MDedge Dermatology

BALTIMORE — A relatively new registry of complications from dermatologic surgery has posted its first results, showing that among laser and energy device treatments, the most common adverse events (AEs) were blistering, hypopigmentation, scars, and burns. But the process of reporting AEs to the registry needs to be made easier to attract more cases and provide a more complete picture of complications after dermatologic procedures, a researcher and observer said.

The Cutaneous Procedures Adverse Events Reporting Registry (CAPER) was established in 2021 to track AEs from dermatologic procedures. Since then, it has logged a total of 81 cases and 147 AEs from 27 unique procedures, Eric Koza, MD, a postdoctoral research fellow in the Department of Dermatology at Northwestern University, Chicago, reported at the annual conference of the American Society for Laser Medicine and Surgery.

Richard Mark Kirkner/MDedge News

“The takeaways from this project is that 20 laser and energy device treatments have been reported to the registry, half of which were nonablative laser treatments,” Dr. Koza said in presenting the results. “Of the adverse events reported, nonphysicians and non-dermatologic physicians were more likely to be associated with severe or persistent adverse events.”

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology launched CAPER. Previously, Dr. Koza said, AEs were typically reported only through the Food and Drug Administration’s AE reporting system. He noted that CAPER is the only voluntary national reporting registry for AEs from dermatologic procedures.

What the Registry Shows So Far

The registry matched 72 of the 81 cases with type of provider, with dermatologist-conducted procedures (51, 70.8%) comprising the majority, followed by nonphysician-conducted procedures (14, 19.4%) and nondermatologist physician–conducted procedures (7, 9.7%).

Of the 81 total cases, the following reports were related to laser and energy device treatments: 12 (14.3%) from nonablative laser treatments, five (6%) from light treatments, and three (3.6%) from ablative laser treatments, Dr. Koza said.

Among nonablative laser treatments, the most common AE was blistering (six reports, 50%). Scar, pain, and hypopigmentation accounted for two cases each (16.67%). Dermatologists performed seven of these cases (58.3%); nonphysicians, four (33.3%); and a non-dermatologist physician, one (8.3%).

For intense pulsed-light treatments, burns were the most common AEs (three reports, 60%), with swelling and inflammation each accounting for one case (20%). Three of these cases (75%) were confirmed to have been performed by nonphysicians.

The ablative laser treatment AEs included one case each of hypopigmentation, scar, and erythema. Two of the three cases were confirmed to have been performed by dermatologists.

Dr. Koza acknowledged the low number of cases is a limitation of this analysis of registry reports. A future goal for CAPER is to publicize it more, he said. “The registry is only 3 years old,” he told this news organization. “Hopefully, we can get more data as time goes on. We’ve been getting more and more each year.” CAPER adapted data entry forms used in other registries.

Submitting a case to the registry takes about 15 minutes of the provider’s time, Dr. Koza said. “We can streamline that to make it easier for people to submit their adverse events,” he said in an interview.

Only registry staff have access to the reports, and when reported, the data “is de-identified and any identifying information pertaining to the patient or reporter is removed,” according to a statement on the CAPER website.
 

‘Needs a Little Help’

Jennifer Lin, MD, a dermatologist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, who was at the meeting, commented on the onerous reporting process and the “low” enrollment. “It’s such an important initiative and with everyone over-logging e-mails, a 15-minute entry just is not going to cut it,” she told this news organization.

For providers, reporting AEs is stressful, she said. “As it is, it’s hard to voluntarily submit an adverse event,” Dr. Lin continued. “There’s a feeling of shame. Hospitals require it in order to monitor adverse events, but there’s no monitoring when you’re out in your own private practice.”

“The idea is excellent, but I think to facilitate better enrollment, the word has to get out at all these meetings” and make it easier to submit cases, Dr. Lin added. “It’s a good idea, but it needs a little help.”

Information on submitting AE reports to CAPER is available on the CAPER website.

Dr. Koza and Dr. Lin had no relevant relationships to disclose.

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

BALTIMORE — A relatively new registry of complications from dermatologic surgery has posted its first results, showing that among laser and energy device treatments, the most common adverse events (AEs) were blistering, hypopigmentation, scars, and burns. But the process of reporting AEs to the registry needs to be made easier to attract more cases and provide a more complete picture of complications after dermatologic procedures, a researcher and observer said.

The Cutaneous Procedures Adverse Events Reporting Registry (CAPER) was established in 2021 to track AEs from dermatologic procedures. Since then, it has logged a total of 81 cases and 147 AEs from 27 unique procedures, Eric Koza, MD, a postdoctoral research fellow in the Department of Dermatology at Northwestern University, Chicago, reported at the annual conference of the American Society for Laser Medicine and Surgery.

Richard Mark Kirkner/MDedge News

“The takeaways from this project is that 20 laser and energy device treatments have been reported to the registry, half of which were nonablative laser treatments,” Dr. Koza said in presenting the results. “Of the adverse events reported, nonphysicians and non-dermatologic physicians were more likely to be associated with severe or persistent adverse events.”

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology launched CAPER. Previously, Dr. Koza said, AEs were typically reported only through the Food and Drug Administration’s AE reporting system. He noted that CAPER is the only voluntary national reporting registry for AEs from dermatologic procedures.

What the Registry Shows So Far

The registry matched 72 of the 81 cases with type of provider, with dermatologist-conducted procedures (51, 70.8%) comprising the majority, followed by nonphysician-conducted procedures (14, 19.4%) and nondermatologist physician–conducted procedures (7, 9.7%).

Of the 81 total cases, the following reports were related to laser and energy device treatments: 12 (14.3%) from nonablative laser treatments, five (6%) from light treatments, and three (3.6%) from ablative laser treatments, Dr. Koza said.

Among nonablative laser treatments, the most common AE was blistering (six reports, 50%). Scar, pain, and hypopigmentation accounted for two cases each (16.67%). Dermatologists performed seven of these cases (58.3%); nonphysicians, four (33.3%); and a non-dermatologist physician, one (8.3%).

For intense pulsed-light treatments, burns were the most common AEs (three reports, 60%), with swelling and inflammation each accounting for one case (20%). Three of these cases (75%) were confirmed to have been performed by nonphysicians.

The ablative laser treatment AEs included one case each of hypopigmentation, scar, and erythema. Two of the three cases were confirmed to have been performed by dermatologists.

Dr. Koza acknowledged the low number of cases is a limitation of this analysis of registry reports. A future goal for CAPER is to publicize it more, he said. “The registry is only 3 years old,” he told this news organization. “Hopefully, we can get more data as time goes on. We’ve been getting more and more each year.” CAPER adapted data entry forms used in other registries.

Submitting a case to the registry takes about 15 minutes of the provider’s time, Dr. Koza said. “We can streamline that to make it easier for people to submit their adverse events,” he said in an interview.

Only registry staff have access to the reports, and when reported, the data “is de-identified and any identifying information pertaining to the patient or reporter is removed,” according to a statement on the CAPER website.
 

‘Needs a Little Help’

Jennifer Lin, MD, a dermatologist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, who was at the meeting, commented on the onerous reporting process and the “low” enrollment. “It’s such an important initiative and with everyone over-logging e-mails, a 15-minute entry just is not going to cut it,” she told this news organization.

For providers, reporting AEs is stressful, she said. “As it is, it’s hard to voluntarily submit an adverse event,” Dr. Lin continued. “There’s a feeling of shame. Hospitals require it in order to monitor adverse events, but there’s no monitoring when you’re out in your own private practice.”

“The idea is excellent, but I think to facilitate better enrollment, the word has to get out at all these meetings” and make it easier to submit cases, Dr. Lin added. “It’s a good idea, but it needs a little help.”

Information on submitting AE reports to CAPER is available on the CAPER website.

Dr. Koza and Dr. Lin had no relevant relationships to disclose.

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

BALTIMORE — A relatively new registry of complications from dermatologic surgery has posted its first results, showing that among laser and energy device treatments, the most common adverse events (AEs) were blistering, hypopigmentation, scars, and burns. But the process of reporting AEs to the registry needs to be made easier to attract more cases and provide a more complete picture of complications after dermatologic procedures, a researcher and observer said.

The Cutaneous Procedures Adverse Events Reporting Registry (CAPER) was established in 2021 to track AEs from dermatologic procedures. Since then, it has logged a total of 81 cases and 147 AEs from 27 unique procedures, Eric Koza, MD, a postdoctoral research fellow in the Department of Dermatology at Northwestern University, Chicago, reported at the annual conference of the American Society for Laser Medicine and Surgery.

Richard Mark Kirkner/MDedge News

“The takeaways from this project is that 20 laser and energy device treatments have been reported to the registry, half of which were nonablative laser treatments,” Dr. Koza said in presenting the results. “Of the adverse events reported, nonphysicians and non-dermatologic physicians were more likely to be associated with severe or persistent adverse events.”

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology launched CAPER. Previously, Dr. Koza said, AEs were typically reported only through the Food and Drug Administration’s AE reporting system. He noted that CAPER is the only voluntary national reporting registry for AEs from dermatologic procedures.

What the Registry Shows So Far

The registry matched 72 of the 81 cases with type of provider, with dermatologist-conducted procedures (51, 70.8%) comprising the majority, followed by nonphysician-conducted procedures (14, 19.4%) and nondermatologist physician–conducted procedures (7, 9.7%).

Of the 81 total cases, the following reports were related to laser and energy device treatments: 12 (14.3%) from nonablative laser treatments, five (6%) from light treatments, and three (3.6%) from ablative laser treatments, Dr. Koza said.

Among nonablative laser treatments, the most common AE was blistering (six reports, 50%). Scar, pain, and hypopigmentation accounted for two cases each (16.67%). Dermatologists performed seven of these cases (58.3%); nonphysicians, four (33.3%); and a non-dermatologist physician, one (8.3%).

For intense pulsed-light treatments, burns were the most common AEs (three reports, 60%), with swelling and inflammation each accounting for one case (20%). Three of these cases (75%) were confirmed to have been performed by nonphysicians.

The ablative laser treatment AEs included one case each of hypopigmentation, scar, and erythema. Two of the three cases were confirmed to have been performed by dermatologists.

Dr. Koza acknowledged the low number of cases is a limitation of this analysis of registry reports. A future goal for CAPER is to publicize it more, he said. “The registry is only 3 years old,” he told this news organization. “Hopefully, we can get more data as time goes on. We’ve been getting more and more each year.” CAPER adapted data entry forms used in other registries.

Submitting a case to the registry takes about 15 minutes of the provider’s time, Dr. Koza said. “We can streamline that to make it easier for people to submit their adverse events,” he said in an interview.

Only registry staff have access to the reports, and when reported, the data “is de-identified and any identifying information pertaining to the patient or reporter is removed,” according to a statement on the CAPER website.
 

‘Needs a Little Help’

Jennifer Lin, MD, a dermatologist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, who was at the meeting, commented on the onerous reporting process and the “low” enrollment. “It’s such an important initiative and with everyone over-logging e-mails, a 15-minute entry just is not going to cut it,” she told this news organization.

For providers, reporting AEs is stressful, she said. “As it is, it’s hard to voluntarily submit an adverse event,” Dr. Lin continued. “There’s a feeling of shame. Hospitals require it in order to monitor adverse events, but there’s no monitoring when you’re out in your own private practice.”

“The idea is excellent, but I think to facilitate better enrollment, the word has to get out at all these meetings” and make it easier to submit cases, Dr. Lin added. “It’s a good idea, but it needs a little help.”

Information on submitting AE reports to CAPER is available on the CAPER website.

Dr. Koza and Dr. Lin had no relevant relationships to disclose.

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

In "Atopic Dermatitis in Early Childhood and Risk of Inflammatory Bowel Disease: A Scandinavian Birth Cohort Study," Lerchova and colleagues found a statistically significant increased risk for inflammatory bowel disease (IBD) in children with atopic dermatitis. The study had a large patient population, giving it the power to identify very small differences. The researchers found increased risks for IBD, Crohn's disease, and ulcerative colitis (UC) in children with atopic dermatitis; UC had the greatest relative risk. But I don't think this risk was clinically meaningful. About 2 in every 1000 children with atopic dermatitis had UC, whereas about 1 in every 1000 children without atopic dermatitis had UC. Even if the increased absolute risk of 1 in 1000 children was due to atopic dermatitis and not to other factors, I don't think it justifies the authors' conclusion that "these findings might be useful in identifying at-risk individuals for IBD."

Sometimes reviewing articles makes me feel like a crotchety old man. A study by Guttman-Yassky and colleagues, "Targeting IL-13 With Tralokinumab Normalizes Type 2 Inflammation in Atopic Dermatitis Both Early and at 2 Years," didn't seem to test any specific hypothesis. The researchers just looked at a variety of inflammation markers in patients with atopic dermatitis treated with tralokinumab, an interleukin-13 (IL-13) antagonist. In these patients, as expected, the atopic dermatitis improved; so did the inflammatory markers. Did we learn anything clinically useful? I don't think so. We already know that IL-13 is important in atopic dermatitis because when we block IL-13, atopic dermatitis improves.

Vitamin D supplementation doesn't appear to improve atopic dermatitis, as reported by Borzutzky and colleagues in "Effect of Weekly Vitamin D Supplementation on the Severity of Atopic Dermatitis and Type 2 Immunity Biomarkers in Children: A Randomized Controlled Trial." A group of 101 children with atopic dermatitis were randomly assigned to receive oral vitamin D supplementation or placebo. The two groups improved to a similar extent. If you know me, you know I'm wondering whether they took the medication. It appears that they did, because at baseline most of the children were vitamin D deficient, and vitamin D levels improved greatly in the group treated with vitamin D but not in the placebo group.

Journals such as the Journal of the American Academy of Dermatology should require articles to report absolute risk. In "Risk of Lymphoma in Patients With Atopic Dermatitis: A Case-Control Study in the All of Us Database," Powers and colleagues tell us that atopic dermatitis is associated with a statistically significantly increased risk for lymphoma. This means that increased risk wasn't likely due to chance alone. The article says nothing, as far as I could tell, about how big the risk is. Does everyone get lymphoma? Or is it a one in a million risk? Without knowing the absolute risk, the relative risk doesn't tell us whether there is a clinically meaningful increased risk or not. I suspect the increased risk is small. If the incidence of lymphoma is about 2 in 10,000 and peripheral T-cell lymphomas (PTCL) account for 10% of those, even a fourfold increase in the risk for PTCL (the form of lymphoma with the highest relative risk) would not amount to much. 

Traidl and colleagues report in "Treatment of Moderate-to-Severe Atopic Dermatitis With Baricitinib: Results From an Interim Analysis of the TREATgermany Registry" that the Janus kinase inhibitor baricitinib makes atopic dermatitis better. 

In "Dupilumab Therapy for Atopic Dermatitis Is Associated With Increased Risk of Cutaneous T Cell Lymphoma," Hasan and colleagues report that "it requires 738 prescriptions of dupilumab to produce one case of CTCL [cutaneous T-cell lymphoma]." It seems that this finding could easily be due to 1 in 738 people with a rash thought to be severe atopic dermatitis needing dupilumab having CTCL, not atopic dermatitis, to begin with. If we were to wonder whether dupilumab causes CTCL, perhaps it would be better to study asthma patients treated with or without dupilumab.
 

In "Atopic Dermatitis in Early Childhood and Risk of Inflammatory Bowel Disease: A Scandinavian Birth Cohort Study," Lerchova and colleagues found a statistically significant increased risk for inflammatory bowel disease (IBD) in children with atopic dermatitis. The study had a large patient population, giving it the power to identify very small differences. The researchers found increased risks for IBD, Crohn's disease, and ulcerative colitis (UC) in children with atopic dermatitis; UC had the greatest relative risk. But I don't think this risk was clinically meaningful. About 2 in every 1000 children with atopic dermatitis had UC, whereas about 1 in every 1000 children without atopic dermatitis had UC. Even if the increased absolute risk of 1 in 1000 children was due to atopic dermatitis and not to other factors, I don't think it justifies the authors' conclusion that "these findings might be useful in identifying at-risk individuals for IBD."

Sometimes reviewing articles makes me feel like a crotchety old man. A study by Guttman-Yassky and colleagues, "Targeting IL-13 With Tralokinumab Normalizes Type 2 Inflammation in Atopic Dermatitis Both Early and at 2 Years," didn't seem to test any specific hypothesis. The researchers just looked at a variety of inflammation markers in patients with atopic dermatitis treated with tralokinumab, an interleukin-13 (IL-13) antagonist. In these patients, as expected, the atopic dermatitis improved; so did the inflammatory markers. Did we learn anything clinically useful? I don't think so. We already know that IL-13 is important in atopic dermatitis because when we block IL-13, atopic dermatitis improves.

Vitamin D supplementation doesn't appear to improve atopic dermatitis, as reported by Borzutzky and colleagues in "Effect of Weekly Vitamin D Supplementation on the Severity of Atopic Dermatitis and Type 2 Immunity Biomarkers in Children: A Randomized Controlled Trial." A group of 101 children with atopic dermatitis were randomly assigned to receive oral vitamin D supplementation or placebo. The two groups improved to a similar extent. If you know me, you know I'm wondering whether they took the medication. It appears that they did, because at baseline most of the children were vitamin D deficient, and vitamin D levels improved greatly in the group treated with vitamin D but not in the placebo group.

Journals such as the Journal of the American Academy of Dermatology should require articles to report absolute risk. In "Risk of Lymphoma in Patients With Atopic Dermatitis: A Case-Control Study in the All of Us Database," Powers and colleagues tell us that atopic dermatitis is associated with a statistically significantly increased risk for lymphoma. This means that increased risk wasn't likely due to chance alone. The article says nothing, as far as I could tell, about how big the risk is. Does everyone get lymphoma? Or is it a one in a million risk? Without knowing the absolute risk, the relative risk doesn't tell us whether there is a clinically meaningful increased risk or not. I suspect the increased risk is small. If the incidence of lymphoma is about 2 in 10,000 and peripheral T-cell lymphomas (PTCL) account for 10% of those, even a fourfold increase in the risk for PTCL (the form of lymphoma with the highest relative risk) would not amount to much. 

Traidl and colleagues report in "Treatment of Moderate-to-Severe Atopic Dermatitis With Baricitinib: Results From an Interim Analysis of the TREATgermany Registry" that the Janus kinase inhibitor baricitinib makes atopic dermatitis better. 

In "Dupilumab Therapy for Atopic Dermatitis Is Associated With Increased Risk of Cutaneous T Cell Lymphoma," Hasan and colleagues report that "it requires 738 prescriptions of dupilumab to produce one case of CTCL [cutaneous T-cell lymphoma]." It seems that this finding could easily be due to 1 in 738 people with a rash thought to be severe atopic dermatitis needing dupilumab having CTCL, not atopic dermatitis, to begin with. If we were to wonder whether dupilumab causes CTCL, perhaps it would be better to study asthma patients treated with or without dupilumab.
 

In "Atopic Dermatitis in Early Childhood and Risk of Inflammatory Bowel Disease: A Scandinavian Birth Cohort Study," Lerchova and colleagues found a statistically significant increased risk for inflammatory bowel disease (IBD) in children with atopic dermatitis. The study had a large patient population, giving it the power to identify very small differences. The researchers found increased risks for IBD, Crohn's disease, and ulcerative colitis (UC) in children with atopic dermatitis; UC had the greatest relative risk. But I don't think this risk was clinically meaningful. About 2 in every 1000 children with atopic dermatitis had UC, whereas about 1 in every 1000 children without atopic dermatitis had UC. Even if the increased absolute risk of 1 in 1000 children was due to atopic dermatitis and not to other factors, I don't think it justifies the authors' conclusion that "these findings might be useful in identifying at-risk individuals for IBD."

Sometimes reviewing articles makes me feel like a crotchety old man. A study by Guttman-Yassky and colleagues, "Targeting IL-13 With Tralokinumab Normalizes Type 2 Inflammation in Atopic Dermatitis Both Early and at 2 Years," didn't seem to test any specific hypothesis. The researchers just looked at a variety of inflammation markers in patients with atopic dermatitis treated with tralokinumab, an interleukin-13 (IL-13) antagonist. In these patients, as expected, the atopic dermatitis improved; so did the inflammatory markers. Did we learn anything clinically useful? I don't think so. We already know that IL-13 is important in atopic dermatitis because when we block IL-13, atopic dermatitis improves.

Vitamin D supplementation doesn't appear to improve atopic dermatitis, as reported by Borzutzky and colleagues in "Effect of Weekly Vitamin D Supplementation on the Severity of Atopic Dermatitis and Type 2 Immunity Biomarkers in Children: A Randomized Controlled Trial." A group of 101 children with atopic dermatitis were randomly assigned to receive oral vitamin D supplementation or placebo. The two groups improved to a similar extent. If you know me, you know I'm wondering whether they took the medication. It appears that they did, because at baseline most of the children were vitamin D deficient, and vitamin D levels improved greatly in the group treated with vitamin D but not in the placebo group.

Journals such as the Journal of the American Academy of Dermatology should require articles to report absolute risk. In "Risk of Lymphoma in Patients With Atopic Dermatitis: A Case-Control Study in the All of Us Database," Powers and colleagues tell us that atopic dermatitis is associated with a statistically significantly increased risk for lymphoma. This means that increased risk wasn't likely due to chance alone. The article says nothing, as far as I could tell, about how big the risk is. Does everyone get lymphoma? Or is it a one in a million risk? Without knowing the absolute risk, the relative risk doesn't tell us whether there is a clinically meaningful increased risk or not. I suspect the increased risk is small. If the incidence of lymphoma is about 2 in 10,000 and peripheral T-cell lymphomas (PTCL) account for 10% of those, even a fourfold increase in the risk for PTCL (the form of lymphoma with the highest relative risk) would not amount to much. 

Traidl and colleagues report in "Treatment of Moderate-to-Severe Atopic Dermatitis With Baricitinib: Results From an Interim Analysis of the TREATgermany Registry" that the Janus kinase inhibitor baricitinib makes atopic dermatitis better. 

In "Dupilumab Therapy for Atopic Dermatitis Is Associated With Increased Risk of Cutaneous T Cell Lymphoma," Hasan and colleagues report that "it requires 738 prescriptions of dupilumab to produce one case of CTCL [cutaneous T-cell lymphoma]." It seems that this finding could easily be due to 1 in 738 people with a rash thought to be severe atopic dermatitis needing dupilumab having CTCL, not atopic dermatitis, to begin with. If we were to wonder whether dupilumab causes CTCL, perhaps it would be better to study asthma patients treated with or without dupilumab.
 

Approximately 108 million individuals have been forcibly displaced across the globe as of 2022, 35 million of whom are formally designated as refugees.^1,2 The United States has coordinated resettlement of more refugee populations than any other country; the most common countries of origin are the Democratic Republic of the Congo, Syria, Afghanistan, and Myanmar.³ In 2021, policy to increase the number of refugees resettled in the United States by more than 700% (from 15,000 up to 125,000) was established; since enactment, the United States has seen more than double the refugee arrivals in 2023 than the prior year, making medical care for this population increasingly relevant for the dermatologist.⁴

Understanding how to care for this population begins with an accurate understanding of the term refugee. The United Nations defines a refugee as a person who is unwilling or unable to return to their country of nationality because of persecution or well-founded fear of persecution due to race, religion, nationality, membership in a particular social group, or political opinion. This term grants a protected status under international law and encompasses access to travel assistance, housing, cultural orientation, and medical evaluation upon resettlement.^5,6

The burden of treatable dermatologic conditions in refugee populations ranges from 19% to 96% in the literature^7,8 and varies from inflammatory disorders to infectious and parasitic diseases.⁹ In one study of 6899 displaced individuals in Greece, the prevalence of dermatologic conditions was higher than traumatic injury, cardiac disease, psychological conditions, and dental disease.¹⁰

When outlining differential diagnoses for parasitic infestations of the skin that affect refugee populations, helpful considerations include the individual’s country of origin, route traveled, and method of travel.¹¹ Parasitic infestations specifically are more common in refugee populations when there are barriers to basic hygiene, crowded living or travel conditions, or lack of access to health care, which they may experience at any point in their home country, during travel, or in resettlement housing.⁸

Even with limited examination and diagnostic resources, the skin is the most accessible first indication of patients’ overall well-being and often provides simple diagnostic clues—in combination with contextualization of the patient’s unique circumstances—necessary for successful diagnosis and treatment of scabies and pediculosis.¹² The dermatologist working with refugee populations may be the first set of eyes available and trained to discern skin infestations and therefore has the potential to improve overall outcomes.

Some parasitic infestations in refugee populations may fall under the category of neglected tropical diseases, including scabies, ascariasis, trypanosomiasis, leishmaniasis, and schistosomiasis; they affect an estimated 1 billion individuals across the globe but historically have been underrepresented in the literature and in health policy due in part to limited access to care.¹³ This review will focus on infestations by the scabies mite (Sarcoptes scabiei var hominis) and the human louse, as these frequently are encountered, easily diagnosed, and treatable by trained clinicians, even in resource-limited settings.

Scabies

Scabies is a parasitic skin infestation caused by the 8-legged mite Sarcoptes scabiei var hominis. The female mite begins the infestation process via penetration of the epidermis, particularly the stratum corneum, and commences laying eggs (Figure 1). The subsequent larvae emerge 48 to 72 hours later and remain burrowed in the epidermis. The larvae mature over the next 10 to 14 days and continue the reproductive cycle.^14,15 Symptoms of infestation occurs due to a hypersensitivity reaction to the mite and its by-products.¹⁶ Transmission of the mite primarily occurs via direct (skin-to-skin) contact with infected individuals or environmental surfaces for 24 to36 hours in specific conditions, though the latter source has been debated in the literature.

The method of transmission is particularly important when considering care for refugee populations. Scabies is found most often in those living in or traveling from tropical regions including East Asia, Southeast Asia, Oceania, and Latin America.¹⁷ In displaced or refugee populations, a lack of access to basic hygiene, extended travel in close quarters, and suboptimal health care access all may lead to an increased incidence of untreated scabies infestations.¹⁸ Scabies is more prevalent in children, with increased potential for secondary bacterial infections with Streptococcus and Staphylococcus species due to excoriation in unsanitary conditions. Secondary infection with Streptococcus pyogenes can lead to acute poststreptococcal glomerulonephritis, which accounts for a large burden of chronic kidney disease in affected populations.¹⁹ However, scabies may be found in any population, regardless of hygiene or health care access. Treating health care providers should keep a broad differential.

Presentation—The latency of scabies symptoms is 2 to 6 weeks in a primary outbreak and may be as short as 1 to 3 days with re-infestation, following the course of delayed-type hypersensitivity.²⁰ The initial hallmark symptom is pruritus with increased severity in the evening. Visible lesions, excoriations, and burrows associated with scattered vesicles or pustules may be seen over the web spaces of the hands and feet, volar surfaces of the wrists, axillae, waist, genitalia, inner thighs, or buttocks.¹⁹ Chronic infestation often manifests with genital nodules. In populations with limited access to health care, there are reports of a sensitization phenomenon in which the individual may become less symptomatic after 4 to 6 weeks and yet be a potential carrier of the mite.²¹

Those with compromised immune function, such as individuals living with HIV or severe malnutrition, may present with crusted scabies, a variant that manifests as widespread hyperkeratotic scaling with more pronounced involvement of the head, neck, and acral areas. In contrast to classic scabies, crusted scabies is associated with minimal pruritus.²²

Diagnosis—The diagnosis of scabies is largely clinical with confirmation through skin scrapings. The International Alliance for Control of Scabies has established diagnostic criteria that include a combination of clinical findings, history, and visualization of mites.²³ A dermatologist working with refugee populations may employ any combination of history (eg, nocturnal itch, exposure to an affected individual) or clinical findings along with a high degree of suspicion in those with elevated risk. Visualization of mites is helpful to confirm the diagnosis and may be completed with the application of mineral oil at the terminal end of a burrow, skin scraping with a surgical blade or needle, and examination under light microscopy.

Treatment—First-line treatment for scabies consists of application of permethrin cream 5% on the skin of the neck to the soles of the feet, which is to be left on for 8 to 14 hours followed by rinsing. Re-application is recommended in 1 to 2 weeks. Oral ivermectin is a reasonable alternative to permethrin cream due to its low cost and easy administration in large affected groups. It is not labeled for use in pregnant women or children weighing less than 15 kg but has no selective fetal toxicity. Treatment of scabies with ivermectin has the benefit of treating many other parasitic infections. Both medications are on the World Health Organization Model List of Essential Medications and are widely available for treating providers, even in resource-limited settings.²⁴

Much of the world still uses benzyl benzoate or precipitated sulfur ointment to treat scabies, and some botanicals used in folk medicine have genuine antiscabetic properties. Pruritus may persist for 1 to 4 weeks following treatment and does not indicate treatment failure. Topical camphor and menthol preparations, low-potency topical corticosteroids, or emollients all may be employed for relief.²⁵ Sarna is a Spanish term for scabies and has become the proprietary name for topical antipruritic agents. Additional methods of treatment and prevention include washing clothes and linens in hot water and drying on high heat. If machine washing is not available, clothing and linens may be sealed in a plastic bag for 72 hours.

Pediculosis

Pediculosis is an infestation caused by the ectoparasite Pediculus humanus, an obligate, sesame seed–sized louse that feeds exclusively on the blood of its host (Figure 2).²⁶ Of the lice species, 2 require humans as hosts; one is P humanus and the other is Pthirus pubis (pubic lice). Pediculus humanus may be further classified into morphologies based largely on the affected area: body (P humanus corporis) or head (P humanus capitis), both of which will be discussed.²⁷

Lice primarily attach to clothing and hair shafts, then transfer to the skin for blood feeds. Females lay eggs that hatch 6 to 10 days later, subsequently maturing into adults. The lifespan of these parasites with regular access to a host is 1 to 3 months for head lice and 18 days for body lice vs only 3 to 5 days without a host.²⁸ Transmission of P humanus capitis primarily occurs via direct contact with affected individuals, either head-to-head contact or sharing of items such as brushes and headscarves; P humanus corporis also may be transmitted via direct contact with affected individuals or clothing.

Pediculosis is an important infestation to consider when providing care for refugee populations. Risk factors include lack of access to basic hygiene, including regular bathing or laundering of clothing, and crowded conditions that make direct person-to-person contact with affected individuals more likely.²⁹ Body lice are associated more often with domestic turbulence and displaced populations³⁰ in comparison to head lice, which have broad demographic variables, most often affecting females and children.²⁸ Fatty acids in adult male sebum make the scalp less hospitable to lice.

Presentation—The most common clinical manifestation of pediculosis is pruritus. Cutaneous findings can include papules, wheals, or hemorrhagic puncta secondary to the louse bite. Due to the Tyndall effect of deep hemosiderin pigment, blue-grey macules termed maculae ceruleae (Figure 3) also may be present in chronic infestations of pediculosis pubis, in contrast to pediculosis capitis or corporis.³¹ Body louse infestation is associated with a general pruritus concentrated on the neck, shoulders, and waist—areas where clothing makes the most direct contact. Lesions may be visible and include eczematous patches with excoriation and possible secondary bacterial infection. Chronic infestation may exhibit lichenification or hyperpigmentation in associated areas. Head lice most often manifest with localized scalp pruritus and associated excoriation and cervical or occipital lymphadenopathy.³²

Diagnosis—The diagnosis of pediculosis is clinical, with confirmation requiring direct examination of the insect or nits (the egg case of the parasite)(Figure 4). Body lice and associated nits can be visualized on clothing seams near areas of highest body temperature, particularly the waistband. Head lice may be visualized crawling on hair shafts or on a louse comb. Nits are firmly attached to hair shafts and are visible to the naked eye, whereas pseudonits slide freely along the hair shaft and are not a manifestation of louse infestation (Figure 5).³¹

Treatment—Treatment varies by affected area. Pediculosis corporis may be treated with permethrin cream 5% applied to the entire body and left on for 8 to 10 hours, but this may not be necessary if facilities are available to wash and dry clothing.³³ The use of oral ivermectin and permethrin-impregnated underwear both have been proposed.^34,35 Treatment of pediculosis capitis may be accomplished with a variety of topical pediculicides including permethrin, pyrethrum with piperonyl butoxide, dimethicone, malathion, benzyl alcohol, spinosad, and topical ivermectin.²² Topical corticosteroids or emollients may be employed for residual pruritus.

Equally important is environmental elimination of infestation. Clothing should be discarded if possible or washed and dried using high heat. If neither approach is possible or appropriate, clothing may be sealed in a plastic bag for 2 weeks or treated with a pediculicide. Nit combing is an important adjunct in the treatment of pediculosis capitis.³⁶ It is important to encourage return to work and/or school immediately after treatment. “No nit” policies are more harmful to education than helpful for prevention of investation.³⁷

Pediculosis corporis may transmit infectious agents including Bartonella quintana, (trench fever, endocarditis, bacillary angiomatosis), Borrelia recurrentis (louse-borne relapsing fever), and Rickettsia prowazekii (epidemic typhus).^31,38,39 Additionally, severe pediculosis infestations have the potential to cause chronic blood loss in affected populations. In a study of patients with active pediculosis infestation, mean hemoglobin values were found to be 2.5 g/dL lower than a matched population without infestation.⁴⁰ It is important to consider pediculosis as a risk for iron-deficiency anemia in populations who are known to lack access to regular medical evaluation.⁴¹

Future Considerations

Increased access to tools and education for clinicians treating refugee populations is key to reducing the burden of parasitic skin disease and related morbidity and mortality in vulnerable groups both domestically and globally. One such tool, the Skin NTDs App, was launched by the World Health Organization in 2020. It is available for free for Android and iOS devices to assist clinicians in the field with the diagnosis and treatment of neglected tropical diseases—including scabies—that may affect refugee populations.⁴²

Additionally, to both improve access and limit preventable sequelae, future investigations into appropriate models of community-based care are paramount. The model of community-based care is centered on the idea of care provision that prioritizes safety, accessibility, affordability, and acceptability in an environment closest to vulnerable populations. The largest dermatologic society, the International League of Dermatological Societies, formed a Migrant Health Dermatology Working Group that prioritizes understanding and improving care for refugee and migrant populations; this group hosted a summit in 2022, bringing together international subject matter leaders to discuss such models of care and set goals for the creation of tool kits for patients, frontline health care workers, and dermatologists.⁴³

Conclusion

Improvement in dermatologic care of refugee populations includes provision of culturally and linguistically appropriate care by trained clinicians, adequate access to the most essential medications, and basic physical or legal access to health care systems in general.^8,11,44 Parasitic infestations have the potential to remain asymptomatic for extended periods of time and result in spread to potentially nonendemic regions of resettlement.⁴⁵ Additionally, the psychosocial well-being of refugee populations upon resettlement may be negatively affected by stigma of disease processes such as scabies and pediculosis, leading to additional barriers to successful re-entry into the patient’s new environment.⁴⁶ Therefore, proper screening, diagnosis, and treatment of the most common parasitic infestations in this population have great potential to improve outcomes for large groups across the globe.

Approximately 108 million individuals have been forcibly displaced across the globe as of 2022, 35 million of whom are formally designated as refugees.^1,2 The United States has coordinated resettlement of more refugee populations than any other country; the most common countries of origin are the Democratic Republic of the Congo, Syria, Afghanistan, and Myanmar.³ In 2021, policy to increase the number of refugees resettled in the United States by more than 700% (from 15,000 up to 125,000) was established; since enactment, the United States has seen more than double the refugee arrivals in 2023 than the prior year, making medical care for this population increasingly relevant for the dermatologist.⁴

Understanding how to care for this population begins with an accurate understanding of the term refugee. The United Nations defines a refugee as a person who is unwilling or unable to return to their country of nationality because of persecution or well-founded fear of persecution due to race, religion, nationality, membership in a particular social group, or political opinion. This term grants a protected status under international law and encompasses access to travel assistance, housing, cultural orientation, and medical evaluation upon resettlement.^5,6

The burden of treatable dermatologic conditions in refugee populations ranges from 19% to 96% in the literature^7,8 and varies from inflammatory disorders to infectious and parasitic diseases.⁹ In one study of 6899 displaced individuals in Greece, the prevalence of dermatologic conditions was higher than traumatic injury, cardiac disease, psychological conditions, and dental disease.¹⁰

When outlining differential diagnoses for parasitic infestations of the skin that affect refugee populations, helpful considerations include the individual’s country of origin, route traveled, and method of travel.¹¹ Parasitic infestations specifically are more common in refugee populations when there are barriers to basic hygiene, crowded living or travel conditions, or lack of access to health care, which they may experience at any point in their home country, during travel, or in resettlement housing.⁸

Even with limited examination and diagnostic resources, the skin is the most accessible first indication of patients’ overall well-being and often provides simple diagnostic clues—in combination with contextualization of the patient’s unique circumstances—necessary for successful diagnosis and treatment of scabies and pediculosis.¹² The dermatologist working with refugee populations may be the first set of eyes available and trained to discern skin infestations and therefore has the potential to improve overall outcomes.

Some parasitic infestations in refugee populations may fall under the category of neglected tropical diseases, including scabies, ascariasis, trypanosomiasis, leishmaniasis, and schistosomiasis; they affect an estimated 1 billion individuals across the globe but historically have been underrepresented in the literature and in health policy due in part to limited access to care.¹³ This review will focus on infestations by the scabies mite (Sarcoptes scabiei var hominis) and the human louse, as these frequently are encountered, easily diagnosed, and treatable by trained clinicians, even in resource-limited settings.

Scabies

Scabies is a parasitic skin infestation caused by the 8-legged mite Sarcoptes scabiei var hominis. The female mite begins the infestation process via penetration of the epidermis, particularly the stratum corneum, and commences laying eggs (Figure 1). The subsequent larvae emerge 48 to 72 hours later and remain burrowed in the epidermis. The larvae mature over the next 10 to 14 days and continue the reproductive cycle.^14,15 Symptoms of infestation occurs due to a hypersensitivity reaction to the mite and its by-products.¹⁶ Transmission of the mite primarily occurs via direct (skin-to-skin) contact with infected individuals or environmental surfaces for 24 to36 hours in specific conditions, though the latter source has been debated in the literature.

The method of transmission is particularly important when considering care for refugee populations. Scabies is found most often in those living in or traveling from tropical regions including East Asia, Southeast Asia, Oceania, and Latin America.¹⁷ In displaced or refugee populations, a lack of access to basic hygiene, extended travel in close quarters, and suboptimal health care access all may lead to an increased incidence of untreated scabies infestations.¹⁸ Scabies is more prevalent in children, with increased potential for secondary bacterial infections with Streptococcus and Staphylococcus species due to excoriation in unsanitary conditions. Secondary infection with Streptococcus pyogenes can lead to acute poststreptococcal glomerulonephritis, which accounts for a large burden of chronic kidney disease in affected populations.¹⁹ However, scabies may be found in any population, regardless of hygiene or health care access. Treating health care providers should keep a broad differential.

Presentation—The latency of scabies symptoms is 2 to 6 weeks in a primary outbreak and may be as short as 1 to 3 days with re-infestation, following the course of delayed-type hypersensitivity.²⁰ The initial hallmark symptom is pruritus with increased severity in the evening. Visible lesions, excoriations, and burrows associated with scattered vesicles or pustules may be seen over the web spaces of the hands and feet, volar surfaces of the wrists, axillae, waist, genitalia, inner thighs, or buttocks.¹⁹ Chronic infestation often manifests with genital nodules. In populations with limited access to health care, there are reports of a sensitization phenomenon in which the individual may become less symptomatic after 4 to 6 weeks and yet be a potential carrier of the mite.²¹

Those with compromised immune function, such as individuals living with HIV or severe malnutrition, may present with crusted scabies, a variant that manifests as widespread hyperkeratotic scaling with more pronounced involvement of the head, neck, and acral areas. In contrast to classic scabies, crusted scabies is associated with minimal pruritus.²²

Diagnosis—The diagnosis of scabies is largely clinical with confirmation through skin scrapings. The International Alliance for Control of Scabies has established diagnostic criteria that include a combination of clinical findings, history, and visualization of mites.²³ A dermatologist working with refugee populations may employ any combination of history (eg, nocturnal itch, exposure to an affected individual) or clinical findings along with a high degree of suspicion in those with elevated risk. Visualization of mites is helpful to confirm the diagnosis and may be completed with the application of mineral oil at the terminal end of a burrow, skin scraping with a surgical blade or needle, and examination under light microscopy.

Treatment—First-line treatment for scabies consists of application of permethrin cream 5% on the skin of the neck to the soles of the feet, which is to be left on for 8 to 14 hours followed by rinsing. Re-application is recommended in 1 to 2 weeks. Oral ivermectin is a reasonable alternative to permethrin cream due to its low cost and easy administration in large affected groups. It is not labeled for use in pregnant women or children weighing less than 15 kg but has no selective fetal toxicity. Treatment of scabies with ivermectin has the benefit of treating many other parasitic infections. Both medications are on the World Health Organization Model List of Essential Medications and are widely available for treating providers, even in resource-limited settings.²⁴

Much of the world still uses benzyl benzoate or precipitated sulfur ointment to treat scabies, and some botanicals used in folk medicine have genuine antiscabetic properties. Pruritus may persist for 1 to 4 weeks following treatment and does not indicate treatment failure. Topical camphor and menthol preparations, low-potency topical corticosteroids, or emollients all may be employed for relief.²⁵ Sarna is a Spanish term for scabies and has become the proprietary name for topical antipruritic agents. Additional methods of treatment and prevention include washing clothes and linens in hot water and drying on high heat. If machine washing is not available, clothing and linens may be sealed in a plastic bag for 72 hours.

Pediculosis

Pediculosis is an infestation caused by the ectoparasite Pediculus humanus, an obligate, sesame seed–sized louse that feeds exclusively on the blood of its host (Figure 2).²⁶ Of the lice species, 2 require humans as hosts; one is P humanus and the other is Pthirus pubis (pubic lice). Pediculus humanus may be further classified into morphologies based largely on the affected area: body (P humanus corporis) or head (P humanus capitis), both of which will be discussed.²⁷

Lice primarily attach to clothing and hair shafts, then transfer to the skin for blood feeds. Females lay eggs that hatch 6 to 10 days later, subsequently maturing into adults. The lifespan of these parasites with regular access to a host is 1 to 3 months for head lice and 18 days for body lice vs only 3 to 5 days without a host.²⁸ Transmission of P humanus capitis primarily occurs via direct contact with affected individuals, either head-to-head contact or sharing of items such as brushes and headscarves; P humanus corporis also may be transmitted via direct contact with affected individuals or clothing.

Pediculosis is an important infestation to consider when providing care for refugee populations. Risk factors include lack of access to basic hygiene, including regular bathing or laundering of clothing, and crowded conditions that make direct person-to-person contact with affected individuals more likely.²⁹ Body lice are associated more often with domestic turbulence and displaced populations³⁰ in comparison to head lice, which have broad demographic variables, most often affecting females and children.²⁸ Fatty acids in adult male sebum make the scalp less hospitable to lice.

Presentation—The most common clinical manifestation of pediculosis is pruritus. Cutaneous findings can include papules, wheals, or hemorrhagic puncta secondary to the louse bite. Due to the Tyndall effect of deep hemosiderin pigment, blue-grey macules termed maculae ceruleae (Figure 3) also may be present in chronic infestations of pediculosis pubis, in contrast to pediculosis capitis or corporis.³¹ Body louse infestation is associated with a general pruritus concentrated on the neck, shoulders, and waist—areas where clothing makes the most direct contact. Lesions may be visible and include eczematous patches with excoriation and possible secondary bacterial infection. Chronic infestation may exhibit lichenification or hyperpigmentation in associated areas. Head lice most often manifest with localized scalp pruritus and associated excoriation and cervical or occipital lymphadenopathy.³²

Diagnosis—The diagnosis of pediculosis is clinical, with confirmation requiring direct examination of the insect or nits (the egg case of the parasite)(Figure 4). Body lice and associated nits can be visualized on clothing seams near areas of highest body temperature, particularly the waistband. Head lice may be visualized crawling on hair shafts or on a louse comb. Nits are firmly attached to hair shafts and are visible to the naked eye, whereas pseudonits slide freely along the hair shaft and are not a manifestation of louse infestation (Figure 5).³¹

Treatment—Treatment varies by affected area. Pediculosis corporis may be treated with permethrin cream 5% applied to the entire body and left on for 8 to 10 hours, but this may not be necessary if facilities are available to wash and dry clothing.³³ The use of oral ivermectin and permethrin-impregnated underwear both have been proposed.^34,35 Treatment of pediculosis capitis may be accomplished with a variety of topical pediculicides including permethrin, pyrethrum with piperonyl butoxide, dimethicone, malathion, benzyl alcohol, spinosad, and topical ivermectin.²² Topical corticosteroids or emollients may be employed for residual pruritus.

Equally important is environmental elimination of infestation. Clothing should be discarded if possible or washed and dried using high heat. If neither approach is possible or appropriate, clothing may be sealed in a plastic bag for 2 weeks or treated with a pediculicide. Nit combing is an important adjunct in the treatment of pediculosis capitis.³⁶ It is important to encourage return to work and/or school immediately after treatment. “No nit” policies are more harmful to education than helpful for prevention of investation.³⁷

Pediculosis corporis may transmit infectious agents including Bartonella quintana, (trench fever, endocarditis, bacillary angiomatosis), Borrelia recurrentis (louse-borne relapsing fever), and Rickettsia prowazekii (epidemic typhus).^31,38,39 Additionally, severe pediculosis infestations have the potential to cause chronic blood loss in affected populations. In a study of patients with active pediculosis infestation, mean hemoglobin values were found to be 2.5 g/dL lower than a matched population without infestation.⁴⁰ It is important to consider pediculosis as a risk for iron-deficiency anemia in populations who are known to lack access to regular medical evaluation.⁴¹

Future Considerations

Increased access to tools and education for clinicians treating refugee populations is key to reducing the burden of parasitic skin disease and related morbidity and mortality in vulnerable groups both domestically and globally. One such tool, the Skin NTDs App, was launched by the World Health Organization in 2020. It is available for free for Android and iOS devices to assist clinicians in the field with the diagnosis and treatment of neglected tropical diseases—including scabies—that may affect refugee populations.⁴²

Additionally, to both improve access and limit preventable sequelae, future investigations into appropriate models of community-based care are paramount. The model of community-based care is centered on the idea of care provision that prioritizes safety, accessibility, affordability, and acceptability in an environment closest to vulnerable populations. The largest dermatologic society, the International League of Dermatological Societies, formed a Migrant Health Dermatology Working Group that prioritizes understanding and improving care for refugee and migrant populations; this group hosted a summit in 2022, bringing together international subject matter leaders to discuss such models of care and set goals for the creation of tool kits for patients, frontline health care workers, and dermatologists.⁴³

Conclusion

Improvement in dermatologic care of refugee populations includes provision of culturally and linguistically appropriate care by trained clinicians, adequate access to the most essential medications, and basic physical or legal access to health care systems in general.^8,11,44 Parasitic infestations have the potential to remain asymptomatic for extended periods of time and result in spread to potentially nonendemic regions of resettlement.⁴⁵ Additionally, the psychosocial well-being of refugee populations upon resettlement may be negatively affected by stigma of disease processes such as scabies and pediculosis, leading to additional barriers to successful re-entry into the patient’s new environment.⁴⁶ Therefore, proper screening, diagnosis, and treatment of the most common parasitic infestations in this population have great potential to improve outcomes for large groups across the globe.

Approximately 108 million individuals have been forcibly displaced across the globe as of 2022, 35 million of whom are formally designated as refugees.^1,2 The United States has coordinated resettlement of more refugee populations than any other country; the most common countries of origin are the Democratic Republic of the Congo, Syria, Afghanistan, and Myanmar.³ In 2021, policy to increase the number of refugees resettled in the United States by more than 700% (from 15,000 up to 125,000) was established; since enactment, the United States has seen more than double the refugee arrivals in 2023 than the prior year, making medical care for this population increasingly relevant for the dermatologist.⁴

Understanding how to care for this population begins with an accurate understanding of the term refugee. The United Nations defines a refugee as a person who is unwilling or unable to return to their country of nationality because of persecution or well-founded fear of persecution due to race, religion, nationality, membership in a particular social group, or political opinion. This term grants a protected status under international law and encompasses access to travel assistance, housing, cultural orientation, and medical evaluation upon resettlement.^5,6

The burden of treatable dermatologic conditions in refugee populations ranges from 19% to 96% in the literature^7,8 and varies from inflammatory disorders to infectious and parasitic diseases.⁹ In one study of 6899 displaced individuals in Greece, the prevalence of dermatologic conditions was higher than traumatic injury, cardiac disease, psychological conditions, and dental disease.¹⁰

When outlining differential diagnoses for parasitic infestations of the skin that affect refugee populations, helpful considerations include the individual’s country of origin, route traveled, and method of travel.¹¹ Parasitic infestations specifically are more common in refugee populations when there are barriers to basic hygiene, crowded living or travel conditions, or lack of access to health care, which they may experience at any point in their home country, during travel, or in resettlement housing.⁸

Even with limited examination and diagnostic resources, the skin is the most accessible first indication of patients’ overall well-being and often provides simple diagnostic clues—in combination with contextualization of the patient’s unique circumstances—necessary for successful diagnosis and treatment of scabies and pediculosis.¹² The dermatologist working with refugee populations may be the first set of eyes available and trained to discern skin infestations and therefore has the potential to improve overall outcomes.

Some parasitic infestations in refugee populations may fall under the category of neglected tropical diseases, including scabies, ascariasis, trypanosomiasis, leishmaniasis, and schistosomiasis; they affect an estimated 1 billion individuals across the globe but historically have been underrepresented in the literature and in health policy due in part to limited access to care.¹³ This review will focus on infestations by the scabies mite (Sarcoptes scabiei var hominis) and the human louse, as these frequently are encountered, easily diagnosed, and treatable by trained clinicians, even in resource-limited settings.

Scabies

Scabies is a parasitic skin infestation caused by the 8-legged mite Sarcoptes scabiei var hominis. The female mite begins the infestation process via penetration of the epidermis, particularly the stratum corneum, and commences laying eggs (Figure 1). The subsequent larvae emerge 48 to 72 hours later and remain burrowed in the epidermis. The larvae mature over the next 10 to 14 days and continue the reproductive cycle.^14,15 Symptoms of infestation occurs due to a hypersensitivity reaction to the mite and its by-products.¹⁶ Transmission of the mite primarily occurs via direct (skin-to-skin) contact with infected individuals or environmental surfaces for 24 to36 hours in specific conditions, though the latter source has been debated in the literature.

The method of transmission is particularly important when considering care for refugee populations. Scabies is found most often in those living in or traveling from tropical regions including East Asia, Southeast Asia, Oceania, and Latin America.¹⁷ In displaced or refugee populations, a lack of access to basic hygiene, extended travel in close quarters, and suboptimal health care access all may lead to an increased incidence of untreated scabies infestations.¹⁸ Scabies is more prevalent in children, with increased potential for secondary bacterial infections with Streptococcus and Staphylococcus species due to excoriation in unsanitary conditions. Secondary infection with Streptococcus pyogenes can lead to acute poststreptococcal glomerulonephritis, which accounts for a large burden of chronic kidney disease in affected populations.¹⁹ However, scabies may be found in any population, regardless of hygiene or health care access. Treating health care providers should keep a broad differential.

Presentation—The latency of scabies symptoms is 2 to 6 weeks in a primary outbreak and may be as short as 1 to 3 days with re-infestation, following the course of delayed-type hypersensitivity.²⁰ The initial hallmark symptom is pruritus with increased severity in the evening. Visible lesions, excoriations, and burrows associated with scattered vesicles or pustules may be seen over the web spaces of the hands and feet, volar surfaces of the wrists, axillae, waist, genitalia, inner thighs, or buttocks.¹⁹ Chronic infestation often manifests with genital nodules. In populations with limited access to health care, there are reports of a sensitization phenomenon in which the individual may become less symptomatic after 4 to 6 weeks and yet be a potential carrier of the mite.²¹

Those with compromised immune function, such as individuals living with HIV or severe malnutrition, may present with crusted scabies, a variant that manifests as widespread hyperkeratotic scaling with more pronounced involvement of the head, neck, and acral areas. In contrast to classic scabies, crusted scabies is associated with minimal pruritus.²²

Diagnosis—The diagnosis of scabies is largely clinical with confirmation through skin scrapings. The International Alliance for Control of Scabies has established diagnostic criteria that include a combination of clinical findings, history, and visualization of mites.²³ A dermatologist working with refugee populations may employ any combination of history (eg, nocturnal itch, exposure to an affected individual) or clinical findings along with a high degree of suspicion in those with elevated risk. Visualization of mites is helpful to confirm the diagnosis and may be completed with the application of mineral oil at the terminal end of a burrow, skin scraping with a surgical blade or needle, and examination under light microscopy.

Treatment—First-line treatment for scabies consists of application of permethrin cream 5% on the skin of the neck to the soles of the feet, which is to be left on for 8 to 14 hours followed by rinsing. Re-application is recommended in 1 to 2 weeks. Oral ivermectin is a reasonable alternative to permethrin cream due to its low cost and easy administration in large affected groups. It is not labeled for use in pregnant women or children weighing less than 15 kg but has no selective fetal toxicity. Treatment of scabies with ivermectin has the benefit of treating many other parasitic infections. Both medications are on the World Health Organization Model List of Essential Medications and are widely available for treating providers, even in resource-limited settings.²⁴

Much of the world still uses benzyl benzoate or precipitated sulfur ointment to treat scabies, and some botanicals used in folk medicine have genuine antiscabetic properties. Pruritus may persist for 1 to 4 weeks following treatment and does not indicate treatment failure. Topical camphor and menthol preparations, low-potency topical corticosteroids, or emollients all may be employed for relief.²⁵ Sarna is a Spanish term for scabies and has become the proprietary name for topical antipruritic agents. Additional methods of treatment and prevention include washing clothes and linens in hot water and drying on high heat. If machine washing is not available, clothing and linens may be sealed in a plastic bag for 72 hours.

Pediculosis

Pediculosis is an infestation caused by the ectoparasite Pediculus humanus, an obligate, sesame seed–sized louse that feeds exclusively on the blood of its host (Figure 2).²⁶ Of the lice species, 2 require humans as hosts; one is P humanus and the other is Pthirus pubis (pubic lice). Pediculus humanus may be further classified into morphologies based largely on the affected area: body (P humanus corporis) or head (P humanus capitis), both of which will be discussed.²⁷

Lice primarily attach to clothing and hair shafts, then transfer to the skin for blood feeds. Females lay eggs that hatch 6 to 10 days later, subsequently maturing into adults. The lifespan of these parasites with regular access to a host is 1 to 3 months for head lice and 18 days for body lice vs only 3 to 5 days without a host.²⁸ Transmission of P humanus capitis primarily occurs via direct contact with affected individuals, either head-to-head contact or sharing of items such as brushes and headscarves; P humanus corporis also may be transmitted via direct contact with affected individuals or clothing.

Pediculosis is an important infestation to consider when providing care for refugee populations. Risk factors include lack of access to basic hygiene, including regular bathing or laundering of clothing, and crowded conditions that make direct person-to-person contact with affected individuals more likely.²⁹ Body lice are associated more often with domestic turbulence and displaced populations³⁰ in comparison to head lice, which have broad demographic variables, most often affecting females and children.²⁸ Fatty acids in adult male sebum make the scalp less hospitable to lice.

Presentation—The most common clinical manifestation of pediculosis is pruritus. Cutaneous findings can include papules, wheals, or hemorrhagic puncta secondary to the louse bite. Due to the Tyndall effect of deep hemosiderin pigment, blue-grey macules termed maculae ceruleae (Figure 3) also may be present in chronic infestations of pediculosis pubis, in contrast to pediculosis capitis or corporis.³¹ Body louse infestation is associated with a general pruritus concentrated on the neck, shoulders, and waist—areas where clothing makes the most direct contact. Lesions may be visible and include eczematous patches with excoriation and possible secondary bacterial infection. Chronic infestation may exhibit lichenification or hyperpigmentation in associated areas. Head lice most often manifest with localized scalp pruritus and associated excoriation and cervical or occipital lymphadenopathy.³²

Diagnosis—The diagnosis of pediculosis is clinical, with confirmation requiring direct examination of the insect or nits (the egg case of the parasite)(Figure 4). Body lice and associated nits can be visualized on clothing seams near areas of highest body temperature, particularly the waistband. Head lice may be visualized crawling on hair shafts or on a louse comb. Nits are firmly attached to hair shafts and are visible to the naked eye, whereas pseudonits slide freely along the hair shaft and are not a manifestation of louse infestation (Figure 5).³¹

Treatment—Treatment varies by affected area. Pediculosis corporis may be treated with permethrin cream 5% applied to the entire body and left on for 8 to 10 hours, but this may not be necessary if facilities are available to wash and dry clothing.³³ The use of oral ivermectin and permethrin-impregnated underwear both have been proposed.^34,35 Treatment of pediculosis capitis may be accomplished with a variety of topical pediculicides including permethrin, pyrethrum with piperonyl butoxide, dimethicone, malathion, benzyl alcohol, spinosad, and topical ivermectin.²² Topical corticosteroids or emollients may be employed for residual pruritus.

Equally important is environmental elimination of infestation. Clothing should be discarded if possible or washed and dried using high heat. If neither approach is possible or appropriate, clothing may be sealed in a plastic bag for 2 weeks or treated with a pediculicide. Nit combing is an important adjunct in the treatment of pediculosis capitis.³⁶ It is important to encourage return to work and/or school immediately after treatment. “No nit” policies are more harmful to education than helpful for prevention of investation.³⁷

Pediculosis corporis may transmit infectious agents including Bartonella quintana, (trench fever, endocarditis, bacillary angiomatosis), Borrelia recurrentis (louse-borne relapsing fever), and Rickettsia prowazekii (epidemic typhus).^31,38,39 Additionally, severe pediculosis infestations have the potential to cause chronic blood loss in affected populations. In a study of patients with active pediculosis infestation, mean hemoglobin values were found to be 2.5 g/dL lower than a matched population without infestation.⁴⁰ It is important to consider pediculosis as a risk for iron-deficiency anemia in populations who are known to lack access to regular medical evaluation.⁴¹

Future Considerations

Increased access to tools and education for clinicians treating refugee populations is key to reducing the burden of parasitic skin disease and related morbidity and mortality in vulnerable groups both domestically and globally. One such tool, the Skin NTDs App, was launched by the World Health Organization in 2020. It is available for free for Android and iOS devices to assist clinicians in the field with the diagnosis and treatment of neglected tropical diseases—including scabies—that may affect refugee populations.⁴²

Additionally, to both improve access and limit preventable sequelae, future investigations into appropriate models of community-based care are paramount. The model of community-based care is centered on the idea of care provision that prioritizes safety, accessibility, affordability, and acceptability in an environment closest to vulnerable populations. The largest dermatologic society, the International League of Dermatological Societies, formed a Migrant Health Dermatology Working Group that prioritizes understanding and improving care for refugee and migrant populations; this group hosted a summit in 2022, bringing together international subject matter leaders to discuss such models of care and set goals for the creation of tool kits for patients, frontline health care workers, and dermatologists.⁴³

Conclusion

Improvement in dermatologic care of refugee populations includes provision of culturally and linguistically appropriate care by trained clinicians, adequate access to the most essential medications, and basic physical or legal access to health care systems in general.^8,11,44 Parasitic infestations have the potential to remain asymptomatic for extended periods of time and result in spread to potentially nonendemic regions of resettlement.⁴⁵ Additionally, the psychosocial well-being of refugee populations upon resettlement may be negatively affected by stigma of disease processes such as scabies and pediculosis, leading to additional barriers to successful re-entry into the patient’s new environment.⁴⁶ Therefore, proper screening, diagnosis, and treatment of the most common parasitic infestations in this population have great potential to improve outcomes for large groups across the globe.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

BALTIMORE — Laser treatment for solar lentigines in individuals with darker skin types has long been associated with a higher risk of postinflammatory hyperpigmentation (PIH), but a small study in Thailand has shown the 532-nm picosecond laser with a fractional beam microlens array (MLA) had a significantly lower incidence of PIH than the full-beam treatment without MLA.

The study enrolled 27 patients with solar lentigines and Fitzpatrick skin types (FSTs) III-IV, Woraphong Manuskiatti, MD, professor of dermatology at Siriraj Hospital, Mahidol University, Bangkok, reported at the annual meeting of the American Society for Laser Medicine and Surgery. They received the fractional beam treatment on one side of the face and the full-beam on the other side. At 6 months, the incidence of PIH was about 81% lower on the fractional-beam side, Dr. Manuskiatti said.

“In the past, when we used laser to treat pigmented lesions, we used the so-called full-beam technique on the pigmented area,” Dr. Manuskiatti told this news organization. “From the study, we found that you don’t need to treat it at 100%. You can fractionally treat the pigmented lesion and get a really comparable treatment outcome and, at that reduced beam, less incidence of postinflammatory hyperpigmentation.”
 

Study Design and Results

Of the 27 patients in the study, 12 were FST III (44%), 14 were FST IV (52%), and one was FST V (4%). On the fractional-beam side, the laser was delivered through a 9-mm spot size with an average fluence of 0.47 J/cm² at a frequency of 2 Hz for a total of two passes without pulse overlapping. On the full-beam side, the laser was operated with a 4.5-mm handpiece, with fluence ranging from 0.3 to 0.7 J/cm² (using an endpoint of slight darkening of the pigmented lesion) at 2 Hz.

The patients received a single treatment and had a clinical evaluation and color reading assessments at 2 weeks, 1 month, 3 months, and 6 months after the treatment. Twenty-five patients completed the study.

The researchers found no statistically significant differences in lesional clearance between the two techniques at any of the follow-up assessments, Dr. Manuskiatti said. “This might be one of the alternative treatments of treating solar lentigines in dark-skinned patients,” he said when presenting the study results.

He reported the rates of PIH on the full-beam and fractional-beam sides, respectively, at the following intervals were: 64% and 8% at 2 weeks, 80% and 32% at 1 month, 96% and 36% at 3 months, and 88% and 16% at 6 months.

“The incidence of PIH on the full-beam side was statistically higher than that on the fractional-beam side throughout the follow-up period,” he said. Transient and mild hypopigmentation was observed in one patient (4%) on the fractional-beam side and in five (20%) on the full-beam side. Dr. Manuskiatti added that no other adverse effects were documented during the study.

“ Normally when you use laser to treat skin type I or II, you don’t have … PIH or darkening of the skin,” Dr. Manuskiatti told this news organization, “but when you have skin type III and above, you run into a really high incidence of postinflammatory hyperpigmentation — and treating that with fractional beam can lead to a reduced incidence of darkening of the skin afterward.”
 

A Lower-Cost Option

This study showed that the 532-nm picosecond laser with fractional beam MLA is a useful option for patients with darker skin types, Kelly Stankiewicz, MD, a dermatologist who practices in Park City, Utah, and moderated the session where these results were presented, told this news organization.

“The most challenging thing about treating lentigines in darker skin types is preventing potential side effects, mainly dyspigmentation,” she said after the meeting. “These side effects are, for the most part, temporary, but they can take 6-18 months to resolve, so it’s important to prevent them in the first place.”

She noted that the 532-nm and 1064-nm wavelengths are the most commonly available for picosecond lasers and that they’re easier to produce and less expensive. “There are picosecond lasers with middle wavelengths in the red light to near-infrared range (650-785 nm) that are better for darker skin types because they are more gentle yet still effective at targeting pigment, but these lasers are more expensive and less widely available,” Dr. Stankiewicz said. 

“The microlens array, used in this study with the 532-nm wavelength, is an inexpensive piece that fits at the end of the laser,” she added. “So, to have an option that turns a 532-nm laser into a safer device for the treatment of lentigines in darker skin types is very helpful.”

Dr. Manuskiatti and Dr. Stankiewicz had no relevant disclosures to report.
 

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

BALTIMORE — Laser treatment for solar lentigines in individuals with darker skin types has long been associated with a higher risk of postinflammatory hyperpigmentation (PIH), but a small study in Thailand has shown the 532-nm picosecond laser with a fractional beam microlens array (MLA) had a significantly lower incidence of PIH than the full-beam treatment without MLA.

The study enrolled 27 patients with solar lentigines and Fitzpatrick skin types (FSTs) III-IV, Woraphong Manuskiatti, MD, professor of dermatology at Siriraj Hospital, Mahidol University, Bangkok, reported at the annual meeting of the American Society for Laser Medicine and Surgery. They received the fractional beam treatment on one side of the face and the full-beam on the other side. At 6 months, the incidence of PIH was about 81% lower on the fractional-beam side, Dr. Manuskiatti said.

“In the past, when we used laser to treat pigmented lesions, we used the so-called full-beam technique on the pigmented area,” Dr. Manuskiatti told this news organization. “From the study, we found that you don’t need to treat it at 100%. You can fractionally treat the pigmented lesion and get a really comparable treatment outcome and, at that reduced beam, less incidence of postinflammatory hyperpigmentation.”
 

Study Design and Results

Of the 27 patients in the study, 12 were FST III (44%), 14 were FST IV (52%), and one was FST V (4%). On the fractional-beam side, the laser was delivered through a 9-mm spot size with an average fluence of 0.47 J/cm² at a frequency of 2 Hz for a total of two passes without pulse overlapping. On the full-beam side, the laser was operated with a 4.5-mm handpiece, with fluence ranging from 0.3 to 0.7 J/cm² (using an endpoint of slight darkening of the pigmented lesion) at 2 Hz.

The patients received a single treatment and had a clinical evaluation and color reading assessments at 2 weeks, 1 month, 3 months, and 6 months after the treatment. Twenty-five patients completed the study.

The researchers found no statistically significant differences in lesional clearance between the two techniques at any of the follow-up assessments, Dr. Manuskiatti said. “This might be one of the alternative treatments of treating solar lentigines in dark-skinned patients,” he said when presenting the study results.

He reported the rates of PIH on the full-beam and fractional-beam sides, respectively, at the following intervals were: 64% and 8% at 2 weeks, 80% and 32% at 1 month, 96% and 36% at 3 months, and 88% and 16% at 6 months.

“The incidence of PIH on the full-beam side was statistically higher than that on the fractional-beam side throughout the follow-up period,” he said. Transient and mild hypopigmentation was observed in one patient (4%) on the fractional-beam side and in five (20%) on the full-beam side. Dr. Manuskiatti added that no other adverse effects were documented during the study.

“ Normally when you use laser to treat skin type I or II, you don’t have … PIH or darkening of the skin,” Dr. Manuskiatti told this news organization, “but when you have skin type III and above, you run into a really high incidence of postinflammatory hyperpigmentation — and treating that with fractional beam can lead to a reduced incidence of darkening of the skin afterward.”
 

A Lower-Cost Option

This study showed that the 532-nm picosecond laser with fractional beam MLA is a useful option for patients with darker skin types, Kelly Stankiewicz, MD, a dermatologist who practices in Park City, Utah, and moderated the session where these results were presented, told this news organization.

“The most challenging thing about treating lentigines in darker skin types is preventing potential side effects, mainly dyspigmentation,” she said after the meeting. “These side effects are, for the most part, temporary, but they can take 6-18 months to resolve, so it’s important to prevent them in the first place.”

She noted that the 532-nm and 1064-nm wavelengths are the most commonly available for picosecond lasers and that they’re easier to produce and less expensive. “There are picosecond lasers with middle wavelengths in the red light to near-infrared range (650-785 nm) that are better for darker skin types because they are more gentle yet still effective at targeting pigment, but these lasers are more expensive and less widely available,” Dr. Stankiewicz said. 

“The microlens array, used in this study with the 532-nm wavelength, is an inexpensive piece that fits at the end of the laser,” she added. “So, to have an option that turns a 532-nm laser into a safer device for the treatment of lentigines in darker skin types is very helpful.”

Dr. Manuskiatti and Dr. Stankiewicz had no relevant disclosures to report.
 

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

BALTIMORE — Laser treatment for solar lentigines in individuals with darker skin types has long been associated with a higher risk of postinflammatory hyperpigmentation (PIH), but a small study in Thailand has shown the 532-nm picosecond laser with a fractional beam microlens array (MLA) had a significantly lower incidence of PIH than the full-beam treatment without MLA.

The study enrolled 27 patients with solar lentigines and Fitzpatrick skin types (FSTs) III-IV, Woraphong Manuskiatti, MD, professor of dermatology at Siriraj Hospital, Mahidol University, Bangkok, reported at the annual meeting of the American Society for Laser Medicine and Surgery. They received the fractional beam treatment on one side of the face and the full-beam on the other side. At 6 months, the incidence of PIH was about 81% lower on the fractional-beam side, Dr. Manuskiatti said.

“In the past, when we used laser to treat pigmented lesions, we used the so-called full-beam technique on the pigmented area,” Dr. Manuskiatti told this news organization. “From the study, we found that you don’t need to treat it at 100%. You can fractionally treat the pigmented lesion and get a really comparable treatment outcome and, at that reduced beam, less incidence of postinflammatory hyperpigmentation.”
 

Study Design and Results

Of the 27 patients in the study, 12 were FST III (44%), 14 were FST IV (52%), and one was FST V (4%). On the fractional-beam side, the laser was delivered through a 9-mm spot size with an average fluence of 0.47 J/cm² at a frequency of 2 Hz for a total of two passes without pulse overlapping. On the full-beam side, the laser was operated with a 4.5-mm handpiece, with fluence ranging from 0.3 to 0.7 J/cm² (using an endpoint of slight darkening of the pigmented lesion) at 2 Hz.

The patients received a single treatment and had a clinical evaluation and color reading assessments at 2 weeks, 1 month, 3 months, and 6 months after the treatment. Twenty-five patients completed the study.

The researchers found no statistically significant differences in lesional clearance between the two techniques at any of the follow-up assessments, Dr. Manuskiatti said. “This might be one of the alternative treatments of treating solar lentigines in dark-skinned patients,” he said when presenting the study results.

He reported the rates of PIH on the full-beam and fractional-beam sides, respectively, at the following intervals were: 64% and 8% at 2 weeks, 80% and 32% at 1 month, 96% and 36% at 3 months, and 88% and 16% at 6 months.

“The incidence of PIH on the full-beam side was statistically higher than that on the fractional-beam side throughout the follow-up period,” he said. Transient and mild hypopigmentation was observed in one patient (4%) on the fractional-beam side and in five (20%) on the full-beam side. Dr. Manuskiatti added that no other adverse effects were documented during the study.

“ Normally when you use laser to treat skin type I or II, you don’t have … PIH or darkening of the skin,” Dr. Manuskiatti told this news organization, “but when you have skin type III and above, you run into a really high incidence of postinflammatory hyperpigmentation — and treating that with fractional beam can lead to a reduced incidence of darkening of the skin afterward.”
 

A Lower-Cost Option

This study showed that the 532-nm picosecond laser with fractional beam MLA is a useful option for patients with darker skin types, Kelly Stankiewicz, MD, a dermatologist who practices in Park City, Utah, and moderated the session where these results were presented, told this news organization.

“The most challenging thing about treating lentigines in darker skin types is preventing potential side effects, mainly dyspigmentation,” she said after the meeting. “These side effects are, for the most part, temporary, but they can take 6-18 months to resolve, so it’s important to prevent them in the first place.”

She noted that the 532-nm and 1064-nm wavelengths are the most commonly available for picosecond lasers and that they’re easier to produce and less expensive. “There are picosecond lasers with middle wavelengths in the red light to near-infrared range (650-785 nm) that are better for darker skin types because they are more gentle yet still effective at targeting pigment, but these lasers are more expensive and less widely available,” Dr. Stankiewicz said. 

“The microlens array, used in this study with the 532-nm wavelength, is an inexpensive piece that fits at the end of the laser,” she added. “So, to have an option that turns a 532-nm laser into a safer device for the treatment of lentigines in darker skin types is very helpful.”

Dr. Manuskiatti and Dr. Stankiewicz had no relevant disclosures to report.
 

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

Safe to say that anyone undertaking the physician journey does so with intense motivation and book smarts. Still, it can be incredibly hard to stand out. Everyone’s a go-getter, but what’s the X factor?

We asked five veteran doctors who have supervised scores of young medical professionals over the years to tell us about that one person who impressed the hell out of them — what they did, why it made them game changers, and what every doctor can learn from them. Here’s what they said ...
 

Lesson #1: Never Be Scared to Ask

Brien Barnewolt, MD, chairman and chief of the Department of Emergency Medicine at Tufts Medical Center, was very much surprised when a resident named Scott G. Weiner did something unexpected: Go after a job in the fall of his junior year residency instead of following the typical senior year trajectory.

“It’s very unusual for a trainee to apply for a job virtually a year ahead of schedule. But he knew what he wanted,” said Dr. Barnewolt. “I’d never had anybody come to me in that same scenario, and I’ve been doing this a long time.”

Under normal circumstances it would’ve been easy for Dr. Barnewolt to say no. But the unexpected request made him and his colleagues take a closer look, and they were impressed with Dr. Weiner’s skills. That, paired with his ambition and demeanor, compelled them to offer him an early job. But there’s more.

As the next year approached, Dr. Weiner explained he had an opportunity to work in emergency medicine in Tuscany and asked if he could take a 1-year delayed start for the position he applied a year early for.

The department held his position, and upon his return, Dr. Weiner made a lasting impact at Tufts before eventually moving on. “He outgrew us, which is nice to see,” Dr. Barnewolt said. (Dr. Weiner is currently McGraw Distinguished Chair in Emergency Medicine at Brigham and Women’s Hospital and associate professor at Harvard Medical School.)

Bottom line: Why did Dr. Barnewolt and his colleagues do so much to accommodate a young candidate? Yes, Dr. Weiner was talented, but he was also up-front about his ambitions from the get-go. Dr. Barnewolt said that kind of initiative can only be looked at positively.

“My advice would be, if you see an opportunity or a potential place where you might want to work, put out those feelers, start those conversations,” he said. “It’s not too early, especially in certain specialties, where the job market is very tight. Then, when circumstances change, be open about it and have that conversation. The worst that somebody can say is no, so it never hurts to be honest and open about where you want to go and what you want to be.”
 

Lesson #2: Chase Your Passion ‘Relentlessly’

Vance G. Fowler, MD, MHS, an infectious disease specialist at Duke University School of Medicine, runs a laboratory that researches methicillin-resistant Staphylococcus aureus (MRSA). Over the years, he’s mentored many doctors but understands the ambitions of young trainees don’t always align with the little free time that they have. “Many of them drop away when you give them a [side] project,” he said.

So when Tori Kinamon asked him to work on an MRSA project — in her first year — he gave her one that focused on researching vertebral osteomyelitis, a bone infection that can coincide with S aureus. What Dr. Fowler didn’t know: Kinamon (now MD) had been a competitive gymnast at Brown and battled her own life-threatening infection with MRSA.

“To my absolute astonishment, not only did she stick to it, but she was able to compile a presentation on the science and gave an oral presentation within a year of walking in the door,” said Dr. Fowler.

She went on to lead an initiative between the National Institutes of Health and US Food and Drug Administration to create endpoints for clinical drug trials, all of which occurred before starting her residency, which she’s about to embark upon.

Dr. Kinamon’s a good example, he said, of what happens when you add genuine passion to book smarts. Those who do always stand out because you can’t fake that. “Find your passion, and then chase it down relentlessly,” he said. “Once you’ve found your passion, things get easy because it stops being work and it starts being something else.”

If you haven’t identified a focus area, Dr. Fowler said to “be agnostic and observant. Keep your eyes open and your options open because you may surprise yourself. It may turn out that you end up liking something a whole lot more than you thought you did.”
 

Lesson #3: When You Say You’ve Always Wanted to Do Something, Do Something

As the chief of pulmonary and critical care medicine at the Northwestern Medicine Canning Thoracic Institute, Scott Budinger, MD, often hears lip service from doctors who want to put their skills to use in their local communities. One of his students actually did it. 

Justin Fiala, MD, a pulmonary, critical care, and sleep specialist at Northwestern Medicine, joined Northwestern as a pulmonary fellow with a big interest in addressing health equity issues.

Dr. Fiala began volunteering with CommunityHealth during his fellowship and saw that many patients of the free Chicago-area clinic needed help with sleep disorders. He launched the organization’s first sleep clinic and its Patient-Centered Apnea Protocols Initiative.

“He developed a plan with some of the partners of the sleep apnea equipment to do home sleep testing for these patients that’s free of cost,” said Dr. Budinger.

Dr. Fiala goes in on Saturdays and runs a free clinic conducting sleep studies for patients and outfits them with devices that they need to improve their conditions, said Dr. Budinger.

“And these patients are the severest of the severe patients,” he said. “These are people that have severe sleep apnea that are driving around the roads, oftentimes don’t have insurance because they’re also precluded from having auto insurance. So, this is really something that not just benefits these patients but benefits our whole community.”

The fact that Dr. Fiala followed through on something that all doctors aspire to do — and in the middle of a very busy training program — is something that Dr. Budinger said makes him stand out in a big way.

“If you talk to any of our trainees or young faculty, everybody’s interested in addressing the issue of health disparities,” said Dr. Budinger. “Justin looked at that and said, ‘Well, you know, I’m not interested in talking about it. What can I do about this problem? And how can I actually get boots on the ground and help?’ That requires a big activation energy that many people don’t have.”
 

Lesson #4: Be a People-Person and a Patient-Person

When hiring employees at American Family Care in Portland, Oregon, Andrew Miller, MD, director of provider training, is always on the lookout for young MDs with emotional intelligence and a good bedside manner. He has been recently blown away, however, by a young physician’s assistant named Joseph Van Bindsbergen, PA-C, who was described as “all-around wonderful” during his reference check.

“Having less than 6 months of experience out of school, he is our highest ranked provider, whether it’s a nurse practitioner, PA, or doctor, in terms of patient satisfaction,” said Dr. Miller. The young PA has an “unprecedented perfect score” on his NPS rating.

Why? Patients said they’ve never felt as heard as they felt with Van Bindsbergen.

“That’s the thing I think that the up-and-coming providers should be focusing on is making your patients feel heard,” explained Dr. Miller. Van Bindsbergen is great at building rapport with a patient, whether they are 6 or 96. “He doesn’t just ask about sore throat symptoms. He asks, ‘what is the impact on your life of the sore throat? How does it affect your family or your work? What do you think this could be besides just strep? What are your concerns?’ ”

Dr. Miller said the magic of Van Bindsbergen is that he has an innate ability to look at patients “not just as a diagnosis but as a person, which they love.”
 

Lesson #5: Remember to Make That Difference With Each Patient

Doctors are used to swooping in and seeing a patient, ordering further testing if needed, and then moving on to the next patient. But one young intern at the start of his medical career broke this mold by giving a very anxious patient some much-needed support.

“There was a resident who was working overnight, and this poor young woman came in who had a new diagnosis of an advanced illness and a lot of anxiety around her condition, the newness of it, and the impact this is going to have on her family and her life,” said Elizabeth Horn Prsic, MD, assistant professor at Yale School of Medicine and firm chief for medical oncology and the director of Adult Inpatient Palliative Care.

Dr. Prsic found out the next morning that this trainee accompanied the patient to the MRI and held her hand as much as he was allowed to throughout the entire experience. “I was like, ‘wait you went down with her to radiology?’ And he’s like, ‘Yes, I was there the whole time,’ ” she recalled.

This gesture not only helped the patient feel calmer after receiving a potentially life-altering diagnosis but also helped ensure the test results were as clear as possible.

“If the study is not done well and a patient is moving or uncomfortable, it has to be stopped early or paused,” said Dr. Prsic. “Then the study is not very useful. In situations like these, medical decisions may be made based on imperfect data. The fact that we had this full complete good quality scan helped us get the care that she needed in a much timelier manner to help her and to move along the care that she that was medically appropriate for her.”

Dr. Prsic got emotional reflecting on the experience. Working at Yale, she saw a ton of intelligent doctors come through the ranks. But this gesture, she said, should serve as a reminder that “you don’t need to be the smartest person in the room to just be there for a patient. It was pure empathic presence and human connection. It gave me hope in the next generation of physicians.”
 

A version of this article appeared on Medscape.com.

Safe to say that anyone undertaking the physician journey does so with intense motivation and book smarts. Still, it can be incredibly hard to stand out. Everyone’s a go-getter, but what’s the X factor?

We asked five veteran doctors who have supervised scores of young medical professionals over the years to tell us about that one person who impressed the hell out of them — what they did, why it made them game changers, and what every doctor can learn from them. Here’s what they said ...
 

Lesson #1: Never Be Scared to Ask

Brien Barnewolt, MD, chairman and chief of the Department of Emergency Medicine at Tufts Medical Center, was very much surprised when a resident named Scott G. Weiner did something unexpected: Go after a job in the fall of his junior year residency instead of following the typical senior year trajectory.

“It’s very unusual for a trainee to apply for a job virtually a year ahead of schedule. But he knew what he wanted,” said Dr. Barnewolt. “I’d never had anybody come to me in that same scenario, and I’ve been doing this a long time.”

Under normal circumstances it would’ve been easy for Dr. Barnewolt to say no. But the unexpected request made him and his colleagues take a closer look, and they were impressed with Dr. Weiner’s skills. That, paired with his ambition and demeanor, compelled them to offer him an early job. But there’s more.

As the next year approached, Dr. Weiner explained he had an opportunity to work in emergency medicine in Tuscany and asked if he could take a 1-year delayed start for the position he applied a year early for.

The department held his position, and upon his return, Dr. Weiner made a lasting impact at Tufts before eventually moving on. “He outgrew us, which is nice to see,” Dr. Barnewolt said. (Dr. Weiner is currently McGraw Distinguished Chair in Emergency Medicine at Brigham and Women’s Hospital and associate professor at Harvard Medical School.)

Bottom line: Why did Dr. Barnewolt and his colleagues do so much to accommodate a young candidate? Yes, Dr. Weiner was talented, but he was also up-front about his ambitions from the get-go. Dr. Barnewolt said that kind of initiative can only be looked at positively.

“My advice would be, if you see an opportunity or a potential place where you might want to work, put out those feelers, start those conversations,” he said. “It’s not too early, especially in certain specialties, where the job market is very tight. Then, when circumstances change, be open about it and have that conversation. The worst that somebody can say is no, so it never hurts to be honest and open about where you want to go and what you want to be.”
 

Lesson #2: Chase Your Passion ‘Relentlessly’

Vance G. Fowler, MD, MHS, an infectious disease specialist at Duke University School of Medicine, runs a laboratory that researches methicillin-resistant Staphylococcus aureus (MRSA). Over the years, he’s mentored many doctors but understands the ambitions of young trainees don’t always align with the little free time that they have. “Many of them drop away when you give them a [side] project,” he said.

So when Tori Kinamon asked him to work on an MRSA project — in her first year — he gave her one that focused on researching vertebral osteomyelitis, a bone infection that can coincide with S aureus. What Dr. Fowler didn’t know: Kinamon (now MD) had been a competitive gymnast at Brown and battled her own life-threatening infection with MRSA.

“To my absolute astonishment, not only did she stick to it, but she was able to compile a presentation on the science and gave an oral presentation within a year of walking in the door,” said Dr. Fowler.

She went on to lead an initiative between the National Institutes of Health and US Food and Drug Administration to create endpoints for clinical drug trials, all of which occurred before starting her residency, which she’s about to embark upon.

Dr. Kinamon’s a good example, he said, of what happens when you add genuine passion to book smarts. Those who do always stand out because you can’t fake that. “Find your passion, and then chase it down relentlessly,” he said. “Once you’ve found your passion, things get easy because it stops being work and it starts being something else.”

If you haven’t identified a focus area, Dr. Fowler said to “be agnostic and observant. Keep your eyes open and your options open because you may surprise yourself. It may turn out that you end up liking something a whole lot more than you thought you did.”
 

Lesson #3: When You Say You’ve Always Wanted to Do Something, Do Something

As the chief of pulmonary and critical care medicine at the Northwestern Medicine Canning Thoracic Institute, Scott Budinger, MD, often hears lip service from doctors who want to put their skills to use in their local communities. One of his students actually did it. 

Justin Fiala, MD, a pulmonary, critical care, and sleep specialist at Northwestern Medicine, joined Northwestern as a pulmonary fellow with a big interest in addressing health equity issues.

Dr. Fiala began volunteering with CommunityHealth during his fellowship and saw that many patients of the free Chicago-area clinic needed help with sleep disorders. He launched the organization’s first sleep clinic and its Patient-Centered Apnea Protocols Initiative.

“He developed a plan with some of the partners of the sleep apnea equipment to do home sleep testing for these patients that’s free of cost,” said Dr. Budinger.

Dr. Fiala goes in on Saturdays and runs a free clinic conducting sleep studies for patients and outfits them with devices that they need to improve their conditions, said Dr. Budinger.

“And these patients are the severest of the severe patients,” he said. “These are people that have severe sleep apnea that are driving around the roads, oftentimes don’t have insurance because they’re also precluded from having auto insurance. So, this is really something that not just benefits these patients but benefits our whole community.”

The fact that Dr. Fiala followed through on something that all doctors aspire to do — and in the middle of a very busy training program — is something that Dr. Budinger said makes him stand out in a big way.

“If you talk to any of our trainees or young faculty, everybody’s interested in addressing the issue of health disparities,” said Dr. Budinger. “Justin looked at that and said, ‘Well, you know, I’m not interested in talking about it. What can I do about this problem? And how can I actually get boots on the ground and help?’ That requires a big activation energy that many people don’t have.”
 

Lesson #4: Be a People-Person and a Patient-Person

When hiring employees at American Family Care in Portland, Oregon, Andrew Miller, MD, director of provider training, is always on the lookout for young MDs with emotional intelligence and a good bedside manner. He has been recently blown away, however, by a young physician’s assistant named Joseph Van Bindsbergen, PA-C, who was described as “all-around wonderful” during his reference check.

“Having less than 6 months of experience out of school, he is our highest ranked provider, whether it’s a nurse practitioner, PA, or doctor, in terms of patient satisfaction,” said Dr. Miller. The young PA has an “unprecedented perfect score” on his NPS rating.

Why? Patients said they’ve never felt as heard as they felt with Van Bindsbergen.

“That’s the thing I think that the up-and-coming providers should be focusing on is making your patients feel heard,” explained Dr. Miller. Van Bindsbergen is great at building rapport with a patient, whether they are 6 or 96. “He doesn’t just ask about sore throat symptoms. He asks, ‘what is the impact on your life of the sore throat? How does it affect your family or your work? What do you think this could be besides just strep? What are your concerns?’ ”

Dr. Miller said the magic of Van Bindsbergen is that he has an innate ability to look at patients “not just as a diagnosis but as a person, which they love.”
 

Lesson #5: Remember to Make That Difference With Each Patient

Doctors are used to swooping in and seeing a patient, ordering further testing if needed, and then moving on to the next patient. But one young intern at the start of his medical career broke this mold by giving a very anxious patient some much-needed support.

“There was a resident who was working overnight, and this poor young woman came in who had a new diagnosis of an advanced illness and a lot of anxiety around her condition, the newness of it, and the impact this is going to have on her family and her life,” said Elizabeth Horn Prsic, MD, assistant professor at Yale School of Medicine and firm chief for medical oncology and the director of Adult Inpatient Palliative Care.

Dr. Prsic found out the next morning that this trainee accompanied the patient to the MRI and held her hand as much as he was allowed to throughout the entire experience. “I was like, ‘wait you went down with her to radiology?’ And he’s like, ‘Yes, I was there the whole time,’ ” she recalled.

This gesture not only helped the patient feel calmer after receiving a potentially life-altering diagnosis but also helped ensure the test results were as clear as possible.

“If the study is not done well and a patient is moving or uncomfortable, it has to be stopped early or paused,” said Dr. Prsic. “Then the study is not very useful. In situations like these, medical decisions may be made based on imperfect data. The fact that we had this full complete good quality scan helped us get the care that she needed in a much timelier manner to help her and to move along the care that she that was medically appropriate for her.”

Dr. Prsic got emotional reflecting on the experience. Working at Yale, she saw a ton of intelligent doctors come through the ranks. But this gesture, she said, should serve as a reminder that “you don’t need to be the smartest person in the room to just be there for a patient. It was pure empathic presence and human connection. It gave me hope in the next generation of physicians.”
 

A version of this article appeared on Medscape.com.

Safe to say that anyone undertaking the physician journey does so with intense motivation and book smarts. Still, it can be incredibly hard to stand out. Everyone’s a go-getter, but what’s the X factor?

We asked five veteran doctors who have supervised scores of young medical professionals over the years to tell us about that one person who impressed the hell out of them — what they did, why it made them game changers, and what every doctor can learn from them. Here’s what they said ...
 

Lesson #1: Never Be Scared to Ask

Brien Barnewolt, MD, chairman and chief of the Department of Emergency Medicine at Tufts Medical Center, was very much surprised when a resident named Scott G. Weiner did something unexpected: Go after a job in the fall of his junior year residency instead of following the typical senior year trajectory.

“It’s very unusual for a trainee to apply for a job virtually a year ahead of schedule. But he knew what he wanted,” said Dr. Barnewolt. “I’d never had anybody come to me in that same scenario, and I’ve been doing this a long time.”

Under normal circumstances it would’ve been easy for Dr. Barnewolt to say no. But the unexpected request made him and his colleagues take a closer look, and they were impressed with Dr. Weiner’s skills. That, paired with his ambition and demeanor, compelled them to offer him an early job. But there’s more.

As the next year approached, Dr. Weiner explained he had an opportunity to work in emergency medicine in Tuscany and asked if he could take a 1-year delayed start for the position he applied a year early for.

The department held his position, and upon his return, Dr. Weiner made a lasting impact at Tufts before eventually moving on. “He outgrew us, which is nice to see,” Dr. Barnewolt said. (Dr. Weiner is currently McGraw Distinguished Chair in Emergency Medicine at Brigham and Women’s Hospital and associate professor at Harvard Medical School.)

Bottom line: Why did Dr. Barnewolt and his colleagues do so much to accommodate a young candidate? Yes, Dr. Weiner was talented, but he was also up-front about his ambitions from the get-go. Dr. Barnewolt said that kind of initiative can only be looked at positively.

“My advice would be, if you see an opportunity or a potential place where you might want to work, put out those feelers, start those conversations,” he said. “It’s not too early, especially in certain specialties, where the job market is very tight. Then, when circumstances change, be open about it and have that conversation. The worst that somebody can say is no, so it never hurts to be honest and open about where you want to go and what you want to be.”
 

Lesson #2: Chase Your Passion ‘Relentlessly’

Vance G. Fowler, MD, MHS, an infectious disease specialist at Duke University School of Medicine, runs a laboratory that researches methicillin-resistant Staphylococcus aureus (MRSA). Over the years, he’s mentored many doctors but understands the ambitions of young trainees don’t always align with the little free time that they have. “Many of them drop away when you give them a [side] project,” he said.

So when Tori Kinamon asked him to work on an MRSA project — in her first year — he gave her one that focused on researching vertebral osteomyelitis, a bone infection that can coincide with S aureus. What Dr. Fowler didn’t know: Kinamon (now MD) had been a competitive gymnast at Brown and battled her own life-threatening infection with MRSA.

“To my absolute astonishment, not only did she stick to it, but she was able to compile a presentation on the science and gave an oral presentation within a year of walking in the door,” said Dr. Fowler.

She went on to lead an initiative between the National Institutes of Health and US Food and Drug Administration to create endpoints for clinical drug trials, all of which occurred before starting her residency, which she’s about to embark upon.

Dr. Kinamon’s a good example, he said, of what happens when you add genuine passion to book smarts. Those who do always stand out because you can’t fake that. “Find your passion, and then chase it down relentlessly,” he said. “Once you’ve found your passion, things get easy because it stops being work and it starts being something else.”

If you haven’t identified a focus area, Dr. Fowler said to “be agnostic and observant. Keep your eyes open and your options open because you may surprise yourself. It may turn out that you end up liking something a whole lot more than you thought you did.”
 

Lesson #3: When You Say You’ve Always Wanted to Do Something, Do Something

As the chief of pulmonary and critical care medicine at the Northwestern Medicine Canning Thoracic Institute, Scott Budinger, MD, often hears lip service from doctors who want to put their skills to use in their local communities. One of his students actually did it. 

Justin Fiala, MD, a pulmonary, critical care, and sleep specialist at Northwestern Medicine, joined Northwestern as a pulmonary fellow with a big interest in addressing health equity issues.

Dr. Fiala began volunteering with CommunityHealth during his fellowship and saw that many patients of the free Chicago-area clinic needed help with sleep disorders. He launched the organization’s first sleep clinic and its Patient-Centered Apnea Protocols Initiative.

“He developed a plan with some of the partners of the sleep apnea equipment to do home sleep testing for these patients that’s free of cost,” said Dr. Budinger.

Dr. Fiala goes in on Saturdays and runs a free clinic conducting sleep studies for patients and outfits them with devices that they need to improve their conditions, said Dr. Budinger.

“And these patients are the severest of the severe patients,” he said. “These are people that have severe sleep apnea that are driving around the roads, oftentimes don’t have insurance because they’re also precluded from having auto insurance. So, this is really something that not just benefits these patients but benefits our whole community.”

The fact that Dr. Fiala followed through on something that all doctors aspire to do — and in the middle of a very busy training program — is something that Dr. Budinger said makes him stand out in a big way.

“If you talk to any of our trainees or young faculty, everybody’s interested in addressing the issue of health disparities,” said Dr. Budinger. “Justin looked at that and said, ‘Well, you know, I’m not interested in talking about it. What can I do about this problem? And how can I actually get boots on the ground and help?’ That requires a big activation energy that many people don’t have.”
 

Lesson #4: Be a People-Person and a Patient-Person

When hiring employees at American Family Care in Portland, Oregon, Andrew Miller, MD, director of provider training, is always on the lookout for young MDs with emotional intelligence and a good bedside manner. He has been recently blown away, however, by a young physician’s assistant named Joseph Van Bindsbergen, PA-C, who was described as “all-around wonderful” during his reference check.

“Having less than 6 months of experience out of school, he is our highest ranked provider, whether it’s a nurse practitioner, PA, or doctor, in terms of patient satisfaction,” said Dr. Miller. The young PA has an “unprecedented perfect score” on his NPS rating.

Why? Patients said they’ve never felt as heard as they felt with Van Bindsbergen.

“That’s the thing I think that the up-and-coming providers should be focusing on is making your patients feel heard,” explained Dr. Miller. Van Bindsbergen is great at building rapport with a patient, whether they are 6 or 96. “He doesn’t just ask about sore throat symptoms. He asks, ‘what is the impact on your life of the sore throat? How does it affect your family or your work? What do you think this could be besides just strep? What are your concerns?’ ”

Dr. Miller said the magic of Van Bindsbergen is that he has an innate ability to look at patients “not just as a diagnosis but as a person, which they love.”
 

Lesson #5: Remember to Make That Difference With Each Patient

Doctors are used to swooping in and seeing a patient, ordering further testing if needed, and then moving on to the next patient. But one young intern at the start of his medical career broke this mold by giving a very anxious patient some much-needed support.

“There was a resident who was working overnight, and this poor young woman came in who had a new diagnosis of an advanced illness and a lot of anxiety around her condition, the newness of it, and the impact this is going to have on her family and her life,” said Elizabeth Horn Prsic, MD, assistant professor at Yale School of Medicine and firm chief for medical oncology and the director of Adult Inpatient Palliative Care.

Dr. Prsic found out the next morning that this trainee accompanied the patient to the MRI and held her hand as much as he was allowed to throughout the entire experience. “I was like, ‘wait you went down with her to radiology?’ And he’s like, ‘Yes, I was there the whole time,’ ” she recalled.

This gesture not only helped the patient feel calmer after receiving a potentially life-altering diagnosis but also helped ensure the test results were as clear as possible.

“If the study is not done well and a patient is moving or uncomfortable, it has to be stopped early or paused,” said Dr. Prsic. “Then the study is not very useful. In situations like these, medical decisions may be made based on imperfect data. The fact that we had this full complete good quality scan helped us get the care that she needed in a much timelier manner to help her and to move along the care that she that was medically appropriate for her.”

Dr. Prsic got emotional reflecting on the experience. Working at Yale, she saw a ton of intelligent doctors come through the ranks. But this gesture, she said, should serve as a reminder that “you don’t need to be the smartest person in the room to just be there for a patient. It was pure empathic presence and human connection. It gave me hope in the next generation of physicians.”
 

A version of this article appeared on Medscape.com.

Key clinical point: Specific behavioral patterns of attention-deficit/hyperactivity disorder, such as impulsivity and hyperactivity, were associated with the development of prurigo nodularis (PN) in children with atopic dermatitis (AD), regardless of AD severity.

Major finding: Among children with AD, the impulsivity/hyperactivity score was significantly higher in those with vs without PN (5.5 ± 4.2 vs 2.9 ± 2.9; P = .038); no significant differences were observed in Eczema Area Severity Index scores, itch numeric rating scale scores, or other AD outcomes in children with vs without PN (P > .05).

Study details: This cross-sectional study included 39 children with AD who did (n = 21) or did not (n = 18) have PN.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Kim Y, Lee J, Shin K, et al. Association between prurigo nodularis and behavioural patterns of attention-deficit/hyperactivity disorder in children with atopic dermatitis: A cross-sectional study. J Eur Acad Dermatol Venereol. 2024(Mar 27). doi: 10.1111/jdv.19967  Source

Key clinical point: Specific behavioral patterns of attention-deficit/hyperactivity disorder, such as impulsivity and hyperactivity, were associated with the development of prurigo nodularis (PN) in children with atopic dermatitis (AD), regardless of AD severity.

Major finding: Among children with AD, the impulsivity/hyperactivity score was significantly higher in those with vs without PN (5.5 ± 4.2 vs 2.9 ± 2.9; P = .038); no significant differences were observed in Eczema Area Severity Index scores, itch numeric rating scale scores, or other AD outcomes in children with vs without PN (P > .05).

Study details: This cross-sectional study included 39 children with AD who did (n = 21) or did not (n = 18) have PN.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Kim Y, Lee J, Shin K, et al. Association between prurigo nodularis and behavioural patterns of attention-deficit/hyperactivity disorder in children with atopic dermatitis: A cross-sectional study. J Eur Acad Dermatol Venereol. 2024(Mar 27). doi: 10.1111/jdv.19967  Source

Key clinical point: Specific behavioral patterns of attention-deficit/hyperactivity disorder, such as impulsivity and hyperactivity, were associated with the development of prurigo nodularis (PN) in children with atopic dermatitis (AD), regardless of AD severity.

Major finding: Among children with AD, the impulsivity/hyperactivity score was significantly higher in those with vs without PN (5.5 ± 4.2 vs 2.9 ± 2.9; P = .038); no significant differences were observed in Eczema Area Severity Index scores, itch numeric rating scale scores, or other AD outcomes in children with vs without PN (P > .05).

Study details: This cross-sectional study included 39 children with AD who did (n = 21) or did not (n = 18) have PN.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Kim Y, Lee J, Shin K, et al. Association between prurigo nodularis and behavioural patterns of attention-deficit/hyperactivity disorder in children with atopic dermatitis: A cross-sectional study. J Eur Acad Dermatol Venereol. 2024(Mar 27). doi: 10.1111/jdv.19967  Source

Key clinical point: Upadacitinib treatment rapidly and sustainably improved multiple patient-reported outcomes, including itch, in adults and adolescents with moderate to severe atopic dermatitis (AD).

Major finding: At week 1, more than 10% and 15% of patients receiving 15 and 30 mg upadacitinib, respectively, experienced improvements in itch; thereafter, response rates increased steadily and sustainably through week 52. Similar improvements were observed for pain and other skin symptoms.

Study details: This pooled analysis included 1609 adults and adolescents with moderate to severe AD from the phase 3 Measure Up 1 and Measure Up 2 studies who had received upadacitinib (15 mg n = 557; 30 mg n = 567) or placebo (followed by upadacitinib 15 or 30 mg after 16 weeks; n = 485).

Disclosures: This study was funded by AbbVie, Inc. Eight authors declared being employees of or holding stock or stock options in AbbVie. The other authors declared serving as speakers for, receiving consulting fees, or having other ties with various sources, including AbbVie.

Source: Silverberg JI, Gooderham MJ, Paller AS, et al. Early and sustained improvements in symptoms and quality of life with upadacitinib in adults and adolescents with moderate-to-severe atopic dermatitis: 52-week results from two phase III randomized clinical trials (Measure Up 1 and Measure Up 2). Am J Clin Dermatol. 2024 (Mar 25). doi: 10.1007/s40257-024-00853-4 Source

Key clinical point: Upadacitinib treatment rapidly and sustainably improved multiple patient-reported outcomes, including itch, in adults and adolescents with moderate to severe atopic dermatitis (AD).

Major finding: At week 1, more than 10% and 15% of patients receiving 15 and 30 mg upadacitinib, respectively, experienced improvements in itch; thereafter, response rates increased steadily and sustainably through week 52. Similar improvements were observed for pain and other skin symptoms.

Study details: This pooled analysis included 1609 adults and adolescents with moderate to severe AD from the phase 3 Measure Up 1 and Measure Up 2 studies who had received upadacitinib (15 mg n = 557; 30 mg n = 567) or placebo (followed by upadacitinib 15 or 30 mg after 16 weeks; n = 485).

Disclosures: This study was funded by AbbVie, Inc. Eight authors declared being employees of or holding stock or stock options in AbbVie. The other authors declared serving as speakers for, receiving consulting fees, or having other ties with various sources, including AbbVie.

Source: Silverberg JI, Gooderham MJ, Paller AS, et al. Early and sustained improvements in symptoms and quality of life with upadacitinib in adults and adolescents with moderate-to-severe atopic dermatitis: 52-week results from two phase III randomized clinical trials (Measure Up 1 and Measure Up 2). Am J Clin Dermatol. 2024 (Mar 25). doi: 10.1007/s40257-024-00853-4 Source

Key clinical point: Upadacitinib treatment rapidly and sustainably improved multiple patient-reported outcomes, including itch, in adults and adolescents with moderate to severe atopic dermatitis (AD).

Major finding: At week 1, more than 10% and 15% of patients receiving 15 and 30 mg upadacitinib, respectively, experienced improvements in itch; thereafter, response rates increased steadily and sustainably through week 52. Similar improvements were observed for pain and other skin symptoms.

Study details: This pooled analysis included 1609 adults and adolescents with moderate to severe AD from the phase 3 Measure Up 1 and Measure Up 2 studies who had received upadacitinib (15 mg n = 557; 30 mg n = 567) or placebo (followed by upadacitinib 15 or 30 mg after 16 weeks; n = 485).

Disclosures: This study was funded by AbbVie, Inc. Eight authors declared being employees of or holding stock or stock options in AbbVie. The other authors declared serving as speakers for, receiving consulting fees, or having other ties with various sources, including AbbVie.

Source: Silverberg JI, Gooderham MJ, Paller AS, et al. Early and sustained improvements in symptoms and quality of life with upadacitinib in adults and adolescents with moderate-to-severe atopic dermatitis: 52-week results from two phase III randomized clinical trials (Measure Up 1 and Measure Up 2). Am J Clin Dermatol. 2024 (Mar 25). doi: 10.1007/s40257-024-00853-4 Source

Key clinical point: Patients with atopic dermatitis (AD) treated with dupilumab have an increased risk for cutaneous T-cell lymphoma (CTCL) compared with those not treated with dupilumab.

Major finding: Patients with AD who did vs did not receive dupilumab had a significantly higher risk of developing CTCL (odds ratio [OR] 4.1003; 95% CI 2.055-8.192). The risk for CTCL persisted in those with no prior exposure to disease-modifying antirheumatic drugs (OR 3.202; 95% CI 1.573-6.514).

Study details: This retrospective cohort study included patients with AD who did (n = 22,888) or did not (n = 22,871) receive dupilumab treatment and did not have a preexisting diagnosis for CTCL, Hodgkin lymphoma, non-Hodgkin lymphoma, nonfollicular lymphoma, leukemia, malignant melanoma, squamous cell carcinoma, or basal cell carcinoma.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Hasan I, Parsons L, Duran S, Zinn Z. Dupilumab therapy for atopic dermatitis is associated with increased risk of cutaneous T cell lymphoma: A retrospective cohort study. J Am Acad Dermatol. 2024 (Apr 6). doi: 10.1016/j.jaad.2024.03.039 Source

Key clinical point: Patients with atopic dermatitis (AD) treated with dupilumab have an increased risk for cutaneous T-cell lymphoma (CTCL) compared with those not treated with dupilumab.

Major finding: Patients with AD who did vs did not receive dupilumab had a significantly higher risk of developing CTCL (odds ratio [OR] 4.1003; 95% CI 2.055-8.192). The risk for CTCL persisted in those with no prior exposure to disease-modifying antirheumatic drugs (OR 3.202; 95% CI 1.573-6.514).

Study details: This retrospective cohort study included patients with AD who did (n = 22,888) or did not (n = 22,871) receive dupilumab treatment and did not have a preexisting diagnosis for CTCL, Hodgkin lymphoma, non-Hodgkin lymphoma, nonfollicular lymphoma, leukemia, malignant melanoma, squamous cell carcinoma, or basal cell carcinoma.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Hasan I, Parsons L, Duran S, Zinn Z. Dupilumab therapy for atopic dermatitis is associated with increased risk of cutaneous T cell lymphoma: A retrospective cohort study. J Am Acad Dermatol. 2024 (Apr 6). doi: 10.1016/j.jaad.2024.03.039 Source

Key clinical point: Patients with atopic dermatitis (AD) treated with dupilumab have an increased risk for cutaneous T-cell lymphoma (CTCL) compared with those not treated with dupilumab.

Major finding: Patients with AD who did vs did not receive dupilumab had a significantly higher risk of developing CTCL (odds ratio [OR] 4.1003; 95% CI 2.055-8.192). The risk for CTCL persisted in those with no prior exposure to disease-modifying antirheumatic drugs (OR 3.202; 95% CI 1.573-6.514).

Study details: This retrospective cohort study included patients with AD who did (n = 22,888) or did not (n = 22,871) receive dupilumab treatment and did not have a preexisting diagnosis for CTCL, Hodgkin lymphoma, non-Hodgkin lymphoma, nonfollicular lymphoma, leukemia, malignant melanoma, squamous cell carcinoma, or basal cell carcinoma.

Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.

Source: Hasan I, Parsons L, Duran S, Zinn Z. Dupilumab therapy for atopic dermatitis is associated with increased risk of cutaneous T cell lymphoma: A retrospective cohort study. J Am Acad Dermatol. 2024 (Apr 6). doi: 10.1016/j.jaad.2024.03.039 Source

Key clinical point: Established and new atopic dermatitis (AD)-associated filaggrin loss-of-function variants are associated with increased risks for clinical AD outcomes and disruption of skin barrier integrity in lesional and nonlesional skin of children with AD.

Major finding: Twenty variants were identified, including one novel variant. The presence of one or more variants was associated with a higher risk for moderate or severe AD vs mild AD (odds ratio 2.00; corrected P = .0394), a higher Scoring AD score (corrected P = .0394), and transepidermal water loss in both lesional (P = .018) and nonlesional (P = .015) skin.

Study details: This study included 438 children with AD (age ≤ 2 years; gestation period ≥ 36 weeks) from the early-life Mechanisms of Progression of Atopic Dermatitis to Asthma in Children cohort without a comorbid lung condition or dependence on immunosuppression or oral steroids for a condition except asthma.

Disclosures: This study was funded by the US National Institutes of Health. Matthew S. Hestand declared being an employee and shareholder of Pacific Biosciences. The other authors declared no conflicts of interest.

Source: Virolainen SJ, Satish L, Biagini JM, et al. Filaggrin loss-of-function variants are associated with atopic dermatitis phenotypes in a diverse, early life prospective cohort. JCI Insight. 2024 (Apr 2). doi: 10.1172/jci.insight.178258 Source

Key clinical point: Established and new atopic dermatitis (AD)-associated filaggrin loss-of-function variants are associated with increased risks for clinical AD outcomes and disruption of skin barrier integrity in lesional and nonlesional skin of children with AD.

Major finding: Twenty variants were identified, including one novel variant. The presence of one or more variants was associated with a higher risk for moderate or severe AD vs mild AD (odds ratio 2.00; corrected P = .0394), a higher Scoring AD score (corrected P = .0394), and transepidermal water loss in both lesional (P = .018) and nonlesional (P = .015) skin.

Study details: This study included 438 children with AD (age ≤ 2 years; gestation period ≥ 36 weeks) from the early-life Mechanisms of Progression of Atopic Dermatitis to Asthma in Children cohort without a comorbid lung condition or dependence on immunosuppression or oral steroids for a condition except asthma.

Disclosures: This study was funded by the US National Institutes of Health. Matthew S. Hestand declared being an employee and shareholder of Pacific Biosciences. The other authors declared no conflicts of interest.

Source: Virolainen SJ, Satish L, Biagini JM, et al. Filaggrin loss-of-function variants are associated with atopic dermatitis phenotypes in a diverse, early life prospective cohort. JCI Insight. 2024 (Apr 2). doi: 10.1172/jci.insight.178258 Source

Key clinical point: Established and new atopic dermatitis (AD)-associated filaggrin loss-of-function variants are associated with increased risks for clinical AD outcomes and disruption of skin barrier integrity in lesional and nonlesional skin of children with AD.

Major finding: Twenty variants were identified, including one novel variant. The presence of one or more variants was associated with a higher risk for moderate or severe AD vs mild AD (odds ratio 2.00; corrected P = .0394), a higher Scoring AD score (corrected P = .0394), and transepidermal water loss in both lesional (P = .018) and nonlesional (P = .015) skin.

Study details: This study included 438 children with AD (age ≤ 2 years; gestation period ≥ 36 weeks) from the early-life Mechanisms of Progression of Atopic Dermatitis to Asthma in Children cohort without a comorbid lung condition or dependence on immunosuppression or oral steroids for a condition except asthma.

Disclosures: This study was funded by the US National Institutes of Health. Matthew S. Hestand declared being an employee and shareholder of Pacific Biosciences. The other authors declared no conflicts of interest.

Source: Virolainen SJ, Satish L, Biagini JM, et al. Filaggrin loss-of-function variants are associated with atopic dermatitis phenotypes in a diverse, early life prospective cohort. JCI Insight. 2024 (Apr 2). doi: 10.1172/jci.insight.178258 Source