficacy against severe disease across all regions studied, Dr. Fauci said.
He cited a study of 22,234 employees of the University of Texas Southwestern Medical Center in Dallas who were vaccinated under a program started on Dec. 15, 2020. The COVID-19 infection rate among these vaccinated employees was 0.05%.
Dr. Fauci recounted the experience in Israel, where the highly transmissible B.1.1.7 strain of SARS-CoV-2 is predominant. A chart of the progress shows clearly that as the vaccine doses delivered steadily increased, the number of COVID-19 cases began a precipitous decline.
Horse race
Fittingly for a speech presented on the day that the Preakness Stakes – the second leg in thoroughbred racing’s Triple Crown – was run, Dr. Fauci closed with a cartoon showing two racehorses, labeled “SARS-CoV-2” and “Vaccines,” nearly neck-and-neck, but with vaccines having a slight lead.
“We are in a race against the virus. The vaccines, and the virus: If we vaccinate the overwhelming proportion of our population, we will without a doubt be able to crush the outbreak in the same way as we have done with other viral-borne diseases like measles, smallpox, and polio.
“So, the message is: Get vaccinated,” he concluded.
Seaweed and other marine-derived products in skin care, Part II: Cosmetic formulations, fucoidan, and salmon eggs
The use of bioactive ingredients culled from the marine environment has increased significantly in recent years for use in skin care because of the reputed antioxidant and anti-aging activity of these substances.1-3
In the last couple of decades, secondary metabolites with bioactive properties have been identified in seaweeds. Among these substances, phlorotannins have been isolated from brown seaweeds and demonstrated to exhibit anti-allergic, anti-inflammatory, antioxidant, anticancer, and antiwrinkling activity, as well as some capacity to promote hair growth.4 Sanjeewa et al. suggest that phlorotannins, or marine polyphenols, derived from brown seaweed are well suited for use in cosmeceutical formulations and appear to exhibit skin whitening and antiwrinkling properties in particular.4 This column will discuss recent findings regarding the use of marine ingredients in cosmetic formulations, with a particular focus on substances such as fucoidan, as well as emerging evidence regarding the benefits to human skin derived from salmon eggs.
Recent studies of marine products in cosmetic formulations
In 2017, Fabrowska et al. showed in two groups of 10 volunteers each (one ranging from 20 to 30 years old and one from 40 to 50 years old) that the freshwater alga Cladophora glomerate is an effective ingredient for use as a cosmetic agent intended to moisturize and firm the skin.5
The next year, Thu et al. reported on the preparation of a cream mask composed of Vietnamese seaweeds (Caulerpa lentillifera, Sargassum crassifolium, Ulva reticulata, and Kappaphycus alvarezii), which they found to be abundant in proteins, polysaccharides, carotenoids, and other vitamins and to have potent antibacterial, cell proliferation, moisture retention, and tyrosinase inhibitory properties. The authors added that the seaweed cream mask was safe, provoked no irritation, and appeared to be effective in delivering anti-aging and moisturizing benefits.6
In 2019, Jesumani et al., in reviewing the potential cutaneous benefits of bioactive substances in seaweed, noted a significant increase in the use of ingredients found in macroalgae or seaweed in cosmetic formulations, also noting the range of reputed bioactivity (i.e., antioxidant, antitumor, anti-inflammatory, antilipidemic, antimicrobial, and anti-allergic).7 Seaweeds are a significant source of vitamins A, B, C, D, and E, and green, red, and brown algae contain pigments that protect against UV irradiation.7,8
Also that year, Hameury et al. conducted an ex vivo assessment to predict the cutaneous anti-aging benefits of an aqueous gel containing 6.1% marine ingredients (amino acid-enriched giant kelp extract, trace element-enriched seawater, and dedifferentiated sea fennel cells) topically applied on human skin explants. The investigators found that 64 proteins were significantly regulated by the gel when marine ingredients were compared with untreated skin explants, with the ingredients shown to act on the epidermis and dermis. These proteins are involved in multiple functions including gene expression, inflammatory processes, dermal extracellular matrix production, and melanogenesis and keratinocyte proliferation, suggesting, according to the authors, that marine ingredients could play a role in preventing cutaneous aging and contributing to the health of the epidermis and dermis.9
Early in 2020, Poulose et al. reported on the first use of a photoprotective cosmetic cream combining nanomelanin and seaweed that exerts antioxidant, antibacterial, and wound healing activity.10
The skin-lightening potential of fucoidan
In 2017, Wang et al. investigated the antimelanogenic activity of fucoidan – a complex sulfated polysaccharide extracted from brown seaweed known to possess a broad array of biologic functions – on B16 murine melanoma cells. Their in vitro studies revealed that fucoidan suppresses B16 melanoma cell proliferation and cellular tyrosinase activity and has potential as a skin-whitening cosmeceutical agent.11
Two years later, Jesumani et al. investigated the polysaccharides extracted from the seaweed species Sargassum vachellianum, S. horneri, and S. hemiphyllum. Found to be abundant in fucose, all of the evaluated polysaccharides demonstrated dose-dependent antioxidant activity and effectiveness in hindering tyrosinase and elastase. The researchers concluded that all of the tested species display potential as key ingredients in cosmeceutical agents intended to treat wrinkles or lighten skin.12
More recently, a comparative study by the same team revealed that both fucoidan-rich polysaccharide extract and polyphenol-rich extract from the seaweed S. vachellianum delivered significant protective activity. Both protected the skin from UV harm: The fucoidan-rich extract showed superior free radical scavenging and antimicrobial activity, while the polyphenol extract performed better at absorbing UV radiation. The investigators suggested that both extracts could provide a balanced approach to skin protection when featured in skin care products.13
In addition, it is worth noting that a key monomeric component of red macroalgae (Rhodophyta), 3,6-anhydro-l-galactose, has been found in vitro to display skin-whitening activity.14
Salmon eggs
In a 2013 double-blind, randomized clinical trial with 66 patients, Lønne et al. reported that subjects treated topically with salmon egg extract experienced significant amelioration of photoaging, including wrinkles, pigmentation, erythema, and xerosis, yielding global skin appearance improvement.3,15
A pilot study by Mekas et al., which was reported 2 years later and included 75 patients, revealed that skin tone and evenness were improved by a topical exfoliative cream featuring hydrolyzed roe proteins, based on subjective and objective measures comparing 4% glycolic acid.3,16
In 2016, Yoshino et al. showed that human dermal fibroblasts incubated with salmon egg extract upregulated the expression of collagen type I genes and several oxidative genes.3,17 The topical application of hydrolyzed salmon roe proteins to human skin has also been demonstrated to eliminate cell-to-cell adhesions thus ameliorating the appearance of photodamaged skin.1,3,16
More recently, a comprehensive PubMed search on the bioactive ingredients used in Korean cosmeceuticals reported early in 2020 that there is increased interest in salmon eggs because they provide a copious supply of unsaturated fatty acids, proteins, vitamins, and minerals known to nurture cutaneous health.3,15
Conclusion
. Research into the numerous bioactive properties of these multitudinous species has ramped up in recent years and is yielding evidence regarding the efficacy and potential broader uses of such ingredients in cutaneous health care. As we build on our understanding of just how dynamic a source of treatment options may lie under the sea, we become increasingly aware, ironically, of the damage that human industrialization exerts on the planet, as well as these precious marine resources (including the possibly deleterious effects of chemical sunscreens like those that are now banned for sale in Hawai‘i). Humanity will need to become much better stewards of the Earth if we are to enhance our future opportunities and possibly harness the potent marine ingredients still available with the potential to enhance skin health and appearance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Kim SK. J Cosmet Dermatol. 2014;13(1):56-67.
2. Venkatesan J et al. Mar Drugs. 2017;15(5):1-18.
3. Nguyen JK et al. J Cosmet Dermatol 2020 Jul;19(7):1555-69.
4. Sanjeewa KKA et al. J Photochem Photobiol B. 2016 Sep;162:100-5.
5. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
6. Thu NTH et al. J Cosmet Sci. Nov/Dec 2018;69(6):447-62.
7. Jesumani V et al. Mar Drugs. 2019 Dec 6;17(12):688.
8. Kim MS et al. Photochem Photobiol. Jul-Aug 2013;89(4):911-8.
9. Hameury S et al. J Cosmet Dermatol. 2019 Feb;18(1):355-70.
10. Poulose N et al. J Photochem Photobiol B. 2020 Apr;205:111816.
11. Wang ZJ et al. Afr J Tradit Complement Altern Med. 2017 Jun 5;14(4);149-55.
12. Jesumani V et al. Int J Biol Macromol. 2019 Nov 1;140:216-24.
13. Jesumani V et al. PLoS One. 2020 Jan 7;15(1):e0227308.
14. Kim JH et al. Mar Drugs. 2017 Oct 20;15(10):321.
15. Lønne GK et al. Int J Cosmet Sci. 2013 Oct;35(5):515-22.
16. Mekas M et al. J Drugs Dermatol. 2015 Nov;14(11):1306-19.
17. Yoshino A et al. Clin Interv Aging. 2016;11:1159-68.
The use of bioactive ingredients culled from the marine environment has increased significantly in recent years for use in skin care because of the reputed antioxidant and anti-aging activity of these substances.1-3
In the last couple of decades, secondary metabolites with bioactive properties have been identified in seaweeds. Among these substances, phlorotannins have been isolated from brown seaweeds and demonstrated to exhibit anti-allergic, anti-inflammatory, antioxidant, anticancer, and antiwrinkling activity, as well as some capacity to promote hair growth.4 Sanjeewa et al. suggest that phlorotannins, or marine polyphenols, derived from brown seaweed are well suited for use in cosmeceutical formulations and appear to exhibit skin whitening and antiwrinkling properties in particular.4 This column will discuss recent findings regarding the use of marine ingredients in cosmetic formulations, with a particular focus on substances such as fucoidan, as well as emerging evidence regarding the benefits to human skin derived from salmon eggs.
Recent studies of marine products in cosmetic formulations
In 2017, Fabrowska et al. showed in two groups of 10 volunteers each (one ranging from 20 to 30 years old and one from 40 to 50 years old) that the freshwater alga Cladophora glomerate is an effective ingredient for use as a cosmetic agent intended to moisturize and firm the skin.5
The next year, Thu et al. reported on the preparation of a cream mask composed of Vietnamese seaweeds (Caulerpa lentillifera, Sargassum crassifolium, Ulva reticulata, and Kappaphycus alvarezii), which they found to be abundant in proteins, polysaccharides, carotenoids, and other vitamins and to have potent antibacterial, cell proliferation, moisture retention, and tyrosinase inhibitory properties. The authors added that the seaweed cream mask was safe, provoked no irritation, and appeared to be effective in delivering anti-aging and moisturizing benefits.6
In 2019, Jesumani et al., in reviewing the potential cutaneous benefits of bioactive substances in seaweed, noted a significant increase in the use of ingredients found in macroalgae or seaweed in cosmetic formulations, also noting the range of reputed bioactivity (i.e., antioxidant, antitumor, anti-inflammatory, antilipidemic, antimicrobial, and anti-allergic).7 Seaweeds are a significant source of vitamins A, B, C, D, and E, and green, red, and brown algae contain pigments that protect against UV irradiation.7,8
Also that year, Hameury et al. conducted an ex vivo assessment to predict the cutaneous anti-aging benefits of an aqueous gel containing 6.1% marine ingredients (amino acid-enriched giant kelp extract, trace element-enriched seawater, and dedifferentiated sea fennel cells) topically applied on human skin explants. The investigators found that 64 proteins were significantly regulated by the gel when marine ingredients were compared with untreated skin explants, with the ingredients shown to act on the epidermis and dermis. These proteins are involved in multiple functions including gene expression, inflammatory processes, dermal extracellular matrix production, and melanogenesis and keratinocyte proliferation, suggesting, according to the authors, that marine ingredients could play a role in preventing cutaneous aging and contributing to the health of the epidermis and dermis.9
Early in 2020, Poulose et al. reported on the first use of a photoprotective cosmetic cream combining nanomelanin and seaweed that exerts antioxidant, antibacterial, and wound healing activity.10
The skin-lightening potential of fucoidan
In 2017, Wang et al. investigated the antimelanogenic activity of fucoidan – a complex sulfated polysaccharide extracted from brown seaweed known to possess a broad array of biologic functions – on B16 murine melanoma cells. Their in vitro studies revealed that fucoidan suppresses B16 melanoma cell proliferation and cellular tyrosinase activity and has potential as a skin-whitening cosmeceutical agent.11
Two years later, Jesumani et al. investigated the polysaccharides extracted from the seaweed species Sargassum vachellianum, S. horneri, and S. hemiphyllum. Found to be abundant in fucose, all of the evaluated polysaccharides demonstrated dose-dependent antioxidant activity and effectiveness in hindering tyrosinase and elastase. The researchers concluded that all of the tested species display potential as key ingredients in cosmeceutical agents intended to treat wrinkles or lighten skin.12
More recently, a comparative study by the same team revealed that both fucoidan-rich polysaccharide extract and polyphenol-rich extract from the seaweed S. vachellianum delivered significant protective activity. Both protected the skin from UV harm: The fucoidan-rich extract showed superior free radical scavenging and antimicrobial activity, while the polyphenol extract performed better at absorbing UV radiation. The investigators suggested that both extracts could provide a balanced approach to skin protection when featured in skin care products.13
In addition, it is worth noting that a key monomeric component of red macroalgae (Rhodophyta), 3,6-anhydro-l-galactose, has been found in vitro to display skin-whitening activity.14
Salmon eggs
In a 2013 double-blind, randomized clinical trial with 66 patients, Lønne et al. reported that subjects treated topically with salmon egg extract experienced significant amelioration of photoaging, including wrinkles, pigmentation, erythema, and xerosis, yielding global skin appearance improvement.3,15
A pilot study by Mekas et al., which was reported 2 years later and included 75 patients, revealed that skin tone and evenness were improved by a topical exfoliative cream featuring hydrolyzed roe proteins, based on subjective and objective measures comparing 4% glycolic acid.3,16
In 2016, Yoshino et al. showed that human dermal fibroblasts incubated with salmon egg extract upregulated the expression of collagen type I genes and several oxidative genes.3,17 The topical application of hydrolyzed salmon roe proteins to human skin has also been demonstrated to eliminate cell-to-cell adhesions thus ameliorating the appearance of photodamaged skin.1,3,16
More recently, a comprehensive PubMed search on the bioactive ingredients used in Korean cosmeceuticals reported early in 2020 that there is increased interest in salmon eggs because they provide a copious supply of unsaturated fatty acids, proteins, vitamins, and minerals known to nurture cutaneous health.3,15
Conclusion
. Research into the numerous bioactive properties of these multitudinous species has ramped up in recent years and is yielding evidence regarding the efficacy and potential broader uses of such ingredients in cutaneous health care. As we build on our understanding of just how dynamic a source of treatment options may lie under the sea, we become increasingly aware, ironically, of the damage that human industrialization exerts on the planet, as well as these precious marine resources (including the possibly deleterious effects of chemical sunscreens like those that are now banned for sale in Hawai‘i). Humanity will need to become much better stewards of the Earth if we are to enhance our future opportunities and possibly harness the potent marine ingredients still available with the potential to enhance skin health and appearance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Kim SK. J Cosmet Dermatol. 2014;13(1):56-67.
2. Venkatesan J et al. Mar Drugs. 2017;15(5):1-18.
3. Nguyen JK et al. J Cosmet Dermatol 2020 Jul;19(7):1555-69.
4. Sanjeewa KKA et al. J Photochem Photobiol B. 2016 Sep;162:100-5.
5. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
6. Thu NTH et al. J Cosmet Sci. Nov/Dec 2018;69(6):447-62.
7. Jesumani V et al. Mar Drugs. 2019 Dec 6;17(12):688.
8. Kim MS et al. Photochem Photobiol. Jul-Aug 2013;89(4):911-8.
9. Hameury S et al. J Cosmet Dermatol. 2019 Feb;18(1):355-70.
10. Poulose N et al. J Photochem Photobiol B. 2020 Apr;205:111816.
11. Wang ZJ et al. Afr J Tradit Complement Altern Med. 2017 Jun 5;14(4);149-55.
12. Jesumani V et al. Int J Biol Macromol. 2019 Nov 1;140:216-24.
13. Jesumani V et al. PLoS One. 2020 Jan 7;15(1):e0227308.
14. Kim JH et al. Mar Drugs. 2017 Oct 20;15(10):321.
15. Lønne GK et al. Int J Cosmet Sci. 2013 Oct;35(5):515-22.
16. Mekas M et al. J Drugs Dermatol. 2015 Nov;14(11):1306-19.
17. Yoshino A et al. Clin Interv Aging. 2016;11:1159-68.
The use of bioactive ingredients culled from the marine environment has increased significantly in recent years for use in skin care because of the reputed antioxidant and anti-aging activity of these substances.1-3
In the last couple of decades, secondary metabolites with bioactive properties have been identified in seaweeds. Among these substances, phlorotannins have been isolated from brown seaweeds and demonstrated to exhibit anti-allergic, anti-inflammatory, antioxidant, anticancer, and antiwrinkling activity, as well as some capacity to promote hair growth.4 Sanjeewa et al. suggest that phlorotannins, or marine polyphenols, derived from brown seaweed are well suited for use in cosmeceutical formulations and appear to exhibit skin whitening and antiwrinkling properties in particular.4 This column will discuss recent findings regarding the use of marine ingredients in cosmetic formulations, with a particular focus on substances such as fucoidan, as well as emerging evidence regarding the benefits to human skin derived from salmon eggs.
Recent studies of marine products in cosmetic formulations
In 2017, Fabrowska et al. showed in two groups of 10 volunteers each (one ranging from 20 to 30 years old and one from 40 to 50 years old) that the freshwater alga Cladophora glomerate is an effective ingredient for use as a cosmetic agent intended to moisturize and firm the skin.5
The next year, Thu et al. reported on the preparation of a cream mask composed of Vietnamese seaweeds (Caulerpa lentillifera, Sargassum crassifolium, Ulva reticulata, and Kappaphycus alvarezii), which they found to be abundant in proteins, polysaccharides, carotenoids, and other vitamins and to have potent antibacterial, cell proliferation, moisture retention, and tyrosinase inhibitory properties. The authors added that the seaweed cream mask was safe, provoked no irritation, and appeared to be effective in delivering anti-aging and moisturizing benefits.6
In 2019, Jesumani et al., in reviewing the potential cutaneous benefits of bioactive substances in seaweed, noted a significant increase in the use of ingredients found in macroalgae or seaweed in cosmetic formulations, also noting the range of reputed bioactivity (i.e., antioxidant, antitumor, anti-inflammatory, antilipidemic, antimicrobial, and anti-allergic).7 Seaweeds are a significant source of vitamins A, B, C, D, and E, and green, red, and brown algae contain pigments that protect against UV irradiation.7,8
Also that year, Hameury et al. conducted an ex vivo assessment to predict the cutaneous anti-aging benefits of an aqueous gel containing 6.1% marine ingredients (amino acid-enriched giant kelp extract, trace element-enriched seawater, and dedifferentiated sea fennel cells) topically applied on human skin explants. The investigators found that 64 proteins were significantly regulated by the gel when marine ingredients were compared with untreated skin explants, with the ingredients shown to act on the epidermis and dermis. These proteins are involved in multiple functions including gene expression, inflammatory processes, dermal extracellular matrix production, and melanogenesis and keratinocyte proliferation, suggesting, according to the authors, that marine ingredients could play a role in preventing cutaneous aging and contributing to the health of the epidermis and dermis.9
Early in 2020, Poulose et al. reported on the first use of a photoprotective cosmetic cream combining nanomelanin and seaweed that exerts antioxidant, antibacterial, and wound healing activity.10
The skin-lightening potential of fucoidan
In 2017, Wang et al. investigated the antimelanogenic activity of fucoidan – a complex sulfated polysaccharide extracted from brown seaweed known to possess a broad array of biologic functions – on B16 murine melanoma cells. Their in vitro studies revealed that fucoidan suppresses B16 melanoma cell proliferation and cellular tyrosinase activity and has potential as a skin-whitening cosmeceutical agent.11
Two years later, Jesumani et al. investigated the polysaccharides extracted from the seaweed species Sargassum vachellianum, S. horneri, and S. hemiphyllum. Found to be abundant in fucose, all of the evaluated polysaccharides demonstrated dose-dependent antioxidant activity and effectiveness in hindering tyrosinase and elastase. The researchers concluded that all of the tested species display potential as key ingredients in cosmeceutical agents intended to treat wrinkles or lighten skin.12
More recently, a comparative study by the same team revealed that both fucoidan-rich polysaccharide extract and polyphenol-rich extract from the seaweed S. vachellianum delivered significant protective activity. Both protected the skin from UV harm: The fucoidan-rich extract showed superior free radical scavenging and antimicrobial activity, while the polyphenol extract performed better at absorbing UV radiation. The investigators suggested that both extracts could provide a balanced approach to skin protection when featured in skin care products.13
In addition, it is worth noting that a key monomeric component of red macroalgae (Rhodophyta), 3,6-anhydro-l-galactose, has been found in vitro to display skin-whitening activity.14
Salmon eggs
In a 2013 double-blind, randomized clinical trial with 66 patients, Lønne et al. reported that subjects treated topically with salmon egg extract experienced significant amelioration of photoaging, including wrinkles, pigmentation, erythema, and xerosis, yielding global skin appearance improvement.3,15
A pilot study by Mekas et al., which was reported 2 years later and included 75 patients, revealed that skin tone and evenness were improved by a topical exfoliative cream featuring hydrolyzed roe proteins, based on subjective and objective measures comparing 4% glycolic acid.3,16
In 2016, Yoshino et al. showed that human dermal fibroblasts incubated with salmon egg extract upregulated the expression of collagen type I genes and several oxidative genes.3,17 The topical application of hydrolyzed salmon roe proteins to human skin has also been demonstrated to eliminate cell-to-cell adhesions thus ameliorating the appearance of photodamaged skin.1,3,16
More recently, a comprehensive PubMed search on the bioactive ingredients used in Korean cosmeceuticals reported early in 2020 that there is increased interest in salmon eggs because they provide a copious supply of unsaturated fatty acids, proteins, vitamins, and minerals known to nurture cutaneous health.3,15
Conclusion
. Research into the numerous bioactive properties of these multitudinous species has ramped up in recent years and is yielding evidence regarding the efficacy and potential broader uses of such ingredients in cutaneous health care. As we build on our understanding of just how dynamic a source of treatment options may lie under the sea, we become increasingly aware, ironically, of the damage that human industrialization exerts on the planet, as well as these precious marine resources (including the possibly deleterious effects of chemical sunscreens like those that are now banned for sale in Hawai‘i). Humanity will need to become much better stewards of the Earth if we are to enhance our future opportunities and possibly harness the potent marine ingredients still available with the potential to enhance skin health and appearance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions Inc., a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Kim SK. J Cosmet Dermatol. 2014;13(1):56-67.
2. Venkatesan J et al. Mar Drugs. 2017;15(5):1-18.
3. Nguyen JK et al. J Cosmet Dermatol 2020 Jul;19(7):1555-69.
4. Sanjeewa KKA et al. J Photochem Photobiol B. 2016 Sep;162:100-5.
5. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.
6. Thu NTH et al. J Cosmet Sci. Nov/Dec 2018;69(6):447-62.
7. Jesumani V et al. Mar Drugs. 2019 Dec 6;17(12):688.
8. Kim MS et al. Photochem Photobiol. Jul-Aug 2013;89(4):911-8.
9. Hameury S et al. J Cosmet Dermatol. 2019 Feb;18(1):355-70.
10. Poulose N et al. J Photochem Photobiol B. 2020 Apr;205:111816.
11. Wang ZJ et al. Afr J Tradit Complement Altern Med. 2017 Jun 5;14(4);149-55.
12. Jesumani V et al. Int J Biol Macromol. 2019 Nov 1;140:216-24.
13. Jesumani V et al. PLoS One. 2020 Jan 7;15(1):e0227308.
14. Kim JH et al. Mar Drugs. 2017 Oct 20;15(10):321.
15. Lønne GK et al. Int J Cosmet Sci. 2013 Oct;35(5):515-22.
16. Mekas M et al. J Drugs Dermatol. 2015 Nov;14(11):1306-19.
17. Yoshino A et al. Clin Interv Aging. 2016;11:1159-68.
FDA preparing an environmental impact statement for 2 sunscreen ingredients
The Food and Drug Administration is launching a process to prepare an environmental impact statement (EIS) regarding the use oxybenzone and octinoxate in over-the-counter sunscreen products.
According to the “Intent to Prepare an Environmental Impact Statement for Certain Sunscreen Drug Products for Over-The-Counter Use,” which was published in the Federal Register on May 13, 2021, the FDA will prepare an EIS “when data or information in an environmental assessment or otherwise available to the Agency leads to a finding that the proposed agency action may significantly affect the quality of the human environment.” The first step in this effort involves a “public scoping process” to evaluate any potential environmental impacts associated with the use of oxybenzone and octinoxate in sunscreens so that an EIS, if required, “can be completed prior to issuance of a final sunscreen order addressing sunscreens containing these ingredients.”
The American Academy of Dermatology Association weighed in on the FDA’s announcement, noting that it “appreciates the efforts of the agency to thoroughly examine all relevant science before issuing a final sunscreen order on these ingredients,” according to a statement released by the AADA on May 13, 2021.
The statement added: “Skin cancer is the most common cancer in the U.S., and unprotected exposure to the sun’s harmful ultraviolet rays is a major risk factor. The AADA continues to focus on encouraging members of the public to protect themselves by seeking shade, wearing protective clothing – including a lightweight and long-sleeved shirt, pants, a wide-brimmed hat and sunglasses – and applying a broad-spectrum sunscreen with an SPF of 30 or higher to all exposed skin.”
According to the FDA document, a series of developments regarding oxybenzone and octinoxate prompted the agency to take this step, including comments the agency received in response to the 2019 proposed rule titled “Sunscreen Drug Products for Over-The-Counter Human Use,” which raised concern about the potential effects of the two ingredients on coral and/or coral reefs, as well as research efforts by the National Oceanic and Atmospheric Administration Coral Reef Conservation Programs on the potential impacts of sunscreen products that include oxybenzone and octinoxate on coral reefs and other aquatic systems. Hawaii’s 2018 state law prohibiting the sale, offer of sale, and distribution of sunscreens that contain oxybenzone and/or octinoxate also influenced the agency’s decision to further evaluate the topic.
“The purpose of the public scoping process is to determine relevant issues that will influence the scope of the environmental analysis, including potential alternatives and the extent to which those issues and impacts will be analyzed,” the FDA document states. “At this initial stage of the scoping process, we have identified the following four alternatives: FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA [new drug application] is impermissible; FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA is permissible; FDA will conclude that inclusion of oxybenzone in sunscreens marketed without an NDA is permissible but that the inclusion of octinoxate in sunscreens marketed without an NDA is impermissible; or FDA will conclude that inclusion of octinoxate in sunscreens marketed without an NDA is permissible but that the inclusion of oxybenzone in sunscreens marketed without an NDA is impermissible.”
Until June 14, the FDA is accepting comments from the public electronically via the Federal eRulemaking Portal at www.regulations.gov (search for Docket No. FDA-2021-N-0352) or by mail to: Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, Md., 20852. Refer to Docket No. FDA-2021-N-0352.
The Food and Drug Administration is launching a process to prepare an environmental impact statement (EIS) regarding the use oxybenzone and octinoxate in over-the-counter sunscreen products.
According to the “Intent to Prepare an Environmental Impact Statement for Certain Sunscreen Drug Products for Over-The-Counter Use,” which was published in the Federal Register on May 13, 2021, the FDA will prepare an EIS “when data or information in an environmental assessment or otherwise available to the Agency leads to a finding that the proposed agency action may significantly affect the quality of the human environment.” The first step in this effort involves a “public scoping process” to evaluate any potential environmental impacts associated with the use of oxybenzone and octinoxate in sunscreens so that an EIS, if required, “can be completed prior to issuance of a final sunscreen order addressing sunscreens containing these ingredients.”
The American Academy of Dermatology Association weighed in on the FDA’s announcement, noting that it “appreciates the efforts of the agency to thoroughly examine all relevant science before issuing a final sunscreen order on these ingredients,” according to a statement released by the AADA on May 13, 2021.
The statement added: “Skin cancer is the most common cancer in the U.S., and unprotected exposure to the sun’s harmful ultraviolet rays is a major risk factor. The AADA continues to focus on encouraging members of the public to protect themselves by seeking shade, wearing protective clothing – including a lightweight and long-sleeved shirt, pants, a wide-brimmed hat and sunglasses – and applying a broad-spectrum sunscreen with an SPF of 30 or higher to all exposed skin.”
According to the FDA document, a series of developments regarding oxybenzone and octinoxate prompted the agency to take this step, including comments the agency received in response to the 2019 proposed rule titled “Sunscreen Drug Products for Over-The-Counter Human Use,” which raised concern about the potential effects of the two ingredients on coral and/or coral reefs, as well as research efforts by the National Oceanic and Atmospheric Administration Coral Reef Conservation Programs on the potential impacts of sunscreen products that include oxybenzone and octinoxate on coral reefs and other aquatic systems. Hawaii’s 2018 state law prohibiting the sale, offer of sale, and distribution of sunscreens that contain oxybenzone and/or octinoxate also influenced the agency’s decision to further evaluate the topic.
“The purpose of the public scoping process is to determine relevant issues that will influence the scope of the environmental analysis, including potential alternatives and the extent to which those issues and impacts will be analyzed,” the FDA document states. “At this initial stage of the scoping process, we have identified the following four alternatives: FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA [new drug application] is impermissible; FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA is permissible; FDA will conclude that inclusion of oxybenzone in sunscreens marketed without an NDA is permissible but that the inclusion of octinoxate in sunscreens marketed without an NDA is impermissible; or FDA will conclude that inclusion of octinoxate in sunscreens marketed without an NDA is permissible but that the inclusion of oxybenzone in sunscreens marketed without an NDA is impermissible.”
Until June 14, the FDA is accepting comments from the public electronically via the Federal eRulemaking Portal at www.regulations.gov (search for Docket No. FDA-2021-N-0352) or by mail to: Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, Md., 20852. Refer to Docket No. FDA-2021-N-0352.
The Food and Drug Administration is launching a process to prepare an environmental impact statement (EIS) regarding the use oxybenzone and octinoxate in over-the-counter sunscreen products.
According to the “Intent to Prepare an Environmental Impact Statement for Certain Sunscreen Drug Products for Over-The-Counter Use,” which was published in the Federal Register on May 13, 2021, the FDA will prepare an EIS “when data or information in an environmental assessment or otherwise available to the Agency leads to a finding that the proposed agency action may significantly affect the quality of the human environment.” The first step in this effort involves a “public scoping process” to evaluate any potential environmental impacts associated with the use of oxybenzone and octinoxate in sunscreens so that an EIS, if required, “can be completed prior to issuance of a final sunscreen order addressing sunscreens containing these ingredients.”
The American Academy of Dermatology Association weighed in on the FDA’s announcement, noting that it “appreciates the efforts of the agency to thoroughly examine all relevant science before issuing a final sunscreen order on these ingredients,” according to a statement released by the AADA on May 13, 2021.
The statement added: “Skin cancer is the most common cancer in the U.S., and unprotected exposure to the sun’s harmful ultraviolet rays is a major risk factor. The AADA continues to focus on encouraging members of the public to protect themselves by seeking shade, wearing protective clothing – including a lightweight and long-sleeved shirt, pants, a wide-brimmed hat and sunglasses – and applying a broad-spectrum sunscreen with an SPF of 30 or higher to all exposed skin.”
According to the FDA document, a series of developments regarding oxybenzone and octinoxate prompted the agency to take this step, including comments the agency received in response to the 2019 proposed rule titled “Sunscreen Drug Products for Over-The-Counter Human Use,” which raised concern about the potential effects of the two ingredients on coral and/or coral reefs, as well as research efforts by the National Oceanic and Atmospheric Administration Coral Reef Conservation Programs on the potential impacts of sunscreen products that include oxybenzone and octinoxate on coral reefs and other aquatic systems. Hawaii’s 2018 state law prohibiting the sale, offer of sale, and distribution of sunscreens that contain oxybenzone and/or octinoxate also influenced the agency’s decision to further evaluate the topic.
“The purpose of the public scoping process is to determine relevant issues that will influence the scope of the environmental analysis, including potential alternatives and the extent to which those issues and impacts will be analyzed,” the FDA document states. “At this initial stage of the scoping process, we have identified the following four alternatives: FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA [new drug application] is impermissible; FDA will conclude that the inclusion of oxybenzone and octinoxate in sunscreens marketed without an NDA is permissible; FDA will conclude that inclusion of oxybenzone in sunscreens marketed without an NDA is permissible but that the inclusion of octinoxate in sunscreens marketed without an NDA is impermissible; or FDA will conclude that inclusion of octinoxate in sunscreens marketed without an NDA is permissible but that the inclusion of oxybenzone in sunscreens marketed without an NDA is impermissible.”
Until June 14, the FDA is accepting comments from the public electronically via the Federal eRulemaking Portal at www.regulations.gov (search for Docket No. FDA-2021-N-0352) or by mail to: Dockets Management Staff (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, Md., 20852. Refer to Docket No. FDA-2021-N-0352.
Telemedicine is popular among Mohs surgeons – for now
A majority of
A variety of factors combine to make it “very difficult for surgeons to make long-term plans for implementing telemedicine in their practices,” said Mario Maruthur, MD, who presented the findings at the annual meeting of the American College of Mohs Surgery. “Telemedicine likely has a role in Mohs practices, particularly with postop follow-up visits. However, postpandemic reimbursement and regulatory issues need to be formally laid out before Mohs surgeons are able to incorporate it into their permanent work flow.”
Dr. Maruthur, a Mohs surgery and dermatologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York, and colleagues sent a survey to ACMS members in September and October 2020. “We saw first-hand in our surgical practice that telemedicine quickly became an important tool when the pandemic surged in the spring of 2020,” he said. Considering that surgical practices are highly dependent on in-person visits, the impetus for this study was to assess to what degree Mohs practices from across the spectrum, including academic and private practices, embraced telemedicine during the pandemic, and “what these surgical practices used telemedicine for, how it was received by their patients, which telemedicine platforms were most often utilized, and lastly, what are their plans if any for incorporating telemedicine into their surgical practices after the pandemic subsides.”
The researchers received responses from 115 surgeons representing all regions of the country (40% Northeast, 21% South, 21% Midwest, and 18% West). Half practiced in urban areas (37%) and large cities (13%), and 40% were in an academic setting versus 36% in a single-specialty private practice.
More than 70% of the respondents said their case load fell by at least 75% during the initial surge of the pandemic; 80% turned to telemedicine, compared with just 23% who relied on the technology prior to the pandemic. The most commonly used telemedicine technologies were FaceTime, Zoom, Doximity, and Epic.
Mohs surgeons reported most commonly using telemedicine for postsurgery management (77% of the total 115 responses). “Telemedicine is a great fit for this category of visits as they allow the surgeon to view the surgical site and answer any questions they patient may have,” Dr. Maruthur said. “If the surgeon does suspect a postop infection or other concern based on a patient’s signs or symptoms, they can easily schedule the patient for an in-person assessment. We suspect that postop follow-up visits may be the best candidate for long-term use of telemedicine in Mohs surgery practices.”
Surgeons also reported using telemedicine for “spot checks” (61%) and surgical consultations (59%).
However, Dr. Maruther noted that preoperative assessments and spot checks can be difficult to perform using telemedicine. “The quality of the video image is not always great, patients can have a difficult time pointing the camera at the right spot and at the right distance. Even appreciating the actual size of the lesion are all difficult over a video encounter. And there is a lot of information gleaned from in-person physical examination, such as whether the lesion is fixed to a deeper structure and whether there are any nearby scars or other suspicious lesions.”
Nearly three-quarters of the surgeons using the technology said most or all patients were receptive to telemedicine.
However, the surgeons reported multiple barriers to the use of telemedicine: Limitations when compared with physical exams (88%), fitting it into the work flow (58%), patient response and training (57%), reimbursement concerns (50%), implementation of the technology (37%), regulations such as HIPAA (24%), training of staff (17%), and licensing (8%).
In an interview, Sumaira Z. Aasi, MD, director of Mohs and dermatologic surgery, Stanford University, agreed that there are many obstacles to routine use of telemedicine by Mohs surgeons. “As surgeons, we rely on the physical and tactile exam to get a sense of the size and extent of the cancer and characteristics such as the laxity of the surrounding tissue whether the tumor is fixed,” she said. “It is very difficult to access this on a telemedicine visit.”
In addition, she said, “many of our patients are in the elderly population, and some may not be comfortable using this technology. Also, it’s not a work flow that we are comfortable or familiar with. And I think that the technology has to improve to allow for better resolution of images as we ‘examine’ patients through a telemedicine visit.”
She added that “another con is there is a reliance on having the patient point out lesions of concern. Many cancers are picked by a careful in-person examination by a qualified physician/dermatologist/Mohs surgeon when the lesion is quite small or subtle and not even noticed by the patient themselves. This approach invariably leads to earlier biopsies and earlier treatments that can prevent morbidity and save health care money.”
On the other hand, she said, telemedicine “may save patients some time and money in terms of the effort and cost of transportation to come in for simpler postoperative medical visits that are often short in their very nature, such as postop check-ups.”
Most of the surgeons surveyed (69%) said telemedicine probably or definitely deserves a place in the practice Mohs surgery, but only 50% said they’d like to or would definitely pursue giving telemedicine a role in their practices once the pandemic is over.
“At the start of the pandemic, many regulations in areas such as HIPAA were eased, and reimbursements were increased, which allowed telemedicine to be quickly adopted,” Dr. Maruther said. “The government and payers have yet to decide which regulations and reimbursements will be in place after the pandemic. That makes it very difficult for surgeons to make long-term plans for implementing telemedicine in their practices.”
Dr. Aasi predicted that telemedicine will become more appealing to patients and physicians as it its technology and usability improves. More familiarity with its use will also be helpful, she said, and surgeons will be more receptive as it’s incorporated into efficient daily work flow.
The study was funded in part by the National Institutes of Health.
A majority of
A variety of factors combine to make it “very difficult for surgeons to make long-term plans for implementing telemedicine in their practices,” said Mario Maruthur, MD, who presented the findings at the annual meeting of the American College of Mohs Surgery. “Telemedicine likely has a role in Mohs practices, particularly with postop follow-up visits. However, postpandemic reimbursement and regulatory issues need to be formally laid out before Mohs surgeons are able to incorporate it into their permanent work flow.”
Dr. Maruthur, a Mohs surgery and dermatologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York, and colleagues sent a survey to ACMS members in September and October 2020. “We saw first-hand in our surgical practice that telemedicine quickly became an important tool when the pandemic surged in the spring of 2020,” he said. Considering that surgical practices are highly dependent on in-person visits, the impetus for this study was to assess to what degree Mohs practices from across the spectrum, including academic and private practices, embraced telemedicine during the pandemic, and “what these surgical practices used telemedicine for, how it was received by their patients, which telemedicine platforms were most often utilized, and lastly, what are their plans if any for incorporating telemedicine into their surgical practices after the pandemic subsides.”
The researchers received responses from 115 surgeons representing all regions of the country (40% Northeast, 21% South, 21% Midwest, and 18% West). Half practiced in urban areas (37%) and large cities (13%), and 40% were in an academic setting versus 36% in a single-specialty private practice.
More than 70% of the respondents said their case load fell by at least 75% during the initial surge of the pandemic; 80% turned to telemedicine, compared with just 23% who relied on the technology prior to the pandemic. The most commonly used telemedicine technologies were FaceTime, Zoom, Doximity, and Epic.
Mohs surgeons reported most commonly using telemedicine for postsurgery management (77% of the total 115 responses). “Telemedicine is a great fit for this category of visits as they allow the surgeon to view the surgical site and answer any questions they patient may have,” Dr. Maruthur said. “If the surgeon does suspect a postop infection or other concern based on a patient’s signs or symptoms, they can easily schedule the patient for an in-person assessment. We suspect that postop follow-up visits may be the best candidate for long-term use of telemedicine in Mohs surgery practices.”
Surgeons also reported using telemedicine for “spot checks” (61%) and surgical consultations (59%).
However, Dr. Maruther noted that preoperative assessments and spot checks can be difficult to perform using telemedicine. “The quality of the video image is not always great, patients can have a difficult time pointing the camera at the right spot and at the right distance. Even appreciating the actual size of the lesion are all difficult over a video encounter. And there is a lot of information gleaned from in-person physical examination, such as whether the lesion is fixed to a deeper structure and whether there are any nearby scars or other suspicious lesions.”
Nearly three-quarters of the surgeons using the technology said most or all patients were receptive to telemedicine.
However, the surgeons reported multiple barriers to the use of telemedicine: Limitations when compared with physical exams (88%), fitting it into the work flow (58%), patient response and training (57%), reimbursement concerns (50%), implementation of the technology (37%), regulations such as HIPAA (24%), training of staff (17%), and licensing (8%).
In an interview, Sumaira Z. Aasi, MD, director of Mohs and dermatologic surgery, Stanford University, agreed that there are many obstacles to routine use of telemedicine by Mohs surgeons. “As surgeons, we rely on the physical and tactile exam to get a sense of the size and extent of the cancer and characteristics such as the laxity of the surrounding tissue whether the tumor is fixed,” she said. “It is very difficult to access this on a telemedicine visit.”
In addition, she said, “many of our patients are in the elderly population, and some may not be comfortable using this technology. Also, it’s not a work flow that we are comfortable or familiar with. And I think that the technology has to improve to allow for better resolution of images as we ‘examine’ patients through a telemedicine visit.”
She added that “another con is there is a reliance on having the patient point out lesions of concern. Many cancers are picked by a careful in-person examination by a qualified physician/dermatologist/Mohs surgeon when the lesion is quite small or subtle and not even noticed by the patient themselves. This approach invariably leads to earlier biopsies and earlier treatments that can prevent morbidity and save health care money.”
On the other hand, she said, telemedicine “may save patients some time and money in terms of the effort and cost of transportation to come in for simpler postoperative medical visits that are often short in their very nature, such as postop check-ups.”
Most of the surgeons surveyed (69%) said telemedicine probably or definitely deserves a place in the practice Mohs surgery, but only 50% said they’d like to or would definitely pursue giving telemedicine a role in their practices once the pandemic is over.
“At the start of the pandemic, many regulations in areas such as HIPAA were eased, and reimbursements were increased, which allowed telemedicine to be quickly adopted,” Dr. Maruther said. “The government and payers have yet to decide which regulations and reimbursements will be in place after the pandemic. That makes it very difficult for surgeons to make long-term plans for implementing telemedicine in their practices.”
Dr. Aasi predicted that telemedicine will become more appealing to patients and physicians as it its technology and usability improves. More familiarity with its use will also be helpful, she said, and surgeons will be more receptive as it’s incorporated into efficient daily work flow.
The study was funded in part by the National Institutes of Health.
A majority of
A variety of factors combine to make it “very difficult for surgeons to make long-term plans for implementing telemedicine in their practices,” said Mario Maruthur, MD, who presented the findings at the annual meeting of the American College of Mohs Surgery. “Telemedicine likely has a role in Mohs practices, particularly with postop follow-up visits. However, postpandemic reimbursement and regulatory issues need to be formally laid out before Mohs surgeons are able to incorporate it into their permanent work flow.”
Dr. Maruthur, a Mohs surgery and dermatologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York, and colleagues sent a survey to ACMS members in September and October 2020. “We saw first-hand in our surgical practice that telemedicine quickly became an important tool when the pandemic surged in the spring of 2020,” he said. Considering that surgical practices are highly dependent on in-person visits, the impetus for this study was to assess to what degree Mohs practices from across the spectrum, including academic and private practices, embraced telemedicine during the pandemic, and “what these surgical practices used telemedicine for, how it was received by their patients, which telemedicine platforms were most often utilized, and lastly, what are their plans if any for incorporating telemedicine into their surgical practices after the pandemic subsides.”
The researchers received responses from 115 surgeons representing all regions of the country (40% Northeast, 21% South, 21% Midwest, and 18% West). Half practiced in urban areas (37%) and large cities (13%), and 40% were in an academic setting versus 36% in a single-specialty private practice.
More than 70% of the respondents said their case load fell by at least 75% during the initial surge of the pandemic; 80% turned to telemedicine, compared with just 23% who relied on the technology prior to the pandemic. The most commonly used telemedicine technologies were FaceTime, Zoom, Doximity, and Epic.
Mohs surgeons reported most commonly using telemedicine for postsurgery management (77% of the total 115 responses). “Telemedicine is a great fit for this category of visits as they allow the surgeon to view the surgical site and answer any questions they patient may have,” Dr. Maruthur said. “If the surgeon does suspect a postop infection or other concern based on a patient’s signs or symptoms, they can easily schedule the patient for an in-person assessment. We suspect that postop follow-up visits may be the best candidate for long-term use of telemedicine in Mohs surgery practices.”
Surgeons also reported using telemedicine for “spot checks” (61%) and surgical consultations (59%).
However, Dr. Maruther noted that preoperative assessments and spot checks can be difficult to perform using telemedicine. “The quality of the video image is not always great, patients can have a difficult time pointing the camera at the right spot and at the right distance. Even appreciating the actual size of the lesion are all difficult over a video encounter. And there is a lot of information gleaned from in-person physical examination, such as whether the lesion is fixed to a deeper structure and whether there are any nearby scars or other suspicious lesions.”
Nearly three-quarters of the surgeons using the technology said most or all patients were receptive to telemedicine.
However, the surgeons reported multiple barriers to the use of telemedicine: Limitations when compared with physical exams (88%), fitting it into the work flow (58%), patient response and training (57%), reimbursement concerns (50%), implementation of the technology (37%), regulations such as HIPAA (24%), training of staff (17%), and licensing (8%).
In an interview, Sumaira Z. Aasi, MD, director of Mohs and dermatologic surgery, Stanford University, agreed that there are many obstacles to routine use of telemedicine by Mohs surgeons. “As surgeons, we rely on the physical and tactile exam to get a sense of the size and extent of the cancer and characteristics such as the laxity of the surrounding tissue whether the tumor is fixed,” she said. “It is very difficult to access this on a telemedicine visit.”
In addition, she said, “many of our patients are in the elderly population, and some may not be comfortable using this technology. Also, it’s not a work flow that we are comfortable or familiar with. And I think that the technology has to improve to allow for better resolution of images as we ‘examine’ patients through a telemedicine visit.”
She added that “another con is there is a reliance on having the patient point out lesions of concern. Many cancers are picked by a careful in-person examination by a qualified physician/dermatologist/Mohs surgeon when the lesion is quite small or subtle and not even noticed by the patient themselves. This approach invariably leads to earlier biopsies and earlier treatments that can prevent morbidity and save health care money.”
On the other hand, she said, telemedicine “may save patients some time and money in terms of the effort and cost of transportation to come in for simpler postoperative medical visits that are often short in their very nature, such as postop check-ups.”
Most of the surgeons surveyed (69%) said telemedicine probably or definitely deserves a place in the practice Mohs surgery, but only 50% said they’d like to or would definitely pursue giving telemedicine a role in their practices once the pandemic is over.
“At the start of the pandemic, many regulations in areas such as HIPAA were eased, and reimbursements were increased, which allowed telemedicine to be quickly adopted,” Dr. Maruther said. “The government and payers have yet to decide which regulations and reimbursements will be in place after the pandemic. That makes it very difficult for surgeons to make long-term plans for implementing telemedicine in their practices.”
Dr. Aasi predicted that telemedicine will become more appealing to patients and physicians as it its technology and usability improves. More familiarity with its use will also be helpful, she said, and surgeons will be more receptive as it’s incorporated into efficient daily work flow.
The study was funded in part by the National Institutes of Health.
FROM THE ACMS ANNUAL MEETING
Widespread Hyperkeratotic Papules in a Transplant Recipient
The Diagnosis: Trichodysplasia Spinulosa
Trichodysplasia spinulosa has been described in case reports over the last several decades, with its causative virus trichodysplasia spinulosa-associated polyomavirus (TSPyV) identified in 2010 by van der Meijden et al.1 Trichodysplasia spinulosa-associated polyomavirus is a small, nonenveloped, double-stranded DNA virus in the Polyomaviridae family, among several other known cutaneous polyomaviruses including Merkel cell polyomavirus, human polyomavirus (HPyV) 6, HPyV7, HPyV10, and possibly HPyV13.2 The primary target of TSPyV is follicular keratinocytes, and it is believed to cause trichodysplasia spinulosa by primary infection rather than by reactivation. Trichodysplasia spinulosa presents in immunosuppressed patients as a folliculocentric eruption of papules with keratinous spines on the face, often with concurrent alopecia, eventually spreading to the trunk and extremities.3 The diagnosis often is clinical, but a biopsy may be performed for histopathologic confirmation. Alternatively, lesional spicules can be painlessly collected manually and submitted for viral polymerase chain reaction (PCR).4 The diagnosis of trichodysplasia spinulosa can be difficult due to similarities with other more common conditions such as keratosis pilaris, milia, filiform warts, or lichen spinulosus.
Similar to trichodysplasia spinulosa, keratosis pilaris also presents with folliculocentric and often erythematous papules.5 Keratosis pilaris most frequently affects the posterior upper arms and thighs but also may affect the cheeks, as seen in trichodysplasia spinulosa. Differentiation between the 2 diagnoses can be made on a clinical basis, as keratosis pilaris lacks the characteristic keratinous spines and often spares the central face and nose, locations that commonly are affected in trichodysplasia spinulosa.3
Milia typically appear as white to yellow papules, often on the cheeks, eyelids, nose, and chin.6 Given their predilection for the face, milia can appear similarly to trichodysplasia spinulosa. Differentiation can be made clinically, as milia typically are not as numerous as the spiculed papules seen in trichodysplasia spinulosa. Morphologically, milia will present as smooth, dome-shaped papules as opposed to the keratinous spicules seen in trichodysplasia spinulosa. The diagnosis of milia can be confirmed by incision and removal of the white chalky keratin core, a feature absent in trichodysplasia spinulosa.
Filiform warts are benign epidermal proliferations caused by human papillomavirus infection that manifest as flesh-colored, verrucous, hyperkeratotic papules.7 They can appear on virtually any skin surface, including the face, and thus may be mistaken for trichodysplasia spinulosa. Close inspection usually will reveal tiny black dots that represent thrombosed capillaries, a feature lacking in trichodysplasia spinulosa. In long-standing lesions or immunocompromised patients, confluent verrucous plaques may develop.8 Diagnosis of filiform warts can be confirmed with biopsy, which will demonstrate a compact stratum corneum, coarse hypergranulosis, and papillomatosis curving inward, while biopsy of a trichodysplasia spinulosa lesion would show polyomavirus infection of the hair follicle and characteristic eosinophilic inclusion bodies.9
Lichen spinulosus may appear as multiple folliculocentric scaly papules with hairlike horny spines.10 Lichen spinulosus differs from trichodysplasia spinulosa in that it commonly appears on the neck, abdomen, trochanteric region, arms, elbows, or knees. Lichen spinulosus also classically appears as a concrete cluster of papules, often localized to a certain region, in contrast to trichodysplasia spinulosa, which will be widespread, often spreading over time. Finally, clinical history may help differentiate the 2 entities. Lichen spinulosus most often appears in children and adolescents and often has an indolent course, typically resolving during puberty, while trichodysplasia spinulosa is seen in immunocompromised patients.
In our patient, the dermatology team made a diagnosis of trichodysplasia spinulosa based on the characteristic clinical presentation, which was confirmed after approximately 10 lesional spicules were removed by tissue forceps and submitted for PCR analysis showing TSPyV (Figure). Two other cases utilized spicule PCR analysis for confirmation of TSPyV.11,12 This technique may represent a viable option for diagnostic confirmation in pediatric cases.
Although some articles have examined the molecular and biologic features of trichodysplasia spinulosa, literature on clinical presentation and management is limited to isolated case reports with no comprehensive studies to establish a standardized treatment. Of these reports, oral valganciclovir 900 mg daily, topical retinoids, cidofovir cream 1% to 3%, and decreasing or altering the immunosuppressive regimen all have been noted to provide clinical improvement.13,14 Other therapies including leflunomide and routine manual extraction of spicules also have shown effectiveness in the treatment of trichodysplasia spinulosa.15
In our patient, treatment included decreasing immunosuppression, as she was getting recurrent sinus and upper respiratory infections. Mycophenolate mofetil was discontinued, and the patient was continued solely on tacrolimus therapy. She demonstrated notable improvement after 3 months, with approximately 50% clearance of the eruption. A mutual decision was made at that visit to initiate therapy with compounded cidofovir cream 1% daily to the lesions until the next follow-up visit. Unfortunately, the patient did not return for her scheduled dermatology visits and was lost to long-term follow-up.
Acknowledgment
We thank Richard C. Wang, MD, PhD (Dallas, Texas), for his dermatologic expertise and assistance in analysis of lesional samples for TSPyV.
- van der Meijden E, Janssens RWA, Lauber C, et al. Discovery of a new human polyomavirus associated with trichodysplasia spinulosa in an immunocompromised patient. PLoS Pathog. 2010;6:E1001024.
- Sheu JC, Tran J, Rady PL, et al. Polyomaviruses of the skin: integrating molecular and clinical advances in an emerging class of viruses. Br J Dermatol. 2019;180:1302-1311.
- Sperling LC, Tomaszewski MM, Thomas DA. Viral-associated trichodysplasia in patients who are immunocompromised. J Am Acad Dermatol. 2004;50:318-322.
- Wu JH, Nguyen HP, Rady PL, et al. Molecular insight into the viral biology and clinical features of trichodysplasia spinulosa. Br J Dermatol. 2016;174:490-498.
- Hwang S, Schwartz RA. Keratosis pilaris: a common follicular hyperkeratosis. Cutis. 2008;82:177-180.
- Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol. 2008;59:1050-1063.
- Micali G, Dall'Oglio F, Nasca MR, et al. Management of cutaneous warts: an evidence-based approach. Am J Clin Dermatol. 2004;5:311-317.
- Bolognia J, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018.
- Elston DM, Ferringer T, Ko CJ. Dermatopathology. 3rd ed. Elsevier; 2018.
- Tilly JJ, Drolet BA, Esterly NB. Lichenoid eruptions in children. J Am Acad Dermatol. 2004;51:606-624.
- Chamseddin BH, Tran BAPD, Lee EE, et al. Trichodysplasia spinulosa in a child: identification of trichodysplasia spinulosa-associated polyomavirus in skin, serum, and urine. Pediatr Dermatol. 2019;36:723-724.
- Sonstegard A, Grossman M, Garg A. Trichodysplasia spinulosa in a kidney transplant recipient. JAMA Dermatol. 2021;157:105.
- Leitenberger JJ, Abdelmalek M, Wang RC, et al. Two cases of trichodysplasia spinulosa responsive to compounded topical cidofovir 3% cream. JAAD Case Rep. 2015;1:S33-S35.
- DeCrescenzo AJ, Philips RC, Wilkerson MG. Trichodysplasia spinulosa: a rare complication of immunosuppression. JAAD Case Rep. 2016;2:307-309.
- Nguyen KD, Chamseddin BH, Cockerell CJ, et al. The biology and clinical features of cutaneous polyomaviruses. J Invest Dermatol. 2019;139:285-292.
The Diagnosis: Trichodysplasia Spinulosa
Trichodysplasia spinulosa has been described in case reports over the last several decades, with its causative virus trichodysplasia spinulosa-associated polyomavirus (TSPyV) identified in 2010 by van der Meijden et al.1 Trichodysplasia spinulosa-associated polyomavirus is a small, nonenveloped, double-stranded DNA virus in the Polyomaviridae family, among several other known cutaneous polyomaviruses including Merkel cell polyomavirus, human polyomavirus (HPyV) 6, HPyV7, HPyV10, and possibly HPyV13.2 The primary target of TSPyV is follicular keratinocytes, and it is believed to cause trichodysplasia spinulosa by primary infection rather than by reactivation. Trichodysplasia spinulosa presents in immunosuppressed patients as a folliculocentric eruption of papules with keratinous spines on the face, often with concurrent alopecia, eventually spreading to the trunk and extremities.3 The diagnosis often is clinical, but a biopsy may be performed for histopathologic confirmation. Alternatively, lesional spicules can be painlessly collected manually and submitted for viral polymerase chain reaction (PCR).4 The diagnosis of trichodysplasia spinulosa can be difficult due to similarities with other more common conditions such as keratosis pilaris, milia, filiform warts, or lichen spinulosus.
Similar to trichodysplasia spinulosa, keratosis pilaris also presents with folliculocentric and often erythematous papules.5 Keratosis pilaris most frequently affects the posterior upper arms and thighs but also may affect the cheeks, as seen in trichodysplasia spinulosa. Differentiation between the 2 diagnoses can be made on a clinical basis, as keratosis pilaris lacks the characteristic keratinous spines and often spares the central face and nose, locations that commonly are affected in trichodysplasia spinulosa.3
Milia typically appear as white to yellow papules, often on the cheeks, eyelids, nose, and chin.6 Given their predilection for the face, milia can appear similarly to trichodysplasia spinulosa. Differentiation can be made clinically, as milia typically are not as numerous as the spiculed papules seen in trichodysplasia spinulosa. Morphologically, milia will present as smooth, dome-shaped papules as opposed to the keratinous spicules seen in trichodysplasia spinulosa. The diagnosis of milia can be confirmed by incision and removal of the white chalky keratin core, a feature absent in trichodysplasia spinulosa.
Filiform warts are benign epidermal proliferations caused by human papillomavirus infection that manifest as flesh-colored, verrucous, hyperkeratotic papules.7 They can appear on virtually any skin surface, including the face, and thus may be mistaken for trichodysplasia spinulosa. Close inspection usually will reveal tiny black dots that represent thrombosed capillaries, a feature lacking in trichodysplasia spinulosa. In long-standing lesions or immunocompromised patients, confluent verrucous plaques may develop.8 Diagnosis of filiform warts can be confirmed with biopsy, which will demonstrate a compact stratum corneum, coarse hypergranulosis, and papillomatosis curving inward, while biopsy of a trichodysplasia spinulosa lesion would show polyomavirus infection of the hair follicle and characteristic eosinophilic inclusion bodies.9
Lichen spinulosus may appear as multiple folliculocentric scaly papules with hairlike horny spines.10 Lichen spinulosus differs from trichodysplasia spinulosa in that it commonly appears on the neck, abdomen, trochanteric region, arms, elbows, or knees. Lichen spinulosus also classically appears as a concrete cluster of papules, often localized to a certain region, in contrast to trichodysplasia spinulosa, which will be widespread, often spreading over time. Finally, clinical history may help differentiate the 2 entities. Lichen spinulosus most often appears in children and adolescents and often has an indolent course, typically resolving during puberty, while trichodysplasia spinulosa is seen in immunocompromised patients.
In our patient, the dermatology team made a diagnosis of trichodysplasia spinulosa based on the characteristic clinical presentation, which was confirmed after approximately 10 lesional spicules were removed by tissue forceps and submitted for PCR analysis showing TSPyV (Figure). Two other cases utilized spicule PCR analysis for confirmation of TSPyV.11,12 This technique may represent a viable option for diagnostic confirmation in pediatric cases.
Although some articles have examined the molecular and biologic features of trichodysplasia spinulosa, literature on clinical presentation and management is limited to isolated case reports with no comprehensive studies to establish a standardized treatment. Of these reports, oral valganciclovir 900 mg daily, topical retinoids, cidofovir cream 1% to 3%, and decreasing or altering the immunosuppressive regimen all have been noted to provide clinical improvement.13,14 Other therapies including leflunomide and routine manual extraction of spicules also have shown effectiveness in the treatment of trichodysplasia spinulosa.15
In our patient, treatment included decreasing immunosuppression, as she was getting recurrent sinus and upper respiratory infections. Mycophenolate mofetil was discontinued, and the patient was continued solely on tacrolimus therapy. She demonstrated notable improvement after 3 months, with approximately 50% clearance of the eruption. A mutual decision was made at that visit to initiate therapy with compounded cidofovir cream 1% daily to the lesions until the next follow-up visit. Unfortunately, the patient did not return for her scheduled dermatology visits and was lost to long-term follow-up.
Acknowledgment
We thank Richard C. Wang, MD, PhD (Dallas, Texas), for his dermatologic expertise and assistance in analysis of lesional samples for TSPyV.
The Diagnosis: Trichodysplasia Spinulosa
Trichodysplasia spinulosa has been described in case reports over the last several decades, with its causative virus trichodysplasia spinulosa-associated polyomavirus (TSPyV) identified in 2010 by van der Meijden et al.1 Trichodysplasia spinulosa-associated polyomavirus is a small, nonenveloped, double-stranded DNA virus in the Polyomaviridae family, among several other known cutaneous polyomaviruses including Merkel cell polyomavirus, human polyomavirus (HPyV) 6, HPyV7, HPyV10, and possibly HPyV13.2 The primary target of TSPyV is follicular keratinocytes, and it is believed to cause trichodysplasia spinulosa by primary infection rather than by reactivation. Trichodysplasia spinulosa presents in immunosuppressed patients as a folliculocentric eruption of papules with keratinous spines on the face, often with concurrent alopecia, eventually spreading to the trunk and extremities.3 The diagnosis often is clinical, but a biopsy may be performed for histopathologic confirmation. Alternatively, lesional spicules can be painlessly collected manually and submitted for viral polymerase chain reaction (PCR).4 The diagnosis of trichodysplasia spinulosa can be difficult due to similarities with other more common conditions such as keratosis pilaris, milia, filiform warts, or lichen spinulosus.
Similar to trichodysplasia spinulosa, keratosis pilaris also presents with folliculocentric and often erythematous papules.5 Keratosis pilaris most frequently affects the posterior upper arms and thighs but also may affect the cheeks, as seen in trichodysplasia spinulosa. Differentiation between the 2 diagnoses can be made on a clinical basis, as keratosis pilaris lacks the characteristic keratinous spines and often spares the central face and nose, locations that commonly are affected in trichodysplasia spinulosa.3
Milia typically appear as white to yellow papules, often on the cheeks, eyelids, nose, and chin.6 Given their predilection for the face, milia can appear similarly to trichodysplasia spinulosa. Differentiation can be made clinically, as milia typically are not as numerous as the spiculed papules seen in trichodysplasia spinulosa. Morphologically, milia will present as smooth, dome-shaped papules as opposed to the keratinous spicules seen in trichodysplasia spinulosa. The diagnosis of milia can be confirmed by incision and removal of the white chalky keratin core, a feature absent in trichodysplasia spinulosa.
Filiform warts are benign epidermal proliferations caused by human papillomavirus infection that manifest as flesh-colored, verrucous, hyperkeratotic papules.7 They can appear on virtually any skin surface, including the face, and thus may be mistaken for trichodysplasia spinulosa. Close inspection usually will reveal tiny black dots that represent thrombosed capillaries, a feature lacking in trichodysplasia spinulosa. In long-standing lesions or immunocompromised patients, confluent verrucous plaques may develop.8 Diagnosis of filiform warts can be confirmed with biopsy, which will demonstrate a compact stratum corneum, coarse hypergranulosis, and papillomatosis curving inward, while biopsy of a trichodysplasia spinulosa lesion would show polyomavirus infection of the hair follicle and characteristic eosinophilic inclusion bodies.9
Lichen spinulosus may appear as multiple folliculocentric scaly papules with hairlike horny spines.10 Lichen spinulosus differs from trichodysplasia spinulosa in that it commonly appears on the neck, abdomen, trochanteric region, arms, elbows, or knees. Lichen spinulosus also classically appears as a concrete cluster of papules, often localized to a certain region, in contrast to trichodysplasia spinulosa, which will be widespread, often spreading over time. Finally, clinical history may help differentiate the 2 entities. Lichen spinulosus most often appears in children and adolescents and often has an indolent course, typically resolving during puberty, while trichodysplasia spinulosa is seen in immunocompromised patients.
In our patient, the dermatology team made a diagnosis of trichodysplasia spinulosa based on the characteristic clinical presentation, which was confirmed after approximately 10 lesional spicules were removed by tissue forceps and submitted for PCR analysis showing TSPyV (Figure). Two other cases utilized spicule PCR analysis for confirmation of TSPyV.11,12 This technique may represent a viable option for diagnostic confirmation in pediatric cases.
Although some articles have examined the molecular and biologic features of trichodysplasia spinulosa, literature on clinical presentation and management is limited to isolated case reports with no comprehensive studies to establish a standardized treatment. Of these reports, oral valganciclovir 900 mg daily, topical retinoids, cidofovir cream 1% to 3%, and decreasing or altering the immunosuppressive regimen all have been noted to provide clinical improvement.13,14 Other therapies including leflunomide and routine manual extraction of spicules also have shown effectiveness in the treatment of trichodysplasia spinulosa.15
In our patient, treatment included decreasing immunosuppression, as she was getting recurrent sinus and upper respiratory infections. Mycophenolate mofetil was discontinued, and the patient was continued solely on tacrolimus therapy. She demonstrated notable improvement after 3 months, with approximately 50% clearance of the eruption. A mutual decision was made at that visit to initiate therapy with compounded cidofovir cream 1% daily to the lesions until the next follow-up visit. Unfortunately, the patient did not return for her scheduled dermatology visits and was lost to long-term follow-up.
Acknowledgment
We thank Richard C. Wang, MD, PhD (Dallas, Texas), for his dermatologic expertise and assistance in analysis of lesional samples for TSPyV.
- van der Meijden E, Janssens RWA, Lauber C, et al. Discovery of a new human polyomavirus associated with trichodysplasia spinulosa in an immunocompromised patient. PLoS Pathog. 2010;6:E1001024.
- Sheu JC, Tran J, Rady PL, et al. Polyomaviruses of the skin: integrating molecular and clinical advances in an emerging class of viruses. Br J Dermatol. 2019;180:1302-1311.
- Sperling LC, Tomaszewski MM, Thomas DA. Viral-associated trichodysplasia in patients who are immunocompromised. J Am Acad Dermatol. 2004;50:318-322.
- Wu JH, Nguyen HP, Rady PL, et al. Molecular insight into the viral biology and clinical features of trichodysplasia spinulosa. Br J Dermatol. 2016;174:490-498.
- Hwang S, Schwartz RA. Keratosis pilaris: a common follicular hyperkeratosis. Cutis. 2008;82:177-180.
- Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol. 2008;59:1050-1063.
- Micali G, Dall'Oglio F, Nasca MR, et al. Management of cutaneous warts: an evidence-based approach. Am J Clin Dermatol. 2004;5:311-317.
- Bolognia J, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018.
- Elston DM, Ferringer T, Ko CJ. Dermatopathology. 3rd ed. Elsevier; 2018.
- Tilly JJ, Drolet BA, Esterly NB. Lichenoid eruptions in children. J Am Acad Dermatol. 2004;51:606-624.
- Chamseddin BH, Tran BAPD, Lee EE, et al. Trichodysplasia spinulosa in a child: identification of trichodysplasia spinulosa-associated polyomavirus in skin, serum, and urine. Pediatr Dermatol. 2019;36:723-724.
- Sonstegard A, Grossman M, Garg A. Trichodysplasia spinulosa in a kidney transplant recipient. JAMA Dermatol. 2021;157:105.
- Leitenberger JJ, Abdelmalek M, Wang RC, et al. Two cases of trichodysplasia spinulosa responsive to compounded topical cidofovir 3% cream. JAAD Case Rep. 2015;1:S33-S35.
- DeCrescenzo AJ, Philips RC, Wilkerson MG. Trichodysplasia spinulosa: a rare complication of immunosuppression. JAAD Case Rep. 2016;2:307-309.
- Nguyen KD, Chamseddin BH, Cockerell CJ, et al. The biology and clinical features of cutaneous polyomaviruses. J Invest Dermatol. 2019;139:285-292.
- van der Meijden E, Janssens RWA, Lauber C, et al. Discovery of a new human polyomavirus associated with trichodysplasia spinulosa in an immunocompromised patient. PLoS Pathog. 2010;6:E1001024.
- Sheu JC, Tran J, Rady PL, et al. Polyomaviruses of the skin: integrating molecular and clinical advances in an emerging class of viruses. Br J Dermatol. 2019;180:1302-1311.
- Sperling LC, Tomaszewski MM, Thomas DA. Viral-associated trichodysplasia in patients who are immunocompromised. J Am Acad Dermatol. 2004;50:318-322.
- Wu JH, Nguyen HP, Rady PL, et al. Molecular insight into the viral biology and clinical features of trichodysplasia spinulosa. Br J Dermatol. 2016;174:490-498.
- Hwang S, Schwartz RA. Keratosis pilaris: a common follicular hyperkeratosis. Cutis. 2008;82:177-180.
- Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol. 2008;59:1050-1063.
- Micali G, Dall'Oglio F, Nasca MR, et al. Management of cutaneous warts: an evidence-based approach. Am J Clin Dermatol. 2004;5:311-317.
- Bolognia J, Schaffer JV, Cerroni L. Dermatology. 4th ed. Elsevier; 2018.
- Elston DM, Ferringer T, Ko CJ. Dermatopathology. 3rd ed. Elsevier; 2018.
- Tilly JJ, Drolet BA, Esterly NB. Lichenoid eruptions in children. J Am Acad Dermatol. 2004;51:606-624.
- Chamseddin BH, Tran BAPD, Lee EE, et al. Trichodysplasia spinulosa in a child: identification of trichodysplasia spinulosa-associated polyomavirus in skin, serum, and urine. Pediatr Dermatol. 2019;36:723-724.
- Sonstegard A, Grossman M, Garg A. Trichodysplasia spinulosa in a kidney transplant recipient. JAMA Dermatol. 2021;157:105.
- Leitenberger JJ, Abdelmalek M, Wang RC, et al. Two cases of trichodysplasia spinulosa responsive to compounded topical cidofovir 3% cream. JAAD Case Rep. 2015;1:S33-S35.
- DeCrescenzo AJ, Philips RC, Wilkerson MG. Trichodysplasia spinulosa: a rare complication of immunosuppression. JAAD Case Rep. 2016;2:307-309.
- Nguyen KD, Chamseddin BH, Cockerell CJ, et al. The biology and clinical features of cutaneous polyomaviruses. J Invest Dermatol. 2019;139:285-292.
A 4-year-old girl with a history of cardiac transplantation 1 year prior for dilated cardiomyopathy presented to the dermatology consultation service with widespread hyperkeratotic papules of 2 months’ duration. The eruption initially had appeared on the face with subsequent involvement of the trunk and extremities. Her immunosuppressive medications included oral tacrolimus and mycophenolate mofetil. No over-the-counter or prescription treatments had been used for the eruption; the patient’s mother had been manually extracting the spicules from the nose, cheeks, and forehead with tweezers. The lesions were asymptomatic with only mild follicular erythema. Physical examination revealed multiple folliculocentric keratinous spicules on the nose, cheeks, forehead (top), trunk (bottom), arms, and legs.
Psoriatic Alopecia in a Patient With Crohn Disease: An Uncommon Manifestation of Tumor Necrosis Factor α Inhibitors
Tumor necrosis factor α (TNF-α) inhibitor–induced psoriasis is a known paradoxical adverse effect of this family of medications, which includes infliximab, adalimumab, etanercept, golimumab, and certolizumab. In the pediatric population, these therapies recently gained approval for nondermatologic conditions—meaning that this phenomenon is encountered more frequently.1 In a systematic review of TNF-α inhibitor–induced psoriasis, severe scalp involvement was associated with alopecia in 7.5% of cases.2 Onset of scalp psoriasis with alopecia in patients being treated with a TNF-α inhibitor should lead to consideration of this condition.
Psoriatic alopecia is an uncommon presentation of psoriasis. Although well described, alopecia as a clinical manifestation of scalp psoriasis is not a well-known concept among clinicians and has never been widely accepted. Adding to the diagnostic challenge is that psoriatic alopecia secondary to TNF-α inhibitor–induced psoriasis rarely has been reported in adults or children.3-5 Including our case, our review of the literature yielded 7 pediatric cases (≤18 years) of TNF-α inhibitor–induced psoriatic alopecia.6,7 A primary literature search of PubMed articles indexed for MEDLINE was conducted using the terms psoriatic alopecia, psoriasiform alopecia, TNF-α inhibitors, infliximab, adalimumab, etanercept, golimumab, and certolizumab.
We present the case of a pediatric patient with psoriatic alopecia secondary to treatment with adalimumab for Crohn disease (CD). We also provide a review of reported cases of psoriatic alopecia induced by a TNF-α inhibitor in the literature.
Case Report
A 12-year-old girl presented to our dermatology clinic with erythematous scaly plaques on the trunk, scalp, arms, and legs of 2 months’ duration. The lesions involved approximately 15% of the body surface area. The patient’s medical history was remarkable for CD diagnosed 4 years prior to presentation of the skin lesions. She had been treated for the past 2 years with adalimumab 40 mg once every 2 weeks and azathioprine 100 mg once daily. Because her CD was poorly controlled, the dosage of adalimumab was increased to 40 mg once weekly 6 months prior to the current presentation.
Our diagnosis was TNF-α inhibitor-induced psoriasis secondary to treatment with adalimumab.
The patient was treated with mometasone lotion 0.1% for the scalp lesions and triamcinolone cream 0.1% for the body lesions. Because of the extent of the psoriasis, we recommended changing adalimumab to ustekinumab, which is approved for CD in adults but is off label in children.
At 1-month follow-up, after receiving the induction dose of ustekinumab, the patient presented with partial improvement of the skin lesions but had developed a large, alopecic, erythematous plaque with thick yellowish scales on the scalp (Figure 1). She also had a positive hair pull test. The presumptive initial diagnosis of the alopecic scalp lesion was tinea capitis, for which multiple potassium hydroxide preparations of scales were performed, all yielding negative results. In addition, histopathologic examination with hematoxylin and eosin staining was performed (Figures 2A and 2B). Sterile tissue cultures for bacteria, fungi, and acid-fast bacilli were obtained and showed no growth. Periodic acid–Schiff staining was negative for fungal structures.
A second biopsy showed a psoriasiform pattern, parakeratosis, and hypogranulosis, highly suggestive of psoriasis (Figure 2C and 2D). Based on those findings, a diagnosis of psoriatic alopecia was made. The mometasone was switched to clobetasol lotion 0.05%. The patient continued treatment with ustekinumab. At 6-month follow-up, her CD was well controlled and she showed hair regrowth in previously alopecic areas (Figure 3).
Comment
Psoriatic alopecia induced by a TNF-α inhibitor was first reported in 2007 in a 30-year-old woman with ankylosing spondylitis who was being treated with adalimumab.8 She had erythematous, scaly, alopecic plaques on the scalp and palmoplantar pustulosis. Findings on skin biopsy were compatible with psoriasis. The patient’s severe scalp psoriasis failed to respond to topical steroid treatment and adalimumab cessation. The extensive hair loss responded to cyclosporine 3 mg/kg daily.8
After conducting an extensive literature review, we found 26 cases of TNF-α–induced psoriatic alopecia, including the current case (Table).6-16 The mean age at diagnosis was 27.8 years (SD, 13.6 years; range, 7–60 years). The female-to-male ratio was 3.3:1. The most common underlying condition for which TNF-α inhibitors were prescribed was CD (77% [20/26]). Psoriatic alopecia most commonly was reported secondary to treatment with infliximab (54% [14/26]), followed by adalimumab (42% [11/26]). Golimumab was the causative drug in 1 (4%) case. We did not find reports of etanercept or certolizumab having induced this manifestation. The onset of the scalp lesions occurred 2 to 46 months after starting treatment with the causative medication.
Laga et al17 reported that TNF-α inhibitor–induced psoriasis can have a variety of histopathologic findings, including typical findings of various stages of psoriasis, a lichenoid pattern mimicking remnants of lichen planus, and sterile pustular folliculitis. Our patient’s 2 scalp biopsies demonstrated results consistent with findings reported by Laga et al.17 In the first biopsy, findings were consistent with a dense neutrophilic infiltrate with negative sterile cultures and negative periodic acid–Schiff stain (sterile folliculitis), with crust and areas of parakeratosis. The second biopsy demonstrated psoriasiform hyperplasia, parakeratosis, and an absent granular layer, all typical features of psoriasis (Figure 2).
Including the current case, our review of the literature yielded 7 pediatric (ie, 0–18 years of age) cases of TNF-α inhibitor–induced psoriatic alopecia. Of the 6 previously reported pediatric cases, 5 occurred after administration of infliximab.6,7
Similar to our case, TNF-α inhibitor–induced psoriatic alopecia was reported in a 7-year-old girl who was treated with adalimumab for juvenile idiopathic arthritis.6 Nine months after starting treatment, that patient presented with a tender, erythematous, eroded, and crusted alopecic plaque along with scaly plaques on the scalp. Adalimumab was discontinued, and cyclosporine and topical steroids were started. Cyclosporine was then discontinued due to partial resolution of the psoriasis; the patient was started on abatacept, with persistence of the psoriasis and alopecia. The patient was then started on oral methotrexate 12.5 mg once weekly with moderate improvement and mild to moderate exacerbations.
Tumor necrosis factor α inhibitor–induced psoriasis may occur as a result of a cytokine imbalance. A TNF-α blockade leads to upregulation of interferon α (IFN-α) and TNF-α production by plasmacytoid dendritic cells (pDCs), usually in genetically susceptible people.6,7,9-15 The IFN-α induces maturation of myeloid dendritic cells (mDCs) responsible for increasing proinflammatory cytokines that contribute to psoriasis.11 Generation of TNF-α by pDCs leads to mature or activated dendritic cells derived from pDCs through autocrine TNF-α production and paracrine IFN-α production from immature mDCs.9 Once pDCs mature, they are incapable of producing IFN-α; TNF-α then inhibits IFN-α production by inducing pDC maturation.11 Overproduction of IFN-α during TNF-α inhibition induces expression of the chemokine receptor CXCR3 on T cells, which recruits T cells to the dermis. The T cells then produce TNF-α, causing psoriatic skin lesions.10,11,13,14
Although TNF-α inhibitor–induced psoriatic alopecia is uncommon, the condition should be considered in female patients with underlying proinflammatory disease—CD in particular. Perman et al6 reported 5 cases of psoriatic alopecia in which 3 patients initially were treated with griseofulvin because of suspected tinea capitis.
Conditions with similar clinical findings should be ruled out before making a diagnosis of TNF-α inhibitor–induced psoriatic alopecia. Although clinicopathologic correlation is essential for making the diagnosis, it is possible that the histologic findings will not be specific for psoriasis.17 It is important to be aware of this condition in patients being treated with a TNF-α inhibitor as early as 2 months to 4 years or longer after starting treatment.
Previously reported cases have demonstrated various treatment options that yielded improvement or resolution of TNF-α inhibitor–induced psoriatic alopecia. These include either continuation or discontinuation of the TNF-α inhibitor combined with topical or intralesional steroids, methotrexate, or cyclosporine. Another option is to switch the TNF-α inhibitor to another biologic. Outcomes vary from patient to patient, making the physician’s clinical judgment crucial in deciding which treatment route to take. Our patient showed notable improvement when she was switched from adalimumab to ustekinumab as well as the combination of ustekinumab and clobetasol lotion 0.05%.
Conclusion
We recommend an individualized approach that provides patients with the safest and least invasive treatment option for TNF-α inhibitor–induced psoriatic alopecia. In most reported cases, the problem resolved with treatment, thereby classifying this form of alopecia as noncicatricial alopecia.
- Horneff G, Seyger MMB, Arikan D, et al. Safety of adalimumab in pediatric patients with polyarticular juvenile idiopathic arthritis, enthesitis-related arthritis, psoriasis, and Crohn’s disease. J Pediatr. 2018;201:166-175.e3. doi:10.1016/j.jpeds.2018.05.042
- Brown G, Wang E, Leon A, et al. Tumor necrosis factor-α inhibitor-induced psoriasis: systematic review of clinical features, histopathological findings, and management experience. J Am Acad Dermatol. 2017;76:334-341. doi:10.1016/j.jaad.2016.08.012
- George SMC, Taylor MR, Farrant PBJ. Psoriatic alopecia. Clin Exp Dermatol. 2015;40:717-721. doi:10.1111/ced.12715
- Shuster S. Psoriatic alopecia. Br J Dermatol. 1972;87:73-77. doi:10.1111/j.1365-2133.1972.tb05103.x
- Silva CY, Brown KL, Kurban AK, et al. Psoriatic alopecia—fact or fiction? a clinicohistopathologic reappraisal. Indian J Dermatol Venereol Leprol. 2012;78:611-619. doi:10.4103/0378-6323.100574
- Perman MJ, Lovell DJ, Denson LA, et al. Five cases of anti-tumor necrosis factor alpha-induced psoriasis presenting with severe scalp involvement in children. Pediatr Dermatol. 2012;29:454-459. doi:10.1111/j.1525-1470.2011.01521.x
- Prata Ribeiro LB, Gonçalves Rego JC, Duque Estrada B, et al. Alopecia secondary to anti-tumor necrosis factor-alpha therapy. An Bras Dermatol. 2015;90:232–235. doi:10.1590/abd1806-4841.20153084
- Papadavid E, Gazi S, Dalamaga M, et al. Palmoplantar and scalp psoriasis occurring during anti-tumour necrosis factor-alpha therapy: a case series of four patients and guidelines for management. J Eur Acad Dermatol Venereol. 2008;22:380-382. doi:10.1111/j.1468-3083.2007.02335.x
- Manni E, Barachini P. Psoriasis induced by infliximab in a patient suffering from Crohn’s disease. Int J Immunopathol Pharmacol. 2009;22:841-844. doi:10.1177/039463200902200331
- El Shabrawi-Caelen L, La Placa M, Vincenzi C, et al. Adalimumab-induced psoriasis of the scalp with diffuse alopecia: a severe potentially irreversible cutaneous side effect of TNF-alpha blockers. Inflamm Bowel Dis. 2010;16:182-183. doi:10.1002/ibd.20954
- Medkour F, Babai S, Chanteloup E, et al. Development of diffuse psoriasis with alopecia during treatment of Crohn’s disease with infliximab. Gastroenterol Clin Biol. 2010;34:140-141. doi:10.1016/j.gcb.2009.10.021
- Doyle LA, Sperling LC, Baksh S, et al. Psoriatic alopecia/alopecia areata-like reactions secondary to anti-tumor necrosis factor-α therapy: a novel cause of noncicatricial alopecia. Am J Dermatopathol. 2011;33:161-166. doi:10.1097/DAD.0b013e3181ef7403
- Osório F, Magro F, Lisboa C, et al. Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature. Dermatology. 2012;225:163-167. doi:10.1159/000342503
- Andrisani G, Marzo M, Celleno L, et al. Development of psoriasis scalp with alopecia during treatment of Crohn’s disease with infliximab and rapid response to both diseases to ustekinumab. Eur Rev Med Pharmacol Sci. 2013;17:2831-2836.
- Afanasiev OK, Zhang CZ, Ruhoy SM. TNF-inhibitor associated psoriatic alopecia: diagnostic utility of sebaceous lobule atrophy. J Cutan Pathol. 2017;44:563-569. doi:10.1111/cup.12932
- Helm MM, Haddad S. Alopecia areata and scarring alopecia presenting during golimumab therapy for ankylosing spondylitis. N Am J Med Sci. 2018;11:22-24. doi:10.7156/najms.2018.110122
- Laga AC, Vleugels RA, Qureshi AA, et al. Histopathologic spectrum of psoriasiform skin reactions associated with tumor necrosis factor-a inhibitor therapy. a study of 16 biopsies. Am J Dermatopathol. 2010;32:568-573. doi:10.1097/DAD.0b013e3181cb3ff7
Tumor necrosis factor α (TNF-α) inhibitor–induced psoriasis is a known paradoxical adverse effect of this family of medications, which includes infliximab, adalimumab, etanercept, golimumab, and certolizumab. In the pediatric population, these therapies recently gained approval for nondermatologic conditions—meaning that this phenomenon is encountered more frequently.1 In a systematic review of TNF-α inhibitor–induced psoriasis, severe scalp involvement was associated with alopecia in 7.5% of cases.2 Onset of scalp psoriasis with alopecia in patients being treated with a TNF-α inhibitor should lead to consideration of this condition.
Psoriatic alopecia is an uncommon presentation of psoriasis. Although well described, alopecia as a clinical manifestation of scalp psoriasis is not a well-known concept among clinicians and has never been widely accepted. Adding to the diagnostic challenge is that psoriatic alopecia secondary to TNF-α inhibitor–induced psoriasis rarely has been reported in adults or children.3-5 Including our case, our review of the literature yielded 7 pediatric cases (≤18 years) of TNF-α inhibitor–induced psoriatic alopecia.6,7 A primary literature search of PubMed articles indexed for MEDLINE was conducted using the terms psoriatic alopecia, psoriasiform alopecia, TNF-α inhibitors, infliximab, adalimumab, etanercept, golimumab, and certolizumab.
We present the case of a pediatric patient with psoriatic alopecia secondary to treatment with adalimumab for Crohn disease (CD). We also provide a review of reported cases of psoriatic alopecia induced by a TNF-α inhibitor in the literature.
Case Report
A 12-year-old girl presented to our dermatology clinic with erythematous scaly plaques on the trunk, scalp, arms, and legs of 2 months’ duration. The lesions involved approximately 15% of the body surface area. The patient’s medical history was remarkable for CD diagnosed 4 years prior to presentation of the skin lesions. She had been treated for the past 2 years with adalimumab 40 mg once every 2 weeks and azathioprine 100 mg once daily. Because her CD was poorly controlled, the dosage of adalimumab was increased to 40 mg once weekly 6 months prior to the current presentation.
Our diagnosis was TNF-α inhibitor-induced psoriasis secondary to treatment with adalimumab.
The patient was treated with mometasone lotion 0.1% for the scalp lesions and triamcinolone cream 0.1% for the body lesions. Because of the extent of the psoriasis, we recommended changing adalimumab to ustekinumab, which is approved for CD in adults but is off label in children.
At 1-month follow-up, after receiving the induction dose of ustekinumab, the patient presented with partial improvement of the skin lesions but had developed a large, alopecic, erythematous plaque with thick yellowish scales on the scalp (Figure 1). She also had a positive hair pull test. The presumptive initial diagnosis of the alopecic scalp lesion was tinea capitis, for which multiple potassium hydroxide preparations of scales were performed, all yielding negative results. In addition, histopathologic examination with hematoxylin and eosin staining was performed (Figures 2A and 2B). Sterile tissue cultures for bacteria, fungi, and acid-fast bacilli were obtained and showed no growth. Periodic acid–Schiff staining was negative for fungal structures.
A second biopsy showed a psoriasiform pattern, parakeratosis, and hypogranulosis, highly suggestive of psoriasis (Figure 2C and 2D). Based on those findings, a diagnosis of psoriatic alopecia was made. The mometasone was switched to clobetasol lotion 0.05%. The patient continued treatment with ustekinumab. At 6-month follow-up, her CD was well controlled and she showed hair regrowth in previously alopecic areas (Figure 3).
Comment
Psoriatic alopecia induced by a TNF-α inhibitor was first reported in 2007 in a 30-year-old woman with ankylosing spondylitis who was being treated with adalimumab.8 She had erythematous, scaly, alopecic plaques on the scalp and palmoplantar pustulosis. Findings on skin biopsy were compatible with psoriasis. The patient’s severe scalp psoriasis failed to respond to topical steroid treatment and adalimumab cessation. The extensive hair loss responded to cyclosporine 3 mg/kg daily.8
After conducting an extensive literature review, we found 26 cases of TNF-α–induced psoriatic alopecia, including the current case (Table).6-16 The mean age at diagnosis was 27.8 years (SD, 13.6 years; range, 7–60 years). The female-to-male ratio was 3.3:1. The most common underlying condition for which TNF-α inhibitors were prescribed was CD (77% [20/26]). Psoriatic alopecia most commonly was reported secondary to treatment with infliximab (54% [14/26]), followed by adalimumab (42% [11/26]). Golimumab was the causative drug in 1 (4%) case. We did not find reports of etanercept or certolizumab having induced this manifestation. The onset of the scalp lesions occurred 2 to 46 months after starting treatment with the causative medication.
Laga et al17 reported that TNF-α inhibitor–induced psoriasis can have a variety of histopathologic findings, including typical findings of various stages of psoriasis, a lichenoid pattern mimicking remnants of lichen planus, and sterile pustular folliculitis. Our patient’s 2 scalp biopsies demonstrated results consistent with findings reported by Laga et al.17 In the first biopsy, findings were consistent with a dense neutrophilic infiltrate with negative sterile cultures and negative periodic acid–Schiff stain (sterile folliculitis), with crust and areas of parakeratosis. The second biopsy demonstrated psoriasiform hyperplasia, parakeratosis, and an absent granular layer, all typical features of psoriasis (Figure 2).
Including the current case, our review of the literature yielded 7 pediatric (ie, 0–18 years of age) cases of TNF-α inhibitor–induced psoriatic alopecia. Of the 6 previously reported pediatric cases, 5 occurred after administration of infliximab.6,7
Similar to our case, TNF-α inhibitor–induced psoriatic alopecia was reported in a 7-year-old girl who was treated with adalimumab for juvenile idiopathic arthritis.6 Nine months after starting treatment, that patient presented with a tender, erythematous, eroded, and crusted alopecic plaque along with scaly plaques on the scalp. Adalimumab was discontinued, and cyclosporine and topical steroids were started. Cyclosporine was then discontinued due to partial resolution of the psoriasis; the patient was started on abatacept, with persistence of the psoriasis and alopecia. The patient was then started on oral methotrexate 12.5 mg once weekly with moderate improvement and mild to moderate exacerbations.
Tumor necrosis factor α inhibitor–induced psoriasis may occur as a result of a cytokine imbalance. A TNF-α blockade leads to upregulation of interferon α (IFN-α) and TNF-α production by plasmacytoid dendritic cells (pDCs), usually in genetically susceptible people.6,7,9-15 The IFN-α induces maturation of myeloid dendritic cells (mDCs) responsible for increasing proinflammatory cytokines that contribute to psoriasis.11 Generation of TNF-α by pDCs leads to mature or activated dendritic cells derived from pDCs through autocrine TNF-α production and paracrine IFN-α production from immature mDCs.9 Once pDCs mature, they are incapable of producing IFN-α; TNF-α then inhibits IFN-α production by inducing pDC maturation.11 Overproduction of IFN-α during TNF-α inhibition induces expression of the chemokine receptor CXCR3 on T cells, which recruits T cells to the dermis. The T cells then produce TNF-α, causing psoriatic skin lesions.10,11,13,14
Although TNF-α inhibitor–induced psoriatic alopecia is uncommon, the condition should be considered in female patients with underlying proinflammatory disease—CD in particular. Perman et al6 reported 5 cases of psoriatic alopecia in which 3 patients initially were treated with griseofulvin because of suspected tinea capitis.
Conditions with similar clinical findings should be ruled out before making a diagnosis of TNF-α inhibitor–induced psoriatic alopecia. Although clinicopathologic correlation is essential for making the diagnosis, it is possible that the histologic findings will not be specific for psoriasis.17 It is important to be aware of this condition in patients being treated with a TNF-α inhibitor as early as 2 months to 4 years or longer after starting treatment.
Previously reported cases have demonstrated various treatment options that yielded improvement or resolution of TNF-α inhibitor–induced psoriatic alopecia. These include either continuation or discontinuation of the TNF-α inhibitor combined with topical or intralesional steroids, methotrexate, or cyclosporine. Another option is to switch the TNF-α inhibitor to another biologic. Outcomes vary from patient to patient, making the physician’s clinical judgment crucial in deciding which treatment route to take. Our patient showed notable improvement when she was switched from adalimumab to ustekinumab as well as the combination of ustekinumab and clobetasol lotion 0.05%.
Conclusion
We recommend an individualized approach that provides patients with the safest and least invasive treatment option for TNF-α inhibitor–induced psoriatic alopecia. In most reported cases, the problem resolved with treatment, thereby classifying this form of alopecia as noncicatricial alopecia.
Tumor necrosis factor α (TNF-α) inhibitor–induced psoriasis is a known paradoxical adverse effect of this family of medications, which includes infliximab, adalimumab, etanercept, golimumab, and certolizumab. In the pediatric population, these therapies recently gained approval for nondermatologic conditions—meaning that this phenomenon is encountered more frequently.1 In a systematic review of TNF-α inhibitor–induced psoriasis, severe scalp involvement was associated with alopecia in 7.5% of cases.2 Onset of scalp psoriasis with alopecia in patients being treated with a TNF-α inhibitor should lead to consideration of this condition.
Psoriatic alopecia is an uncommon presentation of psoriasis. Although well described, alopecia as a clinical manifestation of scalp psoriasis is not a well-known concept among clinicians and has never been widely accepted. Adding to the diagnostic challenge is that psoriatic alopecia secondary to TNF-α inhibitor–induced psoriasis rarely has been reported in adults or children.3-5 Including our case, our review of the literature yielded 7 pediatric cases (≤18 years) of TNF-α inhibitor–induced psoriatic alopecia.6,7 A primary literature search of PubMed articles indexed for MEDLINE was conducted using the terms psoriatic alopecia, psoriasiform alopecia, TNF-α inhibitors, infliximab, adalimumab, etanercept, golimumab, and certolizumab.
We present the case of a pediatric patient with psoriatic alopecia secondary to treatment with adalimumab for Crohn disease (CD). We also provide a review of reported cases of psoriatic alopecia induced by a TNF-α inhibitor in the literature.
Case Report
A 12-year-old girl presented to our dermatology clinic with erythematous scaly plaques on the trunk, scalp, arms, and legs of 2 months’ duration. The lesions involved approximately 15% of the body surface area. The patient’s medical history was remarkable for CD diagnosed 4 years prior to presentation of the skin lesions. She had been treated for the past 2 years with adalimumab 40 mg once every 2 weeks and azathioprine 100 mg once daily. Because her CD was poorly controlled, the dosage of adalimumab was increased to 40 mg once weekly 6 months prior to the current presentation.
Our diagnosis was TNF-α inhibitor-induced psoriasis secondary to treatment with adalimumab.
The patient was treated with mometasone lotion 0.1% for the scalp lesions and triamcinolone cream 0.1% for the body lesions. Because of the extent of the psoriasis, we recommended changing adalimumab to ustekinumab, which is approved for CD in adults but is off label in children.
At 1-month follow-up, after receiving the induction dose of ustekinumab, the patient presented with partial improvement of the skin lesions but had developed a large, alopecic, erythematous plaque with thick yellowish scales on the scalp (Figure 1). She also had a positive hair pull test. The presumptive initial diagnosis of the alopecic scalp lesion was tinea capitis, for which multiple potassium hydroxide preparations of scales were performed, all yielding negative results. In addition, histopathologic examination with hematoxylin and eosin staining was performed (Figures 2A and 2B). Sterile tissue cultures for bacteria, fungi, and acid-fast bacilli were obtained and showed no growth. Periodic acid–Schiff staining was negative for fungal structures.
A second biopsy showed a psoriasiform pattern, parakeratosis, and hypogranulosis, highly suggestive of psoriasis (Figure 2C and 2D). Based on those findings, a diagnosis of psoriatic alopecia was made. The mometasone was switched to clobetasol lotion 0.05%. The patient continued treatment with ustekinumab. At 6-month follow-up, her CD was well controlled and she showed hair regrowth in previously alopecic areas (Figure 3).
Comment
Psoriatic alopecia induced by a TNF-α inhibitor was first reported in 2007 in a 30-year-old woman with ankylosing spondylitis who was being treated with adalimumab.8 She had erythematous, scaly, alopecic plaques on the scalp and palmoplantar pustulosis. Findings on skin biopsy were compatible with psoriasis. The patient’s severe scalp psoriasis failed to respond to topical steroid treatment and adalimumab cessation. The extensive hair loss responded to cyclosporine 3 mg/kg daily.8
After conducting an extensive literature review, we found 26 cases of TNF-α–induced psoriatic alopecia, including the current case (Table).6-16 The mean age at diagnosis was 27.8 years (SD, 13.6 years; range, 7–60 years). The female-to-male ratio was 3.3:1. The most common underlying condition for which TNF-α inhibitors were prescribed was CD (77% [20/26]). Psoriatic alopecia most commonly was reported secondary to treatment with infliximab (54% [14/26]), followed by adalimumab (42% [11/26]). Golimumab was the causative drug in 1 (4%) case. We did not find reports of etanercept or certolizumab having induced this manifestation. The onset of the scalp lesions occurred 2 to 46 months after starting treatment with the causative medication.
Laga et al17 reported that TNF-α inhibitor–induced psoriasis can have a variety of histopathologic findings, including typical findings of various stages of psoriasis, a lichenoid pattern mimicking remnants of lichen planus, and sterile pustular folliculitis. Our patient’s 2 scalp biopsies demonstrated results consistent with findings reported by Laga et al.17 In the first biopsy, findings were consistent with a dense neutrophilic infiltrate with negative sterile cultures and negative periodic acid–Schiff stain (sterile folliculitis), with crust and areas of parakeratosis. The second biopsy demonstrated psoriasiform hyperplasia, parakeratosis, and an absent granular layer, all typical features of psoriasis (Figure 2).
Including the current case, our review of the literature yielded 7 pediatric (ie, 0–18 years of age) cases of TNF-α inhibitor–induced psoriatic alopecia. Of the 6 previously reported pediatric cases, 5 occurred after administration of infliximab.6,7
Similar to our case, TNF-α inhibitor–induced psoriatic alopecia was reported in a 7-year-old girl who was treated with adalimumab for juvenile idiopathic arthritis.6 Nine months after starting treatment, that patient presented with a tender, erythematous, eroded, and crusted alopecic plaque along with scaly plaques on the scalp. Adalimumab was discontinued, and cyclosporine and topical steroids were started. Cyclosporine was then discontinued due to partial resolution of the psoriasis; the patient was started on abatacept, with persistence of the psoriasis and alopecia. The patient was then started on oral methotrexate 12.5 mg once weekly with moderate improvement and mild to moderate exacerbations.
Tumor necrosis factor α inhibitor–induced psoriasis may occur as a result of a cytokine imbalance. A TNF-α blockade leads to upregulation of interferon α (IFN-α) and TNF-α production by plasmacytoid dendritic cells (pDCs), usually in genetically susceptible people.6,7,9-15 The IFN-α induces maturation of myeloid dendritic cells (mDCs) responsible for increasing proinflammatory cytokines that contribute to psoriasis.11 Generation of TNF-α by pDCs leads to mature or activated dendritic cells derived from pDCs through autocrine TNF-α production and paracrine IFN-α production from immature mDCs.9 Once pDCs mature, they are incapable of producing IFN-α; TNF-α then inhibits IFN-α production by inducing pDC maturation.11 Overproduction of IFN-α during TNF-α inhibition induces expression of the chemokine receptor CXCR3 on T cells, which recruits T cells to the dermis. The T cells then produce TNF-α, causing psoriatic skin lesions.10,11,13,14
Although TNF-α inhibitor–induced psoriatic alopecia is uncommon, the condition should be considered in female patients with underlying proinflammatory disease—CD in particular. Perman et al6 reported 5 cases of psoriatic alopecia in which 3 patients initially were treated with griseofulvin because of suspected tinea capitis.
Conditions with similar clinical findings should be ruled out before making a diagnosis of TNF-α inhibitor–induced psoriatic alopecia. Although clinicopathologic correlation is essential for making the diagnosis, it is possible that the histologic findings will not be specific for psoriasis.17 It is important to be aware of this condition in patients being treated with a TNF-α inhibitor as early as 2 months to 4 years or longer after starting treatment.
Previously reported cases have demonstrated various treatment options that yielded improvement or resolution of TNF-α inhibitor–induced psoriatic alopecia. These include either continuation or discontinuation of the TNF-α inhibitor combined with topical or intralesional steroids, methotrexate, or cyclosporine. Another option is to switch the TNF-α inhibitor to another biologic. Outcomes vary from patient to patient, making the physician’s clinical judgment crucial in deciding which treatment route to take. Our patient showed notable improvement when she was switched from adalimumab to ustekinumab as well as the combination of ustekinumab and clobetasol lotion 0.05%.
Conclusion
We recommend an individualized approach that provides patients with the safest and least invasive treatment option for TNF-α inhibitor–induced psoriatic alopecia. In most reported cases, the problem resolved with treatment, thereby classifying this form of alopecia as noncicatricial alopecia.
- Horneff G, Seyger MMB, Arikan D, et al. Safety of adalimumab in pediatric patients with polyarticular juvenile idiopathic arthritis, enthesitis-related arthritis, psoriasis, and Crohn’s disease. J Pediatr. 2018;201:166-175.e3. doi:10.1016/j.jpeds.2018.05.042
- Brown G, Wang E, Leon A, et al. Tumor necrosis factor-α inhibitor-induced psoriasis: systematic review of clinical features, histopathological findings, and management experience. J Am Acad Dermatol. 2017;76:334-341. doi:10.1016/j.jaad.2016.08.012
- George SMC, Taylor MR, Farrant PBJ. Psoriatic alopecia. Clin Exp Dermatol. 2015;40:717-721. doi:10.1111/ced.12715
- Shuster S. Psoriatic alopecia. Br J Dermatol. 1972;87:73-77. doi:10.1111/j.1365-2133.1972.tb05103.x
- Silva CY, Brown KL, Kurban AK, et al. Psoriatic alopecia—fact or fiction? a clinicohistopathologic reappraisal. Indian J Dermatol Venereol Leprol. 2012;78:611-619. doi:10.4103/0378-6323.100574
- Perman MJ, Lovell DJ, Denson LA, et al. Five cases of anti-tumor necrosis factor alpha-induced psoriasis presenting with severe scalp involvement in children. Pediatr Dermatol. 2012;29:454-459. doi:10.1111/j.1525-1470.2011.01521.x
- Prata Ribeiro LB, Gonçalves Rego JC, Duque Estrada B, et al. Alopecia secondary to anti-tumor necrosis factor-alpha therapy. An Bras Dermatol. 2015;90:232–235. doi:10.1590/abd1806-4841.20153084
- Papadavid E, Gazi S, Dalamaga M, et al. Palmoplantar and scalp psoriasis occurring during anti-tumour necrosis factor-alpha therapy: a case series of four patients and guidelines for management. J Eur Acad Dermatol Venereol. 2008;22:380-382. doi:10.1111/j.1468-3083.2007.02335.x
- Manni E, Barachini P. Psoriasis induced by infliximab in a patient suffering from Crohn’s disease. Int J Immunopathol Pharmacol. 2009;22:841-844. doi:10.1177/039463200902200331
- El Shabrawi-Caelen L, La Placa M, Vincenzi C, et al. Adalimumab-induced psoriasis of the scalp with diffuse alopecia: a severe potentially irreversible cutaneous side effect of TNF-alpha blockers. Inflamm Bowel Dis. 2010;16:182-183. doi:10.1002/ibd.20954
- Medkour F, Babai S, Chanteloup E, et al. Development of diffuse psoriasis with alopecia during treatment of Crohn’s disease with infliximab. Gastroenterol Clin Biol. 2010;34:140-141. doi:10.1016/j.gcb.2009.10.021
- Doyle LA, Sperling LC, Baksh S, et al. Psoriatic alopecia/alopecia areata-like reactions secondary to anti-tumor necrosis factor-α therapy: a novel cause of noncicatricial alopecia. Am J Dermatopathol. 2011;33:161-166. doi:10.1097/DAD.0b013e3181ef7403
- Osório F, Magro F, Lisboa C, et al. Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature. Dermatology. 2012;225:163-167. doi:10.1159/000342503
- Andrisani G, Marzo M, Celleno L, et al. Development of psoriasis scalp with alopecia during treatment of Crohn’s disease with infliximab and rapid response to both diseases to ustekinumab. Eur Rev Med Pharmacol Sci. 2013;17:2831-2836.
- Afanasiev OK, Zhang CZ, Ruhoy SM. TNF-inhibitor associated psoriatic alopecia: diagnostic utility of sebaceous lobule atrophy. J Cutan Pathol. 2017;44:563-569. doi:10.1111/cup.12932
- Helm MM, Haddad S. Alopecia areata and scarring alopecia presenting during golimumab therapy for ankylosing spondylitis. N Am J Med Sci. 2018;11:22-24. doi:10.7156/najms.2018.110122
- Laga AC, Vleugels RA, Qureshi AA, et al. Histopathologic spectrum of psoriasiform skin reactions associated with tumor necrosis factor-a inhibitor therapy. a study of 16 biopsies. Am J Dermatopathol. 2010;32:568-573. doi:10.1097/DAD.0b013e3181cb3ff7
- Horneff G, Seyger MMB, Arikan D, et al. Safety of adalimumab in pediatric patients with polyarticular juvenile idiopathic arthritis, enthesitis-related arthritis, psoriasis, and Crohn’s disease. J Pediatr. 2018;201:166-175.e3. doi:10.1016/j.jpeds.2018.05.042
- Brown G, Wang E, Leon A, et al. Tumor necrosis factor-α inhibitor-induced psoriasis: systematic review of clinical features, histopathological findings, and management experience. J Am Acad Dermatol. 2017;76:334-341. doi:10.1016/j.jaad.2016.08.012
- George SMC, Taylor MR, Farrant PBJ. Psoriatic alopecia. Clin Exp Dermatol. 2015;40:717-721. doi:10.1111/ced.12715
- Shuster S. Psoriatic alopecia. Br J Dermatol. 1972;87:73-77. doi:10.1111/j.1365-2133.1972.tb05103.x
- Silva CY, Brown KL, Kurban AK, et al. Psoriatic alopecia—fact or fiction? a clinicohistopathologic reappraisal. Indian J Dermatol Venereol Leprol. 2012;78:611-619. doi:10.4103/0378-6323.100574
- Perman MJ, Lovell DJ, Denson LA, et al. Five cases of anti-tumor necrosis factor alpha-induced psoriasis presenting with severe scalp involvement in children. Pediatr Dermatol. 2012;29:454-459. doi:10.1111/j.1525-1470.2011.01521.x
- Prata Ribeiro LB, Gonçalves Rego JC, Duque Estrada B, et al. Alopecia secondary to anti-tumor necrosis factor-alpha therapy. An Bras Dermatol. 2015;90:232–235. doi:10.1590/abd1806-4841.20153084
- Papadavid E, Gazi S, Dalamaga M, et al. Palmoplantar and scalp psoriasis occurring during anti-tumour necrosis factor-alpha therapy: a case series of four patients and guidelines for management. J Eur Acad Dermatol Venereol. 2008;22:380-382. doi:10.1111/j.1468-3083.2007.02335.x
- Manni E, Barachini P. Psoriasis induced by infliximab in a patient suffering from Crohn’s disease. Int J Immunopathol Pharmacol. 2009;22:841-844. doi:10.1177/039463200902200331
- El Shabrawi-Caelen L, La Placa M, Vincenzi C, et al. Adalimumab-induced psoriasis of the scalp with diffuse alopecia: a severe potentially irreversible cutaneous side effect of TNF-alpha blockers. Inflamm Bowel Dis. 2010;16:182-183. doi:10.1002/ibd.20954
- Medkour F, Babai S, Chanteloup E, et al. Development of diffuse psoriasis with alopecia during treatment of Crohn’s disease with infliximab. Gastroenterol Clin Biol. 2010;34:140-141. doi:10.1016/j.gcb.2009.10.021
- Doyle LA, Sperling LC, Baksh S, et al. Psoriatic alopecia/alopecia areata-like reactions secondary to anti-tumor necrosis factor-α therapy: a novel cause of noncicatricial alopecia. Am J Dermatopathol. 2011;33:161-166. doi:10.1097/DAD.0b013e3181ef7403
- Osório F, Magro F, Lisboa C, et al. Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature. Dermatology. 2012;225:163-167. doi:10.1159/000342503
- Andrisani G, Marzo M, Celleno L, et al. Development of psoriasis scalp with alopecia during treatment of Crohn’s disease with infliximab and rapid response to both diseases to ustekinumab. Eur Rev Med Pharmacol Sci. 2013;17:2831-2836.
- Afanasiev OK, Zhang CZ, Ruhoy SM. TNF-inhibitor associated psoriatic alopecia: diagnostic utility of sebaceous lobule atrophy. J Cutan Pathol. 2017;44:563-569. doi:10.1111/cup.12932
- Helm MM, Haddad S. Alopecia areata and scarring alopecia presenting during golimumab therapy for ankylosing spondylitis. N Am J Med Sci. 2018;11:22-24. doi:10.7156/najms.2018.110122
- Laga AC, Vleugels RA, Qureshi AA, et al. Histopathologic spectrum of psoriasiform skin reactions associated with tumor necrosis factor-a inhibitor therapy. a study of 16 biopsies. Am J Dermatopathol. 2010;32:568-573. doi:10.1097/DAD.0b013e3181cb3ff7
Practice Points
- Psoriatic alopecia is a rare nonscarring alopecia that can present as a complication of treatment with tumor necrosis factor α inhibitors.
- This finding commonly is seen in females undergoing treatment with infliximab or adalimumab, usually for Crohn disease.
- Histopathologic findings can show a psoriasiform-pattern, neutrophil-rich, inflammatory infiltrate involving hair follicles or a lichenoid pattern.
Online patient reviews and HIPAA
In 2013, a California hospital paid $275,000 to settle claims that it violated the HIPAA privacy rule when it disclosed a patient’s health information in response to a negative online review. More recently, a Texas dental practice paid a substantial fine to the Department of Health & Human Services, which enforces HIPAA, after it responded to unfavorable Yelp reviews with patient names and details of their health conditions, treatment plans, and cost information. In addition to the fine, the practice agreed to 2 years of monitoring by HHS for compliance with HIPAA rules.
Most physicians have had the unpleasant experience of finding a negative online review from a disgruntled patient or family member. Some are justified, many are not; either way, your first impulse will often be to post a response – but that is almost always a bad idea. “Social media is not the place for providers to discuss a patient’s care,” an HHS official said in a statement issued about the dental practice case in 2016. “Doctors and dentists must think carefully about patient privacy before responding to online reviews.”
Any information that could be used to identify a patient is a HIPAA breach. This is true even if the patient has already disclosed information, because doing so does not nullify their HIPAA rights, and HIPAA provides no exceptions for responses. Even acknowledging that the reviewer was in fact your patient could, in some cases, be considered a violation.
Responding to good reviews can get you in trouble too, for the same reasons. In 2016, a physical therapy practice paid a $25,000 fine after it posted patient testimonials, “including full names and full-face photographic images to its website without obtaining valid, HIPAA-compliant authorizations.”
And by the way, most malpractice policies specifically exclude disciplinary fines and settlements from coverage.
All of that said,
- Ignore them. This is your best choice most of the time. Most negative reviews have minimal impact and simply do not deserve a response; responding may pour fuel on the fire. Besides, an occasional negative review actually lends credibility to a reviewing site and to the positive reviews posted on that site. Polls show that readers are suspicious of sites that contain only rave reviews. They assume such reviews have been “whitewashed” – or just fabricated.
- Solicit more reviews to that site. The more you can obtain, the less impact any complaints will have, since you know the overwhelming majority of your patients are happy with your care and will post a positive review if asked. Solicit them on your website, on social media, or in your email reminders. To be clear, you must encourage reviews from all patients, whether they have had a positive experience or not. If you invite only the satisfied ones, you are “filtering,” which can be perceived as false or deceptive advertising. (Google calls it “review-gating,” and according to their guidelines, if they catch you doing it they will remove all of your reviews.)
- Respond politely. In those rare cases where you feel you must respond, do so without acknowledging that the individual was a patient, or disclosing any information that may be linked to the patient. For example, you can say that you provide excellent and appropriate care, or describe your general policies. Be polite, professional, and sensitive to the patient’s position. Readers tend to respect and sympathize with a doctor who responds in a professional, respectful manner and does not trash the complainant in retaliation.
- Take the discussion offline. Sometimes the person posting the review is just frustrated and wants to be heard. In those cases, consider contacting the patient and offering to discuss their concerns privately. If you cannot resolve your differences, try to get the patient’s written permission to post a response to their review. If they refuse, you can explain that, thereby capturing the moral high ground.
If the review contains false or defamatory content, that’s a different situation entirely; you will probably need to consult your attorney.
Regardless of how you handle negative reviews, be sure to learn from them. Your critics, as the song goes, are not always evil – and not always wrong. Complaints give you a chance to review your office policies and procedures and your own conduct, identify weaknesses, and make changes as necessary. At the very least, the exercise will help you to avoid similar complaints in the future. Don’t let valuable opportunities like that pass you by.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In 2013, a California hospital paid $275,000 to settle claims that it violated the HIPAA privacy rule when it disclosed a patient’s health information in response to a negative online review. More recently, a Texas dental practice paid a substantial fine to the Department of Health & Human Services, which enforces HIPAA, after it responded to unfavorable Yelp reviews with patient names and details of their health conditions, treatment plans, and cost information. In addition to the fine, the practice agreed to 2 years of monitoring by HHS for compliance with HIPAA rules.
Most physicians have had the unpleasant experience of finding a negative online review from a disgruntled patient or family member. Some are justified, many are not; either way, your first impulse will often be to post a response – but that is almost always a bad idea. “Social media is not the place for providers to discuss a patient’s care,” an HHS official said in a statement issued about the dental practice case in 2016. “Doctors and dentists must think carefully about patient privacy before responding to online reviews.”
Any information that could be used to identify a patient is a HIPAA breach. This is true even if the patient has already disclosed information, because doing so does not nullify their HIPAA rights, and HIPAA provides no exceptions for responses. Even acknowledging that the reviewer was in fact your patient could, in some cases, be considered a violation.
Responding to good reviews can get you in trouble too, for the same reasons. In 2016, a physical therapy practice paid a $25,000 fine after it posted patient testimonials, “including full names and full-face photographic images to its website without obtaining valid, HIPAA-compliant authorizations.”
And by the way, most malpractice policies specifically exclude disciplinary fines and settlements from coverage.
All of that said,
- Ignore them. This is your best choice most of the time. Most negative reviews have minimal impact and simply do not deserve a response; responding may pour fuel on the fire. Besides, an occasional negative review actually lends credibility to a reviewing site and to the positive reviews posted on that site. Polls show that readers are suspicious of sites that contain only rave reviews. They assume such reviews have been “whitewashed” – or just fabricated.
- Solicit more reviews to that site. The more you can obtain, the less impact any complaints will have, since you know the overwhelming majority of your patients are happy with your care and will post a positive review if asked. Solicit them on your website, on social media, or in your email reminders. To be clear, you must encourage reviews from all patients, whether they have had a positive experience or not. If you invite only the satisfied ones, you are “filtering,” which can be perceived as false or deceptive advertising. (Google calls it “review-gating,” and according to their guidelines, if they catch you doing it they will remove all of your reviews.)
- Respond politely. In those rare cases where you feel you must respond, do so without acknowledging that the individual was a patient, or disclosing any information that may be linked to the patient. For example, you can say that you provide excellent and appropriate care, or describe your general policies. Be polite, professional, and sensitive to the patient’s position. Readers tend to respect and sympathize with a doctor who responds in a professional, respectful manner and does not trash the complainant in retaliation.
- Take the discussion offline. Sometimes the person posting the review is just frustrated and wants to be heard. In those cases, consider contacting the patient and offering to discuss their concerns privately. If you cannot resolve your differences, try to get the patient’s written permission to post a response to their review. If they refuse, you can explain that, thereby capturing the moral high ground.
If the review contains false or defamatory content, that’s a different situation entirely; you will probably need to consult your attorney.
Regardless of how you handle negative reviews, be sure to learn from them. Your critics, as the song goes, are not always evil – and not always wrong. Complaints give you a chance to review your office policies and procedures and your own conduct, identify weaknesses, and make changes as necessary. At the very least, the exercise will help you to avoid similar complaints in the future. Don’t let valuable opportunities like that pass you by.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In 2013, a California hospital paid $275,000 to settle claims that it violated the HIPAA privacy rule when it disclosed a patient’s health information in response to a negative online review. More recently, a Texas dental practice paid a substantial fine to the Department of Health & Human Services, which enforces HIPAA, after it responded to unfavorable Yelp reviews with patient names and details of their health conditions, treatment plans, and cost information. In addition to the fine, the practice agreed to 2 years of monitoring by HHS for compliance with HIPAA rules.
Most physicians have had the unpleasant experience of finding a negative online review from a disgruntled patient or family member. Some are justified, many are not; either way, your first impulse will often be to post a response – but that is almost always a bad idea. “Social media is not the place for providers to discuss a patient’s care,” an HHS official said in a statement issued about the dental practice case in 2016. “Doctors and dentists must think carefully about patient privacy before responding to online reviews.”
Any information that could be used to identify a patient is a HIPAA breach. This is true even if the patient has already disclosed information, because doing so does not nullify their HIPAA rights, and HIPAA provides no exceptions for responses. Even acknowledging that the reviewer was in fact your patient could, in some cases, be considered a violation.
Responding to good reviews can get you in trouble too, for the same reasons. In 2016, a physical therapy practice paid a $25,000 fine after it posted patient testimonials, “including full names and full-face photographic images to its website without obtaining valid, HIPAA-compliant authorizations.”
And by the way, most malpractice policies specifically exclude disciplinary fines and settlements from coverage.
All of that said,
- Ignore them. This is your best choice most of the time. Most negative reviews have minimal impact and simply do not deserve a response; responding may pour fuel on the fire. Besides, an occasional negative review actually lends credibility to a reviewing site and to the positive reviews posted on that site. Polls show that readers are suspicious of sites that contain only rave reviews. They assume such reviews have been “whitewashed” – or just fabricated.
- Solicit more reviews to that site. The more you can obtain, the less impact any complaints will have, since you know the overwhelming majority of your patients are happy with your care and will post a positive review if asked. Solicit them on your website, on social media, or in your email reminders. To be clear, you must encourage reviews from all patients, whether they have had a positive experience or not. If you invite only the satisfied ones, you are “filtering,” which can be perceived as false or deceptive advertising. (Google calls it “review-gating,” and according to their guidelines, if they catch you doing it they will remove all of your reviews.)
- Respond politely. In those rare cases where you feel you must respond, do so without acknowledging that the individual was a patient, or disclosing any information that may be linked to the patient. For example, you can say that you provide excellent and appropriate care, or describe your general policies. Be polite, professional, and sensitive to the patient’s position. Readers tend to respect and sympathize with a doctor who responds in a professional, respectful manner and does not trash the complainant in retaliation.
- Take the discussion offline. Sometimes the person posting the review is just frustrated and wants to be heard. In those cases, consider contacting the patient and offering to discuss their concerns privately. If you cannot resolve your differences, try to get the patient’s written permission to post a response to their review. If they refuse, you can explain that, thereby capturing the moral high ground.
If the review contains false or defamatory content, that’s a different situation entirely; you will probably need to consult your attorney.
Regardless of how you handle negative reviews, be sure to learn from them. Your critics, as the song goes, are not always evil – and not always wrong. Complaints give you a chance to review your office policies and procedures and your own conduct, identify weaknesses, and make changes as necessary. At the very least, the exercise will help you to avoid similar complaints in the future. Don’t let valuable opportunities like that pass you by.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
