Article

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.

Background

Integrative health (IH) combines conventional and complementary medicine in a coordinated, evidence-based approach to treat the whole person. Nearly 40% of American adults have used complementary health approaches,¹ yet IH exposure in medical training is limited. In 2022, the San Francisco VA Health Care Center launched a multidisciplinary clinical IH elective for University of California San Francisco (UCSF) internal medicine and SFVA nurse practitioner residents. Based on findings from a general and targeted needs assessment, including faculty and learner feedback, we found that the elective was well-received, but relied on one-on-one patient-based teaching. This structure created variable learning experiences and high faculty burden. Our project aims to formalize and evaluate the IH elective curriculum to better address the needs of both faculty and learners.

Methods

We used Kern’s six-step framework for curriculum development. To reduce variability, we sought to formalize the core curricular content by: 1) reviewing existing elective components, comparing them to similar curricula nationwide, and outlining foundational knowledge based on the exam domains of the American Board of Integrative Medicine (ABOIM);² 2) creating eleven learning objectives across three themes: patient-centered care, systems-based practice, and IH-specific knowledge; 3) developing IH subspecialty experience guides to standardize clinical teaching with suggested takeaways, guided reflection, and curated resources. To reduce faculty burden, we consolidated elective resources into a centralized e-learning hub. Trainees complete a pre/post self-assessment and evaluation at the end of the elective.

Results

We identified key learning opportunities in each IH shadowing experience to enhance learners’ knowledge. We developed an IH e-Learning Hub to provide easy access to elective materials and IH clinical tools. Evaluations from the first two learners who completed the elective indicate that the learning objectives were met and that learners gained increased knowledge of lifestyle medicine, mind-body medicine, manual medicine, and botanicals/dietary supplements. Learners valued increased IH subspecialty familiarity and reported high likelihood of future practice change.

Discussion

The project is ongoing. Next steps include collecting faculty evaluations about their experience, continuing to create and refine experience guides, promoting clinical tools for learner’s future practice, and developing strategies to recruit more learners to the elective.

Background

Among people who use drugs (PWUD), harm reduction (HR) is an evidence-based low barrier approach to mitigating ongoing substance use risks and is considered a key pillar of the Department of Health and Human Service’s Overdose Prevention Strategy.¹ Given the accessibility and continuity, primary care (PC) clinics are optimal sites for education about and provision of HR services.^2,3

Aim

1. Determining the impact of active and passive methods for HR supply.
2. Recognizing the importance of clinician addiction education in the provision of HR services.

Methods

In January 2024, physician and nurse practitioner trainees in the West Haven Veterans Affairs (VA) Center of Education (CoE) in Interprofessional Primary Care received addiction care and HR strategy education. Initially, all patients presenting to the CoE completed a single-item substance use screening. Patients screening positive were offered HR supplies, including fentanyl and xylazine test strips (FTS, XTS), during the encounter (active distribution). Starting October 2024, HR kiosks were implemented in the clinic lobby, offering patients self-serve access to HR supplies (passive distribution). Test strip uptake was tracked through clinical encounter documentation and weekly kiosk inventory.

Results

Between January 2024 and June 2024, 92 FTS and 84 XTS were actively distributed. Upon implementation of the harm reduction kiosk, 253 FTS and 164 XTS were distributed between October 2024 and February 2025. In the CoE, FTS and XTS distribution increased by 275% and 195%, respectively, through passive kiosk distribution relative to active distribution during clinical encounters.

Conclusions

HR kiosk implementation resulted in significantly increased test strip uptake in the CoE, proving passive distribution to be an effective low barrier method of increasing access to HR and substance use disorder (SUD) resources. Although this model may reduce stigma and logistical barriers when presenting for a healthcare encounter, it limits the ability to track and engage patients for more intensive services. While each approach has unique advantages and disadvantages, test strip demand via both methods highlights the significant need for HR resources in PC settings. Continuing education for PC clinicians on low barrier SUD care and HR is critical to optimizing care for this population.

Background

Among people who use drugs (PWUD), harm reduction (HR) is an evidence-based low barrier approach to mitigating ongoing substance use risks and is considered a key pillar of the Department of Health and Human Service’s Overdose Prevention Strategy.¹ Given the accessibility and continuity, primary care (PC) clinics are optimal sites for education about and provision of HR services.^2,3

Aim

1. Determining the impact of active and passive methods for HR supply.
2. Recognizing the importance of clinician addiction education in the provision of HR services.

Methods

In January 2024, physician and nurse practitioner trainees in the West Haven Veterans Affairs (VA) Center of Education (CoE) in Interprofessional Primary Care received addiction care and HR strategy education. Initially, all patients presenting to the CoE completed a single-item substance use screening. Patients screening positive were offered HR supplies, including fentanyl and xylazine test strips (FTS, XTS), during the encounter (active distribution). Starting October 2024, HR kiosks were implemented in the clinic lobby, offering patients self-serve access to HR supplies (passive distribution). Test strip uptake was tracked through clinical encounter documentation and weekly kiosk inventory.

Results

Between January 2024 and June 2024, 92 FTS and 84 XTS were actively distributed. Upon implementation of the harm reduction kiosk, 253 FTS and 164 XTS were distributed between October 2024 and February 2025. In the CoE, FTS and XTS distribution increased by 275% and 195%, respectively, through passive kiosk distribution relative to active distribution during clinical encounters.

Conclusions

HR kiosk implementation resulted in significantly increased test strip uptake in the CoE, proving passive distribution to be an effective low barrier method of increasing access to HR and substance use disorder (SUD) resources. Although this model may reduce stigma and logistical barriers when presenting for a healthcare encounter, it limits the ability to track and engage patients for more intensive services. While each approach has unique advantages and disadvantages, test strip demand via both methods highlights the significant need for HR resources in PC settings. Continuing education for PC clinicians on low barrier SUD care and HR is critical to optimizing care for this population.

Background

Among people who use drugs (PWUD), harm reduction (HR) is an evidence-based low barrier approach to mitigating ongoing substance use risks and is considered a key pillar of the Department of Health and Human Service’s Overdose Prevention Strategy.¹ Given the accessibility and continuity, primary care (PC) clinics are optimal sites for education about and provision of HR services.^2,3

Aim

1. Determining the impact of active and passive methods for HR supply.
2. Recognizing the importance of clinician addiction education in the provision of HR services.

Methods

In January 2024, physician and nurse practitioner trainees in the West Haven Veterans Affairs (VA) Center of Education (CoE) in Interprofessional Primary Care received addiction care and HR strategy education. Initially, all patients presenting to the CoE completed a single-item substance use screening. Patients screening positive were offered HR supplies, including fentanyl and xylazine test strips (FTS, XTS), during the encounter (active distribution). Starting October 2024, HR kiosks were implemented in the clinic lobby, offering patients self-serve access to HR supplies (passive distribution). Test strip uptake was tracked through clinical encounter documentation and weekly kiosk inventory.

Results

Between January 2024 and June 2024, 92 FTS and 84 XTS were actively distributed. Upon implementation of the harm reduction kiosk, 253 FTS and 164 XTS were distributed between October 2024 and February 2025. In the CoE, FTS and XTS distribution increased by 275% and 195%, respectively, through passive kiosk distribution relative to active distribution during clinical encounters.

Conclusions

HR kiosk implementation resulted in significantly increased test strip uptake in the CoE, proving passive distribution to be an effective low barrier method of increasing access to HR and substance use disorder (SUD) resources. Although this model may reduce stigma and logistical barriers when presenting for a healthcare encounter, it limits the ability to track and engage patients for more intensive services. While each approach has unique advantages and disadvantages, test strip demand via both methods highlights the significant need for HR resources in PC settings. Continuing education for PC clinicians on low barrier SUD care and HR is critical to optimizing care for this population.

Background

Rural women veterans often confront unique healthcare barriers—geographic isolation, gender-related stigma, and limited provider cultural sensitivity that undermine trust and engagement. In response, we co-designed an interprofessional communication curriculum to promote relational, patient-centered care grounded in psychological need support.

Innovation

Anchored in Self Determination Theory (SDT), this curriculum equips nurses and social workers with need-supportive communication strategies that nurture autonomy, competence, and relatedness, integrating two transformative learning methods for enhancing respectful and inclusive listening:

• Cultural humility reflections for veteran-centered care—personal narratives, storytelling, and power-awareness discussions to build lifelong reflective practices.
• Medical improv simulations—adaptive improvisational role plays for healthcare environments fostering presence, adaptability, empathy, trust-building, and real-time responsiveness.

Delivered via a multiday health professions learning lab, the training combines asynchronous workshops with in-person facilitated interactions. Core modules cover SDT foundations, need supportive dialogue, veteran-centered cultural humility, and shared decision-making practices that uplift rural women veterans’ voices. Using Kirkpatrick’s Four Level Model, we assess impact at multiple tiers:

1. Reaction: Participant satisfaction and perceived training relevance.
2. Learning: Pre/post assessments track SDT knowledge and communication skills gains.
3. Behavior: Observe simulations and self-reported changes in communication practices.
4. Results: Qualitative satisfaction metrics and care engagement trends among rural women veterans.

Results

A pilot cohort (N = 20) across two rural sites is pending implementation. pre/post surveys will assess any improved confidence in applying need supportive communication and the most effective component in building empathetic presence. Feedback measures will also indicate the significance of combined uses of medical improv and cultural humility on deepened relational capacity and trust.

Discussion

This program operationalizes SDT within healthcare communications, integrating cultural humility and improvisation learning modalities to enhance care quality for rural women veterans, ultimately strengthening provider-patient connections. Using health professions learning lab environments can foster sustained behavioral impacts. Future iterations will expand to additional rural VA sites, co-designing with the voices of women veterans through focus groups.

Background

Rural women veterans often confront unique healthcare barriers—geographic isolation, gender-related stigma, and limited provider cultural sensitivity that undermine trust and engagement. In response, we co-designed an interprofessional communication curriculum to promote relational, patient-centered care grounded in psychological need support.

Innovation

Anchored in Self Determination Theory (SDT), this curriculum equips nurses and social workers with need-supportive communication strategies that nurture autonomy, competence, and relatedness, integrating two transformative learning methods for enhancing respectful and inclusive listening:

• Cultural humility reflections for veteran-centered care—personal narratives, storytelling, and power-awareness discussions to build lifelong reflective practices.
• Medical improv simulations—adaptive improvisational role plays for healthcare environments fostering presence, adaptability, empathy, trust-building, and real-time responsiveness.

Delivered via a multiday health professions learning lab, the training combines asynchronous workshops with in-person facilitated interactions. Core modules cover SDT foundations, need supportive dialogue, veteran-centered cultural humility, and shared decision-making practices that uplift rural women veterans’ voices. Using Kirkpatrick’s Four Level Model, we assess impact at multiple tiers:

1. Reaction: Participant satisfaction and perceived training relevance.
2. Learning: Pre/post assessments track SDT knowledge and communication skills gains.
3. Behavior: Observe simulations and self-reported changes in communication practices.
4. Results: Qualitative satisfaction metrics and care engagement trends among rural women veterans.

Results

A pilot cohort (N = 20) across two rural sites is pending implementation. pre/post surveys will assess any improved confidence in applying need supportive communication and the most effective component in building empathetic presence. Feedback measures will also indicate the significance of combined uses of medical improv and cultural humility on deepened relational capacity and trust.

Discussion

This program operationalizes SDT within healthcare communications, integrating cultural humility and improvisation learning modalities to enhance care quality for rural women veterans, ultimately strengthening provider-patient connections. Using health professions learning lab environments can foster sustained behavioral impacts. Future iterations will expand to additional rural VA sites, co-designing with the voices of women veterans through focus groups.

Background

Rural women veterans often confront unique healthcare barriers—geographic isolation, gender-related stigma, and limited provider cultural sensitivity that undermine trust and engagement. In response, we co-designed an interprofessional communication curriculum to promote relational, patient-centered care grounded in psychological need support.

Innovation

Anchored in Self Determination Theory (SDT), this curriculum equips nurses and social workers with need-supportive communication strategies that nurture autonomy, competence, and relatedness, integrating two transformative learning methods for enhancing respectful and inclusive listening:

• Cultural humility reflections for veteran-centered care—personal narratives, storytelling, and power-awareness discussions to build lifelong reflective practices.
• Medical improv simulations—adaptive improvisational role plays for healthcare environments fostering presence, adaptability, empathy, trust-building, and real-time responsiveness.

Delivered via a multiday health professions learning lab, the training combines asynchronous workshops with in-person facilitated interactions. Core modules cover SDT foundations, need supportive dialogue, veteran-centered cultural humility, and shared decision-making practices that uplift rural women veterans’ voices. Using Kirkpatrick’s Four Level Model, we assess impact at multiple tiers:

1. Reaction: Participant satisfaction and perceived training relevance.
2. Learning: Pre/post assessments track SDT knowledge and communication skills gains.
3. Behavior: Observe simulations and self-reported changes in communication practices.
4. Results: Qualitative satisfaction metrics and care engagement trends among rural women veterans.

Results

A pilot cohort (N = 20) across two rural sites is pending implementation. pre/post surveys will assess any improved confidence in applying need supportive communication and the most effective component in building empathetic presence. Feedback measures will also indicate the significance of combined uses of medical improv and cultural humility on deepened relational capacity and trust.

Discussion

This program operationalizes SDT within healthcare communications, integrating cultural humility and improvisation learning modalities to enhance care quality for rural women veterans, ultimately strengthening provider-patient connections. Using health professions learning lab environments can foster sustained behavioral impacts. Future iterations will expand to additional rural VA sites, co-designing with the voices of women veterans through focus groups.

Background

The original program consisted of 12 movements that were to be split up between 3 weeks teaching 4 movements each week. Range of mobility was the main consideration for developing this HPE quality improvement project. Veterans who wanted to participate in Tai Chi were not able to engage in the activity due to the range of movement traditional Tai Chi required.

Innovation

The HPE Quality Improvement program developed a 15-movement warm-up, 12 co-ordinational movements consistent with the original program, 18 supplemental Tai Chi movements that were not included in the original program all of which focus on movements remaining below the shoulders and can be done standing or sitting. Four advanced exercises including “hip over heel” were included to target participants balance if able and to improve their hip strength, knee tendon/ligament strength. Tai Chi loses its potential to increase balance when performed in a sitting position.¹ The movements drew upon Fu style Tai Chi and the program developer was given permission from Tommy Kirchoff to use his DVD Healing Exercises. The HPE program consisted of four 30–60-minute weekly sessions of learning the movements with another 4 weekly sessions of demonstrating the movements. Instructors were given written and visual documents to learn from and were evaluated by the developer during the last 4 weeks.
.

Results

Qualitative Data: Instructors notice a difference in how they feel, and appreciate having another option to offer veterans with mobility/standing issues. Patients expressed improvement in mobility relating to bending, arm extension, arm raising, muscle strengthening, hip strengthening and rotation.

Discussion

Future research will want to look at taking measurements before and after patient implementation to determine quantitative data related to balance, strength and range of movement including grip strength, stand up and go, and one-legged stands.

Background

The original program consisted of 12 movements that were to be split up between 3 weeks teaching 4 movements each week. Range of mobility was the main consideration for developing this HPE quality improvement project. Veterans who wanted to participate in Tai Chi were not able to engage in the activity due to the range of movement traditional Tai Chi required.

Innovation

The HPE Quality Improvement program developed a 15-movement warm-up, 12 co-ordinational movements consistent with the original program, 18 supplemental Tai Chi movements that were not included in the original program all of which focus on movements remaining below the shoulders and can be done standing or sitting. Four advanced exercises including “hip over heel” were included to target participants balance if able and to improve their hip strength, knee tendon/ligament strength. Tai Chi loses its potential to increase balance when performed in a sitting position.¹ The movements drew upon Fu style Tai Chi and the program developer was given permission from Tommy Kirchoff to use his DVD Healing Exercises. The HPE program consisted of four 30–60-minute weekly sessions of learning the movements with another 4 weekly sessions of demonstrating the movements. Instructors were given written and visual documents to learn from and were evaluated by the developer during the last 4 weeks.
.

Results

Qualitative Data: Instructors notice a difference in how they feel, and appreciate having another option to offer veterans with mobility/standing issues. Patients expressed improvement in mobility relating to bending, arm extension, arm raising, muscle strengthening, hip strengthening and rotation.

Discussion

Future research will want to look at taking measurements before and after patient implementation to determine quantitative data related to balance, strength and range of movement including grip strength, stand up and go, and one-legged stands.

Background

The original program consisted of 12 movements that were to be split up between 3 weeks teaching 4 movements each week. Range of mobility was the main consideration for developing this HPE quality improvement project. Veterans who wanted to participate in Tai Chi were not able to engage in the activity due to the range of movement traditional Tai Chi required.

Innovation

The HPE Quality Improvement program developed a 15-movement warm-up, 12 co-ordinational movements consistent with the original program, 18 supplemental Tai Chi movements that were not included in the original program all of which focus on movements remaining below the shoulders and can be done standing or sitting. Four advanced exercises including “hip over heel” were included to target participants balance if able and to improve their hip strength, knee tendon/ligament strength. Tai Chi loses its potential to increase balance when performed in a sitting position.¹ The movements drew upon Fu style Tai Chi and the program developer was given permission from Tommy Kirchoff to use his DVD Healing Exercises. The HPE program consisted of four 30–60-minute weekly sessions of learning the movements with another 4 weekly sessions of demonstrating the movements. Instructors were given written and visual documents to learn from and were evaluated by the developer during the last 4 weeks.
.

Results

Qualitative Data: Instructors notice a difference in how they feel, and appreciate having another option to offer veterans with mobility/standing issues. Patients expressed improvement in mobility relating to bending, arm extension, arm raising, muscle strengthening, hip strengthening and rotation.

Discussion

Future research will want to look at taking measurements before and after patient implementation to determine quantitative data related to balance, strength and range of movement including grip strength, stand up and go, and one-legged stands.

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Cost-effectiveness (CE) evaluations, for existing and anticipated programs, are common in healthcare, but are rarely used in health professions education (HPE). A systematic review of HPE literature found not only few examples of CE evaluations, but also unclear and inconsistent methodology.¹ One proposed reason HPE has been slow to adopt CE evaluations is uncertainty over terminology and how to adapt this methodology to HPE.² CE evaluations present further challenges for HPE since educational outcomes are often not easily monetized. However, given the reality of constrained budgets and limited resources, CE evaluations can be a powerful tool for educators to strengthen arguments for proposed innovations, and for scholars seeking to conduct rigorous work that sustains critical review.

Innovation

This project aims to make CE evaluations more understandable to HPE educators, using a one-page infographic and glossary. This will provide a primer, operationalizing the steps involved in CE evaluations and addressing why and when CE evaluations might be considered in HPE. To improve comprehension, this is being developed collaboratively with health professions educators and an economist. This infographic will be submitted for publication, as a resource to facilitate educators’ scholarly work and conversations with fiscal administrators.

Results

The infographic includes 1) an overview of CE evaluations, 2) information about inputs required for CE evaluations, 3) guidance on interpreting results, 4) a glossary of key terminology, and 5) considerations for why educators might consider this type of analysis. A final draft will be pilot tested with a focus group to assess interdisciplinary accessibility.

Discussion

Discussions between health professions educators and an economist on this infographic uncovered concepts that were poorly understood or defined differently across disciplines, determining specific knowledge gaps and misunderstandings. For example, facilitating conversation between educators and economists highlighted key terms that were a source of misunderstanding. These were then added to the glossary, creating a shared vocabulary. This also helped clarify the steps and information necessary for conducting CE evaluations in HPE, particularly the issue of perspective choice for the analysis (educator, patient, learner, etc.). Overall, this collaboration aimed at making CE evaluations more approachable and understandable for HPE professionals through this infographic.

Background

Cost-effectiveness (CE) evaluations, for existing and anticipated programs, are common in healthcare, but are rarely used in health professions education (HPE). A systematic review of HPE literature found not only few examples of CE evaluations, but also unclear and inconsistent methodology.¹ One proposed reason HPE has been slow to adopt CE evaluations is uncertainty over terminology and how to adapt this methodology to HPE.² CE evaluations present further challenges for HPE since educational outcomes are often not easily monetized. However, given the reality of constrained budgets and limited resources, CE evaluations can be a powerful tool for educators to strengthen arguments for proposed innovations, and for scholars seeking to conduct rigorous work that sustains critical review.

Innovation

This project aims to make CE evaluations more understandable to HPE educators, using a one-page infographic and glossary. This will provide a primer, operationalizing the steps involved in CE evaluations and addressing why and when CE evaluations might be considered in HPE. To improve comprehension, this is being developed collaboratively with health professions educators and an economist. This infographic will be submitted for publication, as a resource to facilitate educators’ scholarly work and conversations with fiscal administrators.

Results

The infographic includes 1) an overview of CE evaluations, 2) information about inputs required for CE evaluations, 3) guidance on interpreting results, 4) a glossary of key terminology, and 5) considerations for why educators might consider this type of analysis. A final draft will be pilot tested with a focus group to assess interdisciplinary accessibility.

Discussion

Discussions between health professions educators and an economist on this infographic uncovered concepts that were poorly understood or defined differently across disciplines, determining specific knowledge gaps and misunderstandings. For example, facilitating conversation between educators and economists highlighted key terms that were a source of misunderstanding. These were then added to the glossary, creating a shared vocabulary. This also helped clarify the steps and information necessary for conducting CE evaluations in HPE, particularly the issue of perspective choice for the analysis (educator, patient, learner, etc.). Overall, this collaboration aimed at making CE evaluations more approachable and understandable for HPE professionals through this infographic.

Background

Cost-effectiveness (CE) evaluations, for existing and anticipated programs, are common in healthcare, but are rarely used in health professions education (HPE). A systematic review of HPE literature found not only few examples of CE evaluations, but also unclear and inconsistent methodology.¹ One proposed reason HPE has been slow to adopt CE evaluations is uncertainty over terminology and how to adapt this methodology to HPE.² CE evaluations present further challenges for HPE since educational outcomes are often not easily monetized. However, given the reality of constrained budgets and limited resources, CE evaluations can be a powerful tool for educators to strengthen arguments for proposed innovations, and for scholars seeking to conduct rigorous work that sustains critical review.

Innovation

This project aims to make CE evaluations more understandable to HPE educators, using a one-page infographic and glossary. This will provide a primer, operationalizing the steps involved in CE evaluations and addressing why and when CE evaluations might be considered in HPE. To improve comprehension, this is being developed collaboratively with health professions educators and an economist. This infographic will be submitted for publication, as a resource to facilitate educators’ scholarly work and conversations with fiscal administrators.

Results

The infographic includes 1) an overview of CE evaluations, 2) information about inputs required for CE evaluations, 3) guidance on interpreting results, 4) a glossary of key terminology, and 5) considerations for why educators might consider this type of analysis. A final draft will be pilot tested with a focus group to assess interdisciplinary accessibility.

Discussion

Discussions between health professions educators and an economist on this infographic uncovered concepts that were poorly understood or defined differently across disciplines, determining specific knowledge gaps and misunderstandings. For example, facilitating conversation between educators and economists highlighted key terms that were a source of misunderstanding. These were then added to the glossary, creating a shared vocabulary. This also helped clarify the steps and information necessary for conducting CE evaluations in HPE, particularly the issue of perspective choice for the analysis (educator, patient, learner, etc.). Overall, this collaboration aimed at making CE evaluations more approachable and understandable for HPE professionals through this infographic.

What qualities are dermatology programs looking for that may be different from 5 years ago? 

DR. WORSWICK: Every dermatology residency program is different, and as a result, each program is looking for different qualities in its applicants. Overall, I don’t think there has been a huge change in what programs are generally looking for, though. While each program may have a particular trait it values more than another, in general, programs are looking to find residents who will be competent and caring doctors, who work well in teams, and who could be future leaders in our field. 

What are common mistakes you see in dermatology residency interviews, and how can applicants avoid them? 

DR. WORSWICK: Most dermatology applicants are highly accomplished and empathic soon-to-be physicians, so I haven’t found a lot of “mistakes” from this incredible group of people that we have the privilege of interviewing. From time to time, an applicant will lie in an interview, usually out of a desire to appear to be a certain way, and occasionally, they may be nervous and stumble over their words. The former is a really big problem when it happens, and I would recommend that applicants be honest in all their encounters. The latter is not a major problem, and in some cases, might be avoided by lots of practice in advance. 

What types of questions do you recommend applicants ask their interviewers to demonstrate genuine interest in the program? 

DR. WORSWICK: Because of the signaling system, I think that programs assume interest at baseline once an applicant has sent the signal. So, “demonstrating interest” is generally not something I would recommend to applicants during the interview day. It is important for applicants to determine on interview day if a program is a fit for them, so applicants should showcase their unique strengths and skills and find out about what makes any given program different from another. The match generally works well and gets applicants into a program that closely aligns with their strengths and interests. So, think of interview day as your time to figure out how good a fit a program is for you, and not the other way around. 

How can applicants who feel they don't have standout research or leadership credentials differentiate themselves in the interview? 

DR. WORSWICK: While leadership, and less so research experience, is a trait valued highly by most if not all dermatology programs, it is only a part of what an applicant can offer a program. Most programs employ holistic review and consider several factors, probably most commonly grades in medical school, leadership experience, mentorship, teaching, volunteering, Step 2 scores, and letters of recommendation. Any given applicant does not need to excel in all of these. If an applicant has not done a lot of research, they may not match into a research-heavy program, but it doesn’t mean they won’t match. They should determine in which areas they shine and signal the programs that align with those interests/strengths. 

How should applicants discuss nontraditional experiences in a way that adds value rather than raising red flags? 

DR. WORSWICK: In general, my recommendation would be to explain what happened leading up to the change or challenge so that someone reading the application clearly understands the circumstances of the experience, then add value to the description by explaining what was learned and how this might relate to the applicant being a dermatology resident. For example, if a resident took time off for financial reasons and had to work as a medical assitant for a year, a concise description that explains the need for the leave (financial) as well as what value was gained (a year of hands-on patient care experience that validated their choice of going into medicine) could be very helpful.

What qualities are dermatology programs looking for that may be different from 5 years ago? 

DR. WORSWICK: Every dermatology residency program is different, and as a result, each program is looking for different qualities in its applicants. Overall, I don’t think there has been a huge change in what programs are generally looking for, though. While each program may have a particular trait it values more than another, in general, programs are looking to find residents who will be competent and caring doctors, who work well in teams, and who could be future leaders in our field. 

What are common mistakes you see in dermatology residency interviews, and how can applicants avoid them? 

DR. WORSWICK: Most dermatology applicants are highly accomplished and empathic soon-to-be physicians, so I haven’t found a lot of “mistakes” from this incredible group of people that we have the privilege of interviewing. From time to time, an applicant will lie in an interview, usually out of a desire to appear to be a certain way, and occasionally, they may be nervous and stumble over their words. The former is a really big problem when it happens, and I would recommend that applicants be honest in all their encounters. The latter is not a major problem, and in some cases, might be avoided by lots of practice in advance. 

What types of questions do you recommend applicants ask their interviewers to demonstrate genuine interest in the program? 

DR. WORSWICK: Because of the signaling system, I think that programs assume interest at baseline once an applicant has sent the signal. So, “demonstrating interest” is generally not something I would recommend to applicants during the interview day. It is important for applicants to determine on interview day if a program is a fit for them, so applicants should showcase their unique strengths and skills and find out about what makes any given program different from another. The match generally works well and gets applicants into a program that closely aligns with their strengths and interests. So, think of interview day as your time to figure out how good a fit a program is for you, and not the other way around. 

How can applicants who feel they don't have standout research or leadership credentials differentiate themselves in the interview? 

DR. WORSWICK: While leadership, and less so research experience, is a trait valued highly by most if not all dermatology programs, it is only a part of what an applicant can offer a program. Most programs employ holistic review and consider several factors, probably most commonly grades in medical school, leadership experience, mentorship, teaching, volunteering, Step 2 scores, and letters of recommendation. Any given applicant does not need to excel in all of these. If an applicant has not done a lot of research, they may not match into a research-heavy program, but it doesn’t mean they won’t match. They should determine in which areas they shine and signal the programs that align with those interests/strengths. 

How should applicants discuss nontraditional experiences in a way that adds value rather than raising red flags? 

DR. WORSWICK: In general, my recommendation would be to explain what happened leading up to the change or challenge so that someone reading the application clearly understands the circumstances of the experience, then add value to the description by explaining what was learned and how this might relate to the applicant being a dermatology resident. For example, if a resident took time off for financial reasons and had to work as a medical assitant for a year, a concise description that explains the need for the leave (financial) as well as what value was gained (a year of hands-on patient care experience that validated their choice of going into medicine) could be very helpful.

What qualities are dermatology programs looking for that may be different from 5 years ago? 

DR. WORSWICK: Every dermatology residency program is different, and as a result, each program is looking for different qualities in its applicants. Overall, I don’t think there has been a huge change in what programs are generally looking for, though. While each program may have a particular trait it values more than another, in general, programs are looking to find residents who will be competent and caring doctors, who work well in teams, and who could be future leaders in our field. 

What are common mistakes you see in dermatology residency interviews, and how can applicants avoid them? 

DR. WORSWICK: Most dermatology applicants are highly accomplished and empathic soon-to-be physicians, so I haven’t found a lot of “mistakes” from this incredible group of people that we have the privilege of interviewing. From time to time, an applicant will lie in an interview, usually out of a desire to appear to be a certain way, and occasionally, they may be nervous and stumble over their words. The former is a really big problem when it happens, and I would recommend that applicants be honest in all their encounters. The latter is not a major problem, and in some cases, might be avoided by lots of practice in advance. 

What types of questions do you recommend applicants ask their interviewers to demonstrate genuine interest in the program? 

DR. WORSWICK: Because of the signaling system, I think that programs assume interest at baseline once an applicant has sent the signal. So, “demonstrating interest” is generally not something I would recommend to applicants during the interview day. It is important for applicants to determine on interview day if a program is a fit for them, so applicants should showcase their unique strengths and skills and find out about what makes any given program different from another. The match generally works well and gets applicants into a program that closely aligns with their strengths and interests. So, think of interview day as your time to figure out how good a fit a program is for you, and not the other way around. 

How can applicants who feel they don't have standout research or leadership credentials differentiate themselves in the interview? 

DR. WORSWICK: While leadership, and less so research experience, is a trait valued highly by most if not all dermatology programs, it is only a part of what an applicant can offer a program. Most programs employ holistic review and consider several factors, probably most commonly grades in medical school, leadership experience, mentorship, teaching, volunteering, Step 2 scores, and letters of recommendation. Any given applicant does not need to excel in all of these. If an applicant has not done a lot of research, they may not match into a research-heavy program, but it doesn’t mean they won’t match. They should determine in which areas they shine and signal the programs that align with those interests/strengths. 

How should applicants discuss nontraditional experiences in a way that adds value rather than raising red flags? 

DR. WORSWICK: In general, my recommendation would be to explain what happened leading up to the change or challenge so that someone reading the application clearly understands the circumstances of the experience, then add value to the description by explaining what was learned and how this might relate to the applicant being a dermatology resident. For example, if a resident took time off for financial reasons and had to work as a medical assitant for a year, a concise description that explains the need for the leave (financial) as well as what value was gained (a year of hands-on patient care experience that validated their choice of going into medicine) could be very helpful.

Facial hair growth in women is complex and multifaceted. It is not a disease but rather a part of normal anatomy or a symptom influenced by an underlying condition such as hypertrichosis, a hormonal imbalance (eg, hirsutism due to polycystic ovary syndrome [PCOS]), mechanical factors such as pseudofolliculitis barbae (PFB) from shaving, and perimenopausal and postmenopausal hormonal shifts. Additionally, normal facial hair patterns can vary substantially based on genetics, ethnicity, and cultural background. Some populations may naturally have more visible vellus or terminal hairs on the face, which are entirely physiologic rather than indicative of an underlying disorder. Despite this, societal expectations and beauty standards across many cultures dictate that facial hair in women is undesirable, often associating hair-free skin with femininity and attractiveness. This perception drives many women to seek treatment—not necessarily for medical reasons, but due to social pressure and aesthetic preferences.

Hypertrichosis, whether congenital or acquired, refers to excessive hair growth that is not androgen dependent and can appear on any site of the body. Causes include genetic predisposition, porphyria, thyroid disorders, internal malignancies, malnutrition, anorexia nervosa, or use of medications such as cyclosporine, prednisolone, and phenytoin.¹ Hirsutism, by contrast, is characterized by the growth of terminal hairs in women at androgen-dependent sites such as the face, neck, and upper chest, where coarse hair typically grows in men.² This condition often is associated with excess androgens produced by the ovaries or adrenal glands, most commonly due to PCOS although genetic factors may contribute. 

Before initiating treatment, a thorough history and physical examination are essential to determine the underlying cause of conditions associated with facial hair growth in women. Clinicians should assess for signs of hyperandrogenism, menstrual irregularities, virilization, medication use, and family history. In cases of a suspected endocrine disorder, further laboratory evaluation may be warranted to guide appropriate management. While each cause of facial hair growth in women has unique management considerations, the shared impact on psychosocial well-being and adherence to grooming standards in the US military warrants an all-encompassing yet targeted approach. This comprehensive review discusses management options for women with facial hair in the military based on a review of PubMed articles indexed for MEDLINE conducted in November 2024 using combinations of the following search terms: hirsutism, facial hair, pseudofolliculitis barbae, women, female, military, grooming standards, hyperandrogenism, and hair removal.

Treatment Modalities

The available treatment modalities, including their mechanisms, potential risks, and considerations are summarized in the eTable.

Mechanical—Shaving remains one of the most widely utilized methods of hair removal in women due to its accessibility and ease of use. It does not disrupt the anagen phase of the hair growth cycle, making it a temporary method that requires frequent repetition (often daily), particularly for individuals with rapid hair growth. The belief that shaving causes hair to grow back thicker or faster is a common misconception. Shaving does not alter the thickness or growth rate of hair; instead, it leaves a blunt tip, making the hair feel coarser or appear thicker than uncut hair.³ Despite its relative convenience, shaving can lead to skin irritation due to mechanical trauma. Potential complications include PFB, superficial abrasions known more broadly as shaving irritation, and an increased risk for infections such as bacterial or fungal folliculitis.⁴

Chemical depilation, which uses thioglycolates mixed with alkali compounds, disrupts disulfide bonds in the hair, effectively breaking down the shaft without affecting the bulb. The depilatory requires application to the skin for approximately 3 to 15 minutes depending on the specific formulation and the thickness or texture of the hair. While it is a cost-effective option that easily can be done at home, the chemicals involved may trigger irritant contact dermatitis or folliculitis and produce an unpleasant odor from hydrogen disulfide gas.⁵ They also can lead to PFB.

Epilation removes the entire hair shaft and bulb, with results lasting approximately 6 weeks.⁶ Methods range from using tweezers to pluck single hairs and devices that simultaneously remove multiple hairs to hot or cold waxing, which use resin to grip and remove hair. Threading is a technique that uses twisted thread to remove the hair at the follicle level; this method may not alter hair growth unless performed during the anagen phase, during which repeated plucking can damage the matrix and potentially lead to permanent hair reduction.⁵ Common adverse effects include pain during removal, burns from waxing, folliculitis, PFB, postinflammatory hyperpigmentation, and scarring, particularly when multiple hairs are removed at once.

Pharmacologic—Pharmacologic therapy commonly is used to manage hirsutism and typically begins with a trial of combined oral contraceptives (COCs) containing estrogen and progestin, which are considered the first-line option unless contraindicated.⁷ If response to COC monotherapy is inadequate, an antiandrogen such as spironolactone may be added. Combination therapy with a COC and an antiandrogen generally is reserved for severe cases or patients who previously have shown suboptimal response to COCs alone.⁷ Patients should be counseled to discontinue antiandrogen therapy if they become pregnant due to the risk for fetal undervirilization observed in animal studies.^8,9 Typical dosing of spironolactone, a competitive inhibitor of 5-α-reductase and androgen receptors, ranges from 100 mg to 200 mg daily.¹⁰ Reported adverse effects include polyuria, postural hypotension, menstrual irregularities, hyperkalemia, and potential liver dysfunction. Although spironolactone has demonstrated tumorigenic effects in animal studies, no such effects have been observed in humans.¹¹

Eflornithine hydrochloride cream 13.9% is the first topical prescription medication approved by the US Food and Drug Administration for reduction of unwanted facial hair in women.¹² It works by irreversibly blocking the activity of ornithine decarboxylase, an enzyme involved in the rate-limiting step of polyamine synthesis, which is essential for hair growth. In a randomized, double-blind clinical trial evaluating its effectiveness and safety, twice-daily application for 24 weeks resulted in a clinically meaningful reduction in hair length and density (measured as surface area) compared with the control group.¹³ When eflornithine hydrochloride cream 13.9% is discontinued, hair growth gradually returns to baseline. Studies have shown that hair regrowth typically begins within 8 weeks after treatment is stopped; within several months, hair returns to pretreatment levels.¹⁴ Adverse effects of eflornithine hydrochloride cream generally are mild and may include local irritation and acneform eruptions. In a randomized bilateral vehicle-controlled trial of 31 women, both eflornithine and vehicle creams were well tolerated, with 1 patient reporting mild tingling with eflornithine that resolved with continued use for 7 days.¹⁵

Procedural—Photoepilation therapies widely are considered by dermatologists to be among the most effective methods for reducing unwanted hair.¹⁶ Laser hair removal employs selective photothermolysis, a principle by which specific wavelengths of light target melanin in hair follicles. This method results in localized thermal damage, destroying hair follicles and reducing regrowth. Wavelengths between 600 and 1100 nm are most effective for hair removal; widely used devices include the ruby (694 nm), alexandrite (755 nm), diode (800-810 nm), and long-pulsed Nd:YAG lasers (1064 nm). Cooling mechanisms such as cryogen spray or contact cooling often are employed to minimize epidermal damage and lessen patient discomfort.

The hair matrix is most responsive to laser treatment during the anagen phase, necessitating multiple sessions to ensure all hairs are treated during this optimal growth stage. Generally, 4 to 6 sessions spaced at intervals of 4 to 6 weeks are required to achieve satisfactory results.¹⁷ Matching the laser wavelength to the absorption properties of melanin—the target chromophore—enables selective destruction of melanin-rich hair follicles while minimizing damage to surrounding skin.

The ideal laser wavelength primarily affects melanin concentrated in the hair bulb, leading to follicular destruction while reducing the risk for unintended depigmentation of the epidermis; however, competing structures in the skin (eg, epidermal pigment) also can absorb laser energy, diminishing treatment efficacy and increasing the risk for adverse effects. Shorter wavelengths are effective for lighter skin types, while longer wavelengths such as the Nd:YAG laser are safer for individuals with darker skin types as they bypass melanin in the epidermis.

It is important to note that laser hair removal is ineffective for white and gray hairs due to the lack of melanin. As a result, alternative methods such as electrolysis, which does not rely on pigment, may be more appropriate for permanent hair removal in individuals with nonpigmented hairs. Research indicates that combining topical eflornithine with alexandrite or Nd:YAG lasers improves outcomes for reducing unwanted facial hair.¹⁸

In military settings, laser hair removal is utilized for specific conditions such as PFB in male service members to assist with the reduction of hair and mitigation of symptoms.¹⁹ The majority of military dermatology clinics have devices for laser hair removal; however, dermatology services are not available at many military treatment facilities, and dermatologic care may be provided by the local civilian dermatologists. That said, laser therapy is covered in the civilian sector for active-duty service members with PFB of the face and neck under certain criteria. These include a documented safety risk in environments requiring respiratory protection, failure of conservative treatments, and evaluation by a military dermatologist who confirms the necessity of civilian-provided laser therapy when it is unavailable at a military facility.²⁰ While such policies demonstrate the military’s recognition of laser therapy as a viable solution for certain grooming-related conditions, many are unaware that the existing laser hair removal policy also applies to women. Increasing awareness of this coverage could help female service members access treatment options that align with both medical and professional grooming needs.

Intense pulsed light (IPL) systems are nonlaser devices that emit broad-spectrum light in the 590- to 1200-nm range. They utilize a flash lamp to achieve thermal damage. Filters are used to narrow the wavelength range based on the specific target. Intense pulsed light devices are less precise than lasers but remain effective for hair reduction. In addition to hair removal, IPL devices are employed in the treatment of pigmented and vascular lesions. Common adverse effects of both laser and IPL hair removal include transient erythema, perifollicular edema, and pigmentary changes, especially in patients with darker skin types. Rare complications include blistering, scarring, and paradoxical hair stimulation in which untreated areas develop increased hair growth.

Electrolysis is recognized as the only method of truly permanent hair removal and is effective for all hair colors.²¹ However, the variability in technique among practitioners often leads to inconsistent results, with some patients experiencing hair regrowth. Galvanic electrolysis involves inserting a fine needle into the hair follicle and applying an electrical current to destroy the it and the rapidly dividing cells of the matrix.²² The introduction of thermolytic electrolysis, which uses a high-frequency alternating current (commonly 13.56 MHz or 27.12 MHz), has enhanced efficiency by creating heat at the needle tip to destroy the follicle. This approach is faster and now is commonly combined with galvanic electrolysis.²³ While no controlled clinical trials directly compare these methods, many patients experience permanent hair removal, with approximately 15% to 25% regrowth within 6 months.^22,24

Alternative Options—Home-use laser and light-based devices have become increasingly popular for managing unwanted hair due to their affordability and convenience, with most devices priced less than $1000.²⁵ These devices utilize various technologies, including lasers (808 nm), IPL, or combinations of IPL and radiofrequency.²⁶ Despite their accessibility, peer-reviewed research on their safety profile and effectiveness is limited, as existing data primarily come from industry-funded, uncontrolled studies with short follow-up durations—making it difficult to assess long-term outcomes.²⁵

Psychosocial Impact

A 2023 study of active-duty female service members with PCOS highlighted the unique challenges they face while managing symptoms such as facial hair within the constraints of military service.²⁷ Although the study focused on PCOS, the findings shed light on how facial hair specifically impacts the psychological well-being of servicewomen. Participants described facial hair as one of the most visible and stigmatizing symptoms, often leading to feelings of embarrassment and diminished confidence. Participants also highlighted the professional implications of facial hair, with some describing feelings of scrutiny and judgment from peers and leadership in public. These challenges can be more pronounced in deployments or field exercises where hygiene resources are limited. The lack of access not only affects self-perception but also can hinder the ability of servicewomen to meet implicit expectations for grooming and appearance.²⁷ There is a notable gap in research examining the impact of facial hair on military servicewomen. Given the unique environmental challenges and professional expectations, further investigation is warranted to better understand how facial hair affects women and to optimize treatment approaches in this population.

Final Thoughts

Limited awareness and understanding of facial hair in woman contribute to stigma, often leaving affected individuals to navigate challenges in isolation. Given the impact on confidence, professional appearance, and adherence to military grooming standards, it is essential for health care practitioners to recognize and address facial hair in women. Importantly, laser hair removal is covered by TRICARE for active-duty female service members with PFB, yet many remain unaware of this benefit. Increased awareness of available mechanical, pharmacologic, and procedural treatment options allows for tailored management, ensuring that women receive appropriate medical care.

Facial hair growth in women is complex and multifaceted. It is not a disease but rather a part of normal anatomy or a symptom influenced by an underlying condition such as hypertrichosis, a hormonal imbalance (eg, hirsutism due to polycystic ovary syndrome [PCOS]), mechanical factors such as pseudofolliculitis barbae (PFB) from shaving, and perimenopausal and postmenopausal hormonal shifts. Additionally, normal facial hair patterns can vary substantially based on genetics, ethnicity, and cultural background. Some populations may naturally have more visible vellus or terminal hairs on the face, which are entirely physiologic rather than indicative of an underlying disorder. Despite this, societal expectations and beauty standards across many cultures dictate that facial hair in women is undesirable, often associating hair-free skin with femininity and attractiveness. This perception drives many women to seek treatment—not necessarily for medical reasons, but due to social pressure and aesthetic preferences.

Hypertrichosis, whether congenital or acquired, refers to excessive hair growth that is not androgen dependent and can appear on any site of the body. Causes include genetic predisposition, porphyria, thyroid disorders, internal malignancies, malnutrition, anorexia nervosa, or use of medications such as cyclosporine, prednisolone, and phenytoin.¹ Hirsutism, by contrast, is characterized by the growth of terminal hairs in women at androgen-dependent sites such as the face, neck, and upper chest, where coarse hair typically grows in men.² This condition often is associated with excess androgens produced by the ovaries or adrenal glands, most commonly due to PCOS although genetic factors may contribute. 

Before initiating treatment, a thorough history and physical examination are essential to determine the underlying cause of conditions associated with facial hair growth in women. Clinicians should assess for signs of hyperandrogenism, menstrual irregularities, virilization, medication use, and family history. In cases of a suspected endocrine disorder, further laboratory evaluation may be warranted to guide appropriate management. While each cause of facial hair growth in women has unique management considerations, the shared impact on psychosocial well-being and adherence to grooming standards in the US military warrants an all-encompassing yet targeted approach. This comprehensive review discusses management options for women with facial hair in the military based on a review of PubMed articles indexed for MEDLINE conducted in November 2024 using combinations of the following search terms: hirsutism, facial hair, pseudofolliculitis barbae, women, female, military, grooming standards, hyperandrogenism, and hair removal.

Treatment Modalities

The available treatment modalities, including their mechanisms, potential risks, and considerations are summarized in the eTable.

Mechanical—Shaving remains one of the most widely utilized methods of hair removal in women due to its accessibility and ease of use. It does not disrupt the anagen phase of the hair growth cycle, making it a temporary method that requires frequent repetition (often daily), particularly for individuals with rapid hair growth. The belief that shaving causes hair to grow back thicker or faster is a common misconception. Shaving does not alter the thickness or growth rate of hair; instead, it leaves a blunt tip, making the hair feel coarser or appear thicker than uncut hair.³ Despite its relative convenience, shaving can lead to skin irritation due to mechanical trauma. Potential complications include PFB, superficial abrasions known more broadly as shaving irritation, and an increased risk for infections such as bacterial or fungal folliculitis.⁴

Chemical depilation, which uses thioglycolates mixed with alkali compounds, disrupts disulfide bonds in the hair, effectively breaking down the shaft without affecting the bulb. The depilatory requires application to the skin for approximately 3 to 15 minutes depending on the specific formulation and the thickness or texture of the hair. While it is a cost-effective option that easily can be done at home, the chemicals involved may trigger irritant contact dermatitis or folliculitis and produce an unpleasant odor from hydrogen disulfide gas.⁵ They also can lead to PFB.

Epilation removes the entire hair shaft and bulb, with results lasting approximately 6 weeks.⁶ Methods range from using tweezers to pluck single hairs and devices that simultaneously remove multiple hairs to hot or cold waxing, which use resin to grip and remove hair. Threading is a technique that uses twisted thread to remove the hair at the follicle level; this method may not alter hair growth unless performed during the anagen phase, during which repeated plucking can damage the matrix and potentially lead to permanent hair reduction.⁵ Common adverse effects include pain during removal, burns from waxing, folliculitis, PFB, postinflammatory hyperpigmentation, and scarring, particularly when multiple hairs are removed at once.

Pharmacologic—Pharmacologic therapy commonly is used to manage hirsutism and typically begins with a trial of combined oral contraceptives (COCs) containing estrogen and progestin, which are considered the first-line option unless contraindicated.⁷ If response to COC monotherapy is inadequate, an antiandrogen such as spironolactone may be added. Combination therapy with a COC and an antiandrogen generally is reserved for severe cases or patients who previously have shown suboptimal response to COCs alone.⁷ Patients should be counseled to discontinue antiandrogen therapy if they become pregnant due to the risk for fetal undervirilization observed in animal studies.^8,9 Typical dosing of spironolactone, a competitive inhibitor of 5-α-reductase and androgen receptors, ranges from 100 mg to 200 mg daily.¹⁰ Reported adverse effects include polyuria, postural hypotension, menstrual irregularities, hyperkalemia, and potential liver dysfunction. Although spironolactone has demonstrated tumorigenic effects in animal studies, no such effects have been observed in humans.¹¹

Eflornithine hydrochloride cream 13.9% is the first topical prescription medication approved by the US Food and Drug Administration for reduction of unwanted facial hair in women.¹² It works by irreversibly blocking the activity of ornithine decarboxylase, an enzyme involved in the rate-limiting step of polyamine synthesis, which is essential for hair growth. In a randomized, double-blind clinical trial evaluating its effectiveness and safety, twice-daily application for 24 weeks resulted in a clinically meaningful reduction in hair length and density (measured as surface area) compared with the control group.¹³ When eflornithine hydrochloride cream 13.9% is discontinued, hair growth gradually returns to baseline. Studies have shown that hair regrowth typically begins within 8 weeks after treatment is stopped; within several months, hair returns to pretreatment levels.¹⁴ Adverse effects of eflornithine hydrochloride cream generally are mild and may include local irritation and acneform eruptions. In a randomized bilateral vehicle-controlled trial of 31 women, both eflornithine and vehicle creams were well tolerated, with 1 patient reporting mild tingling with eflornithine that resolved with continued use for 7 days.¹⁵

Procedural—Photoepilation therapies widely are considered by dermatologists to be among the most effective methods for reducing unwanted hair.¹⁶ Laser hair removal employs selective photothermolysis, a principle by which specific wavelengths of light target melanin in hair follicles. This method results in localized thermal damage, destroying hair follicles and reducing regrowth. Wavelengths between 600 and 1100 nm are most effective for hair removal; widely used devices include the ruby (694 nm), alexandrite (755 nm), diode (800-810 nm), and long-pulsed Nd:YAG lasers (1064 nm). Cooling mechanisms such as cryogen spray or contact cooling often are employed to minimize epidermal damage and lessen patient discomfort.

The hair matrix is most responsive to laser treatment during the anagen phase, necessitating multiple sessions to ensure all hairs are treated during this optimal growth stage. Generally, 4 to 6 sessions spaced at intervals of 4 to 6 weeks are required to achieve satisfactory results.¹⁷ Matching the laser wavelength to the absorption properties of melanin—the target chromophore—enables selective destruction of melanin-rich hair follicles while minimizing damage to surrounding skin.

The ideal laser wavelength primarily affects melanin concentrated in the hair bulb, leading to follicular destruction while reducing the risk for unintended depigmentation of the epidermis; however, competing structures in the skin (eg, epidermal pigment) also can absorb laser energy, diminishing treatment efficacy and increasing the risk for adverse effects. Shorter wavelengths are effective for lighter skin types, while longer wavelengths such as the Nd:YAG laser are safer for individuals with darker skin types as they bypass melanin in the epidermis.

It is important to note that laser hair removal is ineffective for white and gray hairs due to the lack of melanin. As a result, alternative methods such as electrolysis, which does not rely on pigment, may be more appropriate for permanent hair removal in individuals with nonpigmented hairs. Research indicates that combining topical eflornithine with alexandrite or Nd:YAG lasers improves outcomes for reducing unwanted facial hair.¹⁸

In military settings, laser hair removal is utilized for specific conditions such as PFB in male service members to assist with the reduction of hair and mitigation of symptoms.¹⁹ The majority of military dermatology clinics have devices for laser hair removal; however, dermatology services are not available at many military treatment facilities, and dermatologic care may be provided by the local civilian dermatologists. That said, laser therapy is covered in the civilian sector for active-duty service members with PFB of the face and neck under certain criteria. These include a documented safety risk in environments requiring respiratory protection, failure of conservative treatments, and evaluation by a military dermatologist who confirms the necessity of civilian-provided laser therapy when it is unavailable at a military facility.²⁰ While such policies demonstrate the military’s recognition of laser therapy as a viable solution for certain grooming-related conditions, many are unaware that the existing laser hair removal policy also applies to women. Increasing awareness of this coverage could help female service members access treatment options that align with both medical and professional grooming needs.

Intense pulsed light (IPL) systems are nonlaser devices that emit broad-spectrum light in the 590- to 1200-nm range. They utilize a flash lamp to achieve thermal damage. Filters are used to narrow the wavelength range based on the specific target. Intense pulsed light devices are less precise than lasers but remain effective for hair reduction. In addition to hair removal, IPL devices are employed in the treatment of pigmented and vascular lesions. Common adverse effects of both laser and IPL hair removal include transient erythema, perifollicular edema, and pigmentary changes, especially in patients with darker skin types. Rare complications include blistering, scarring, and paradoxical hair stimulation in which untreated areas develop increased hair growth.

Electrolysis is recognized as the only method of truly permanent hair removal and is effective for all hair colors.²¹ However, the variability in technique among practitioners often leads to inconsistent results, with some patients experiencing hair regrowth. Galvanic electrolysis involves inserting a fine needle into the hair follicle and applying an electrical current to destroy the it and the rapidly dividing cells of the matrix.²² The introduction of thermolytic electrolysis, which uses a high-frequency alternating current (commonly 13.56 MHz or 27.12 MHz), has enhanced efficiency by creating heat at the needle tip to destroy the follicle. This approach is faster and now is commonly combined with galvanic electrolysis.²³ While no controlled clinical trials directly compare these methods, many patients experience permanent hair removal, with approximately 15% to 25% regrowth within 6 months.^22,24

Alternative Options—Home-use laser and light-based devices have become increasingly popular for managing unwanted hair due to their affordability and convenience, with most devices priced less than $1000.²⁵ These devices utilize various technologies, including lasers (808 nm), IPL, or combinations of IPL and radiofrequency.²⁶ Despite their accessibility, peer-reviewed research on their safety profile and effectiveness is limited, as existing data primarily come from industry-funded, uncontrolled studies with short follow-up durations—making it difficult to assess long-term outcomes.²⁵

Psychosocial Impact

A 2023 study of active-duty female service members with PCOS highlighted the unique challenges they face while managing symptoms such as facial hair within the constraints of military service.²⁷ Although the study focused on PCOS, the findings shed light on how facial hair specifically impacts the psychological well-being of servicewomen. Participants described facial hair as one of the most visible and stigmatizing symptoms, often leading to feelings of embarrassment and diminished confidence. Participants also highlighted the professional implications of facial hair, with some describing feelings of scrutiny and judgment from peers and leadership in public. These challenges can be more pronounced in deployments or field exercises where hygiene resources are limited. The lack of access not only affects self-perception but also can hinder the ability of servicewomen to meet implicit expectations for grooming and appearance.²⁷ There is a notable gap in research examining the impact of facial hair on military servicewomen. Given the unique environmental challenges and professional expectations, further investigation is warranted to better understand how facial hair affects women and to optimize treatment approaches in this population.

Final Thoughts

Limited awareness and understanding of facial hair in woman contribute to stigma, often leaving affected individuals to navigate challenges in isolation. Given the impact on confidence, professional appearance, and adherence to military grooming standards, it is essential for health care practitioners to recognize and address facial hair in women. Importantly, laser hair removal is covered by TRICARE for active-duty female service members with PFB, yet many remain unaware of this benefit. Increased awareness of available mechanical, pharmacologic, and procedural treatment options allows for tailored management, ensuring that women receive appropriate medical care.

Facial hair growth in women is complex and multifaceted. It is not a disease but rather a part of normal anatomy or a symptom influenced by an underlying condition such as hypertrichosis, a hormonal imbalance (eg, hirsutism due to polycystic ovary syndrome [PCOS]), mechanical factors such as pseudofolliculitis barbae (PFB) from shaving, and perimenopausal and postmenopausal hormonal shifts. Additionally, normal facial hair patterns can vary substantially based on genetics, ethnicity, and cultural background. Some populations may naturally have more visible vellus or terminal hairs on the face, which are entirely physiologic rather than indicative of an underlying disorder. Despite this, societal expectations and beauty standards across many cultures dictate that facial hair in women is undesirable, often associating hair-free skin with femininity and attractiveness. This perception drives many women to seek treatment—not necessarily for medical reasons, but due to social pressure and aesthetic preferences.

Hypertrichosis, whether congenital or acquired, refers to excessive hair growth that is not androgen dependent and can appear on any site of the body. Causes include genetic predisposition, porphyria, thyroid disorders, internal malignancies, malnutrition, anorexia nervosa, or use of medications such as cyclosporine, prednisolone, and phenytoin.¹ Hirsutism, by contrast, is characterized by the growth of terminal hairs in women at androgen-dependent sites such as the face, neck, and upper chest, where coarse hair typically grows in men.² This condition often is associated with excess androgens produced by the ovaries or adrenal glands, most commonly due to PCOS although genetic factors may contribute. 

Before initiating treatment, a thorough history and physical examination are essential to determine the underlying cause of conditions associated with facial hair growth in women. Clinicians should assess for signs of hyperandrogenism, menstrual irregularities, virilization, medication use, and family history. In cases of a suspected endocrine disorder, further laboratory evaluation may be warranted to guide appropriate management. While each cause of facial hair growth in women has unique management considerations, the shared impact on psychosocial well-being and adherence to grooming standards in the US military warrants an all-encompassing yet targeted approach. This comprehensive review discusses management options for women with facial hair in the military based on a review of PubMed articles indexed for MEDLINE conducted in November 2024 using combinations of the following search terms: hirsutism, facial hair, pseudofolliculitis barbae, women, female, military, grooming standards, hyperandrogenism, and hair removal.

Treatment Modalities

The available treatment modalities, including their mechanisms, potential risks, and considerations are summarized in the eTable.

Mechanical—Shaving remains one of the most widely utilized methods of hair removal in women due to its accessibility and ease of use. It does not disrupt the anagen phase of the hair growth cycle, making it a temporary method that requires frequent repetition (often daily), particularly for individuals with rapid hair growth. The belief that shaving causes hair to grow back thicker or faster is a common misconception. Shaving does not alter the thickness or growth rate of hair; instead, it leaves a blunt tip, making the hair feel coarser or appear thicker than uncut hair.³ Despite its relative convenience, shaving can lead to skin irritation due to mechanical trauma. Potential complications include PFB, superficial abrasions known more broadly as shaving irritation, and an increased risk for infections such as bacterial or fungal folliculitis.⁴

Chemical depilation, which uses thioglycolates mixed with alkali compounds, disrupts disulfide bonds in the hair, effectively breaking down the shaft without affecting the bulb. The depilatory requires application to the skin for approximately 3 to 15 minutes depending on the specific formulation and the thickness or texture of the hair. While it is a cost-effective option that easily can be done at home, the chemicals involved may trigger irritant contact dermatitis or folliculitis and produce an unpleasant odor from hydrogen disulfide gas.⁵ They also can lead to PFB.

Epilation removes the entire hair shaft and bulb, with results lasting approximately 6 weeks.⁶ Methods range from using tweezers to pluck single hairs and devices that simultaneously remove multiple hairs to hot or cold waxing, which use resin to grip and remove hair. Threading is a technique that uses twisted thread to remove the hair at the follicle level; this method may not alter hair growth unless performed during the anagen phase, during which repeated plucking can damage the matrix and potentially lead to permanent hair reduction.⁵ Common adverse effects include pain during removal, burns from waxing, folliculitis, PFB, postinflammatory hyperpigmentation, and scarring, particularly when multiple hairs are removed at once.

Pharmacologic—Pharmacologic therapy commonly is used to manage hirsutism and typically begins with a trial of combined oral contraceptives (COCs) containing estrogen and progestin, which are considered the first-line option unless contraindicated.⁷ If response to COC monotherapy is inadequate, an antiandrogen such as spironolactone may be added. Combination therapy with a COC and an antiandrogen generally is reserved for severe cases or patients who previously have shown suboptimal response to COCs alone.⁷ Patients should be counseled to discontinue antiandrogen therapy if they become pregnant due to the risk for fetal undervirilization observed in animal studies.^8,9 Typical dosing of spironolactone, a competitive inhibitor of 5-α-reductase and androgen receptors, ranges from 100 mg to 200 mg daily.¹⁰ Reported adverse effects include polyuria, postural hypotension, menstrual irregularities, hyperkalemia, and potential liver dysfunction. Although spironolactone has demonstrated tumorigenic effects in animal studies, no such effects have been observed in humans.¹¹

Eflornithine hydrochloride cream 13.9% is the first topical prescription medication approved by the US Food and Drug Administration for reduction of unwanted facial hair in women.¹² It works by irreversibly blocking the activity of ornithine decarboxylase, an enzyme involved in the rate-limiting step of polyamine synthesis, which is essential for hair growth. In a randomized, double-blind clinical trial evaluating its effectiveness and safety, twice-daily application for 24 weeks resulted in a clinically meaningful reduction in hair length and density (measured as surface area) compared with the control group.¹³ When eflornithine hydrochloride cream 13.9% is discontinued, hair growth gradually returns to baseline. Studies have shown that hair regrowth typically begins within 8 weeks after treatment is stopped; within several months, hair returns to pretreatment levels.¹⁴ Adverse effects of eflornithine hydrochloride cream generally are mild and may include local irritation and acneform eruptions. In a randomized bilateral vehicle-controlled trial of 31 women, both eflornithine and vehicle creams were well tolerated, with 1 patient reporting mild tingling with eflornithine that resolved with continued use for 7 days.¹⁵

Procedural—Photoepilation therapies widely are considered by dermatologists to be among the most effective methods for reducing unwanted hair.¹⁶ Laser hair removal employs selective photothermolysis, a principle by which specific wavelengths of light target melanin in hair follicles. This method results in localized thermal damage, destroying hair follicles and reducing regrowth. Wavelengths between 600 and 1100 nm are most effective for hair removal; widely used devices include the ruby (694 nm), alexandrite (755 nm), diode (800-810 nm), and long-pulsed Nd:YAG lasers (1064 nm). Cooling mechanisms such as cryogen spray or contact cooling often are employed to minimize epidermal damage and lessen patient discomfort.

The hair matrix is most responsive to laser treatment during the anagen phase, necessitating multiple sessions to ensure all hairs are treated during this optimal growth stage. Generally, 4 to 6 sessions spaced at intervals of 4 to 6 weeks are required to achieve satisfactory results.¹⁷ Matching the laser wavelength to the absorption properties of melanin—the target chromophore—enables selective destruction of melanin-rich hair follicles while minimizing damage to surrounding skin.

The ideal laser wavelength primarily affects melanin concentrated in the hair bulb, leading to follicular destruction while reducing the risk for unintended depigmentation of the epidermis; however, competing structures in the skin (eg, epidermal pigment) also can absorb laser energy, diminishing treatment efficacy and increasing the risk for adverse effects. Shorter wavelengths are effective for lighter skin types, while longer wavelengths such as the Nd:YAG laser are safer for individuals with darker skin types as they bypass melanin in the epidermis.

It is important to note that laser hair removal is ineffective for white and gray hairs due to the lack of melanin. As a result, alternative methods such as electrolysis, which does not rely on pigment, may be more appropriate for permanent hair removal in individuals with nonpigmented hairs. Research indicates that combining topical eflornithine with alexandrite or Nd:YAG lasers improves outcomes for reducing unwanted facial hair.¹⁸

In military settings, laser hair removal is utilized for specific conditions such as PFB in male service members to assist with the reduction of hair and mitigation of symptoms.¹⁹ The majority of military dermatology clinics have devices for laser hair removal; however, dermatology services are not available at many military treatment facilities, and dermatologic care may be provided by the local civilian dermatologists. That said, laser therapy is covered in the civilian sector for active-duty service members with PFB of the face and neck under certain criteria. These include a documented safety risk in environments requiring respiratory protection, failure of conservative treatments, and evaluation by a military dermatologist who confirms the necessity of civilian-provided laser therapy when it is unavailable at a military facility.²⁰ While such policies demonstrate the military’s recognition of laser therapy as a viable solution for certain grooming-related conditions, many are unaware that the existing laser hair removal policy also applies to women. Increasing awareness of this coverage could help female service members access treatment options that align with both medical and professional grooming needs.

Intense pulsed light (IPL) systems are nonlaser devices that emit broad-spectrum light in the 590- to 1200-nm range. They utilize a flash lamp to achieve thermal damage. Filters are used to narrow the wavelength range based on the specific target. Intense pulsed light devices are less precise than lasers but remain effective for hair reduction. In addition to hair removal, IPL devices are employed in the treatment of pigmented and vascular lesions. Common adverse effects of both laser and IPL hair removal include transient erythema, perifollicular edema, and pigmentary changes, especially in patients with darker skin types. Rare complications include blistering, scarring, and paradoxical hair stimulation in which untreated areas develop increased hair growth.

Electrolysis is recognized as the only method of truly permanent hair removal and is effective for all hair colors.²¹ However, the variability in technique among practitioners often leads to inconsistent results, with some patients experiencing hair regrowth. Galvanic electrolysis involves inserting a fine needle into the hair follicle and applying an electrical current to destroy the it and the rapidly dividing cells of the matrix.²² The introduction of thermolytic electrolysis, which uses a high-frequency alternating current (commonly 13.56 MHz or 27.12 MHz), has enhanced efficiency by creating heat at the needle tip to destroy the follicle. This approach is faster and now is commonly combined with galvanic electrolysis.²³ While no controlled clinical trials directly compare these methods, many patients experience permanent hair removal, with approximately 15% to 25% regrowth within 6 months.^22,24

Alternative Options—Home-use laser and light-based devices have become increasingly popular for managing unwanted hair due to their affordability and convenience, with most devices priced less than $1000.²⁵ These devices utilize various technologies, including lasers (808 nm), IPL, or combinations of IPL and radiofrequency.²⁶ Despite their accessibility, peer-reviewed research on their safety profile and effectiveness is limited, as existing data primarily come from industry-funded, uncontrolled studies with short follow-up durations—making it difficult to assess long-term outcomes.²⁵

Psychosocial Impact

A 2023 study of active-duty female service members with PCOS highlighted the unique challenges they face while managing symptoms such as facial hair within the constraints of military service.²⁷ Although the study focused on PCOS, the findings shed light on how facial hair specifically impacts the psychological well-being of servicewomen. Participants described facial hair as one of the most visible and stigmatizing symptoms, often leading to feelings of embarrassment and diminished confidence. Participants also highlighted the professional implications of facial hair, with some describing feelings of scrutiny and judgment from peers and leadership in public. These challenges can be more pronounced in deployments or field exercises where hygiene resources are limited. The lack of access not only affects self-perception but also can hinder the ability of servicewomen to meet implicit expectations for grooming and appearance.²⁷ There is a notable gap in research examining the impact of facial hair on military servicewomen. Given the unique environmental challenges and professional expectations, further investigation is warranted to better understand how facial hair affects women and to optimize treatment approaches in this population.

Final Thoughts

Limited awareness and understanding of facial hair in woman contribute to stigma, often leaving affected individuals to navigate challenges in isolation. Given the impact on confidence, professional appearance, and adherence to military grooming standards, it is essential for health care practitioners to recognize and address facial hair in women. Importantly, laser hair removal is covered by TRICARE for active-duty female service members with PFB, yet many remain unaware of this benefit. Increased awareness of available mechanical, pharmacologic, and procedural treatment options allows for tailored management, ensuring that women receive appropriate medical care.

To the Editor:

Millipedes do not have nearly as many feet as their name would suggest; most have fewer than 100.¹ They are not actually insects; they are a wormlike arthropod in the Diplopoda class. Generally these harmless animals can be a welcome resident in gardens because they break down decaying plant material and rejuvenate the soil.¹ However, they are less welcome in the home or underfoot because of what happens when these invertebrates are threatened or crushed.²

Millipedes, which typically have at least 30 pairs of legs, have 2 defense mechanisms: (1) body coiling to withstand external pressure, and (2) secretion of fluids with insecticidal properties from specialized glands distributed along their body.³ These secretions, which are used by the millipede to defend against predators, contain organic compounds including benzoquinone. When these secretions come into contact with skin, pigmentary changes resembling a burn or necrosis and irritation to the skin (pain, burning, itching) occur.^4,5

Millipedes typically are found in tropical and temperate regions worldwide, such as the Amazon rainforest, Southeast Asia, tropical areas of Africa, forests, grasslands, and gardens in North America and Europe.⁶ They also are found in every US state as well as Puerto Rico.¹ Millipedes are nocturnal, favor dark places, and can make their way into residential areas, including homes, basements, gardens, and yards.^2,6 Although millipede burns commonly are reported in tropical regions, we present a case in China.⁶A 33-year-old woman presented with purplish-red discoloration on all 5 toes on the left foot. The patient recounted that she discovered a millipede in her shoe earlier in the day, removed it, and crushed it with her bare foot. That night, while taking a bath, she noticed that the toes had turned purplish-red (Figure 1). The patient brought the crushed millipede with her to the emergency department where she sought treatment. The dermatologist confirmed that it was a millipede; however, the team was unable to determine the specific species because it had been crushed (Figure 2).

Physical examination of the affected toes showed a clear boundary and iodinelike staining. The patient did not report pain. The stained skin had a normal temperature, pulse, texture, and sensation. Dermoscopy revealed multiple black-brown patches on the toes (Figure 3). The pigmented area gradually faded over a 1-month period. Superficial damage to the toenail revealed evidence of black-brown pigmentation on both the nail and the skin underneath. The diagnosis in the dermoscopy report suggested exogenous pigmentation of the toes. The patient was advised that no treatment was needed and that the condition would resolve on its own. At 1-month follow-up, the patient’s toes had returned to their normal color (Figure 4).

The feet are common sites of millipede burns; other exposed areas, such as the arms, face, and eyes, also are potential sites of involvement.⁵ The cutaneous pigmentary changes seen on our patient’s foot were a result of the millipede’s defense mechanism—secreted toxic chemicals that stained the foot. It is important to note that the pigmentation was not associated with the death of the millipede, as the millipede was still alive upon initial contact with the patient’s foot in her shoe. 

When a patient presents with pigmentary changes, several conditions must be ruled out—notably acute arterial thrombosis. Patients with this condition will describe acute pain and weakness in the area of involvement. Physicians inspecting the area will note coldness and pallor in the affected limb as well as a diminished or absent pulse. In severe cases, the skin may exhibit a purplish-red appearance.⁵ Millipede burns also should be distinguished from bacterial endocarditis and cryoglobulinemia.⁷ All 3 conditions can manifest with redness, swelling, blisters, and purpuralike changes. Positive blood culture is an important diagnostic basis for bacterial endocarditis; in addition, routine blood tests will demonstrate a decrease in red blood cells and hemoglobin, and routine urinalysis may show proteinuria and microscopic hematuria. Patients with cryoglobulinemia will have a positive cryoglobulin assay, increased IgM, and often decreased complement.⁷ It also is worth noting that millipede burns might resemble child abuse in pediatric patients, necessitating further evaluation.⁵ 

It is unusual to see a millipede burn in nontropical regions. Therefore, the identification of our patient’s millipede burn was notable and serves as a reminder to keep this diagnosis in the differential when caring for patients with pigmentary changes. An accurate diagnosis hinges on being alert to a millipede exposure history and recognizing the clinical manifestations. For affected patients, it may be beneficial to recommend they advise friends and relatives to avoid skin contact with millipedes and most importantly to avoid stepping on them with bare feet.

To the Editor:

Millipedes do not have nearly as many feet as their name would suggest; most have fewer than 100.¹ They are not actually insects; they are a wormlike arthropod in the Diplopoda class. Generally these harmless animals can be a welcome resident in gardens because they break down decaying plant material and rejuvenate the soil.¹ However, they are less welcome in the home or underfoot because of what happens when these invertebrates are threatened or crushed.²

Millipedes, which typically have at least 30 pairs of legs, have 2 defense mechanisms: (1) body coiling to withstand external pressure, and (2) secretion of fluids with insecticidal properties from specialized glands distributed along their body.³ These secretions, which are used by the millipede to defend against predators, contain organic compounds including benzoquinone. When these secretions come into contact with skin, pigmentary changes resembling a burn or necrosis and irritation to the skin (pain, burning, itching) occur.^4,5

Millipedes typically are found in tropical and temperate regions worldwide, such as the Amazon rainforest, Southeast Asia, tropical areas of Africa, forests, grasslands, and gardens in North America and Europe.⁶ They also are found in every US state as well as Puerto Rico.¹ Millipedes are nocturnal, favor dark places, and can make their way into residential areas, including homes, basements, gardens, and yards.^2,6 Although millipede burns commonly are reported in tropical regions, we present a case in China.⁶A 33-year-old woman presented with purplish-red discoloration on all 5 toes on the left foot. The patient recounted that she discovered a millipede in her shoe earlier in the day, removed it, and crushed it with her bare foot. That night, while taking a bath, she noticed that the toes had turned purplish-red (Figure 1). The patient brought the crushed millipede with her to the emergency department where she sought treatment. The dermatologist confirmed that it was a millipede; however, the team was unable to determine the specific species because it had been crushed (Figure 2).

Physical examination of the affected toes showed a clear boundary and iodinelike staining. The patient did not report pain. The stained skin had a normal temperature, pulse, texture, and sensation. Dermoscopy revealed multiple black-brown patches on the toes (Figure 3). The pigmented area gradually faded over a 1-month period. Superficial damage to the toenail revealed evidence of black-brown pigmentation on both the nail and the skin underneath. The diagnosis in the dermoscopy report suggested exogenous pigmentation of the toes. The patient was advised that no treatment was needed and that the condition would resolve on its own. At 1-month follow-up, the patient’s toes had returned to their normal color (Figure 4).

The feet are common sites of millipede burns; other exposed areas, such as the arms, face, and eyes, also are potential sites of involvement.⁵ The cutaneous pigmentary changes seen on our patient’s foot were a result of the millipede’s defense mechanism—secreted toxic chemicals that stained the foot. It is important to note that the pigmentation was not associated with the death of the millipede, as the millipede was still alive upon initial contact with the patient’s foot in her shoe. 

When a patient presents with pigmentary changes, several conditions must be ruled out—notably acute arterial thrombosis. Patients with this condition will describe acute pain and weakness in the area of involvement. Physicians inspecting the area will note coldness and pallor in the affected limb as well as a diminished or absent pulse. In severe cases, the skin may exhibit a purplish-red appearance.⁵ Millipede burns also should be distinguished from bacterial endocarditis and cryoglobulinemia.⁷ All 3 conditions can manifest with redness, swelling, blisters, and purpuralike changes. Positive blood culture is an important diagnostic basis for bacterial endocarditis; in addition, routine blood tests will demonstrate a decrease in red blood cells and hemoglobin, and routine urinalysis may show proteinuria and microscopic hematuria. Patients with cryoglobulinemia will have a positive cryoglobulin assay, increased IgM, and often decreased complement.⁷ It also is worth noting that millipede burns might resemble child abuse in pediatric patients, necessitating further evaluation.⁵ 

It is unusual to see a millipede burn in nontropical regions. Therefore, the identification of our patient’s millipede burn was notable and serves as a reminder to keep this diagnosis in the differential when caring for patients with pigmentary changes. An accurate diagnosis hinges on being alert to a millipede exposure history and recognizing the clinical manifestations. For affected patients, it may be beneficial to recommend they advise friends and relatives to avoid skin contact with millipedes and most importantly to avoid stepping on them with bare feet.

To the Editor:

Millipedes do not have nearly as many feet as their name would suggest; most have fewer than 100.¹ They are not actually insects; they are a wormlike arthropod in the Diplopoda class. Generally these harmless animals can be a welcome resident in gardens because they break down decaying plant material and rejuvenate the soil.¹ However, they are less welcome in the home or underfoot because of what happens when these invertebrates are threatened or crushed.²

Millipedes, which typically have at least 30 pairs of legs, have 2 defense mechanisms: (1) body coiling to withstand external pressure, and (2) secretion of fluids with insecticidal properties from specialized glands distributed along their body.³ These secretions, which are used by the millipede to defend against predators, contain organic compounds including benzoquinone. When these secretions come into contact with skin, pigmentary changes resembling a burn or necrosis and irritation to the skin (pain, burning, itching) occur.^4,5

Millipedes typically are found in tropical and temperate regions worldwide, such as the Amazon rainforest, Southeast Asia, tropical areas of Africa, forests, grasslands, and gardens in North America and Europe.⁶ They also are found in every US state as well as Puerto Rico.¹ Millipedes are nocturnal, favor dark places, and can make their way into residential areas, including homes, basements, gardens, and yards.^2,6 Although millipede burns commonly are reported in tropical regions, we present a case in China.⁶A 33-year-old woman presented with purplish-red discoloration on all 5 toes on the left foot. The patient recounted that she discovered a millipede in her shoe earlier in the day, removed it, and crushed it with her bare foot. That night, while taking a bath, she noticed that the toes had turned purplish-red (Figure 1). The patient brought the crushed millipede with her to the emergency department where she sought treatment. The dermatologist confirmed that it was a millipede; however, the team was unable to determine the specific species because it had been crushed (Figure 2).

Physical examination of the affected toes showed a clear boundary and iodinelike staining. The patient did not report pain. The stained skin had a normal temperature, pulse, texture, and sensation. Dermoscopy revealed multiple black-brown patches on the toes (Figure 3). The pigmented area gradually faded over a 1-month period. Superficial damage to the toenail revealed evidence of black-brown pigmentation on both the nail and the skin underneath. The diagnosis in the dermoscopy report suggested exogenous pigmentation of the toes. The patient was advised that no treatment was needed and that the condition would resolve on its own. At 1-month follow-up, the patient’s toes had returned to their normal color (Figure 4).

The feet are common sites of millipede burns; other exposed areas, such as the arms, face, and eyes, also are potential sites of involvement.⁵ The cutaneous pigmentary changes seen on our patient’s foot were a result of the millipede’s defense mechanism—secreted toxic chemicals that stained the foot. It is important to note that the pigmentation was not associated with the death of the millipede, as the millipede was still alive upon initial contact with the patient’s foot in her shoe. 

When a patient presents with pigmentary changes, several conditions must be ruled out—notably acute arterial thrombosis. Patients with this condition will describe acute pain and weakness in the area of involvement. Physicians inspecting the area will note coldness and pallor in the affected limb as well as a diminished or absent pulse. In severe cases, the skin may exhibit a purplish-red appearance.⁵ Millipede burns also should be distinguished from bacterial endocarditis and cryoglobulinemia.⁷ All 3 conditions can manifest with redness, swelling, blisters, and purpuralike changes. Positive blood culture is an important diagnostic basis for bacterial endocarditis; in addition, routine blood tests will demonstrate a decrease in red blood cells and hemoglobin, and routine urinalysis may show proteinuria and microscopic hematuria. Patients with cryoglobulinemia will have a positive cryoglobulin assay, increased IgM, and often decreased complement.⁷ It also is worth noting that millipede burns might resemble child abuse in pediatric patients, necessitating further evaluation.⁵ 

It is unusual to see a millipede burn in nontropical regions. Therefore, the identification of our patient’s millipede burn was notable and serves as a reminder to keep this diagnosis in the differential when caring for patients with pigmentary changes. An accurate diagnosis hinges on being alert to a millipede exposure history and recognizing the clinical manifestations. For affected patients, it may be beneficial to recommend they advise friends and relatives to avoid skin contact with millipedes and most importantly to avoid stepping on them with bare feet.

THE DIAGNOSIS: Malignant Proliferating Trichilemmal Tumor

Biopsy revealed a squamous epithelium with cystic changes, trichilemmal differentiation, squamous eddy formation, keratinocyte atypia, focal necrotic changes, and a focus of atypical keratinocytes invading the dermis (Figure 1). Based on these findings, a diagnosis of malignant proliferating trichilemmal tumor (MPTT) was made.

Malignant proliferating trichilemmal tumor is a rare adnexal tumor that develops from the outer root sheath of the hair follicle. It often arises due to malignant transformation of pre-existing trichilemmal cysts, but some cases occur de novo.¹ Malignant transformation is thought to start from a trichilemmal cyst in an adenomatous histologic stage, progressing to a proliferating trichilemmal cyst (PTC) in an epitheliomatous phase, ultimately becoming carcinomatous with MPTT.^2-4 This transformation has been categorized into 3 morphologic groups to predict tumor behavior, including benign PTCs (curable by excision), low-grade malignant PTCs (minor risk for local recurrence), and high-grade malignant PTCs (risk for regional spread and metastasis with cytologic atypical features and potential for aggressive growth).¹

More commonly observed in women in the fourth to eighth decades of life, MPTT may manifest as a fast- growing, painless, solitary nodule or as a progressively enlarging nodule at the site of a previously stable, long-standing lesion. Malignant proliferating trichilemmal tumor manifests frequently on the scalp, face, or neck, but there are reports of MPTT manifesting on the trunk and even as multiple concurrent lesions.^1-4 The variability in clinical presentation and the potential to be mistaken for benign conditions makes excisional biopsy essential for diagnosis of MPTT. Histopathology classically demonstrates trichilemmal keratinization, a high mitotic index, and cellular atypia with invasion into the dermis.⁴ Malignant transformation frequently follows a prior history of trauma to the area or local inflammation.

Given the locally aggressive nature of MPTT, our patient was referred to a Mohs micrographic surgeon. While both wide excision with tumor-free margins and Mohs micrographic surgery are accepted surgical procedures for MPTT, there is no consensus in the literature on a standard treatment recommendation. Following surgery, close monitoring is needed for potential recurrence and metastases intracranially to the dura and muscles,⁵ as well as to the lungs.⁶ Further imaging using computed tomography or positron emission tomography can be ordered to rule out metastatic disease.⁴

Pilomatrixomas are benign neoplasms that arise from hair matrix cells and have been associated with catenin beta-1 gene mutations, as well as genetic syndromes and trauma.⁷ Clinically, pilomatrixomas manifest as solitary, firm, painless, slow-growing nodules that commonly are found in the head and neck region. This tumor has a slight predominance in women and occurs frequently in adolescent years. The overlying skin may appear normal or show grey-bluish discoloration.⁸ Histopathology shows basaloid cells resembling primitive hair matrix cells with an abrupt transition to shadow cells composed of transformed keratinocytes without nuclei and calcification.^7-8 This tumor can be differentiated by the presence of basaloid and shadow cells with calcification on histopathology, while MPTT will show atypical, mitotically active squamous cells with trichilemmal keratinization (Figure 2).

Proliferating trichilemmal cyst is a variant of trichilemmal cyst (TC) arising from the outer root sheath cells of the hair follicle. While TCs usually are slow growing and benign, the proliferating variant can be more aggressive with malignant potential. Patients often present with a solitary, well-circumscribed, rapidly growing nodule on the scalp. The lesion may be painful, and ulceration can occur, exposing the cystic contents. Histopathologically, PTCs resemble TCs with trichilemmal keratinization but also exhibit notable epithelial proliferation within the cystic space.⁹ While there can be considerable histopathologic overlap between PTC and MPTT—including extensive trichilemmal keratinization, variable atypia, and mitotic activity—PTC typically should not demonstrate invasion into the surrounding soft tissue or the degree of high-grade atypia, brisk mitoses, or necrosis seen in MPTT (eFigure 1).¹ Immunohistochemistry may help distinguish PTC from MPTT and squamous cell carcinoma (SCC).^10-11 The pattern of Ki-67 and p53 expression may be helpful with classification of PTC/MPTT into the 3 groups (benign, low-grade malignant, and high-grade malignant) proposed by Ye et al.¹ Other investigators have suggested that Ki-67 expression may correlate potential for recurrence and clinical prognosis.¹² Expression of CD34 (a marker that supports outer root sheath origin) might favor PTC/MPTT over SCC; however, cases of CD34- negative MPTT have been reported, particularly those with poorly differentiated histopathology.

Squamous cell carcinoma with cystic features is a histologic variant of SCC characterized by cystlike spaces containing malignant squamous epithelial cells.¹³ Squamous cell carcinoma with cystic features can manifest as a firm nodule with ulceration similar to MPTT or PTC but also can mimic a benign cyst.¹⁴ The diagnosis of invasive SCC with cystic features typically is straightforward and characterized by cords and nests of atypical keratinocytes extending into the dermis with areas of cystic architecture (eFigure 2). While both SCC with cystic features and MPTT may show cystic histopathologic architecture, MPTT typically shows areas of PTC, whereas SCC with cystic features lacks such areas.

Verrucous cysts refer to infundibular cysts or less commonly pilar cysts or hybrid pilar-epidermoid cysts that exhibit superimposed human papillomavirus (HPV) cytopathic changes. Clinically, a verrucous cyst manifests as a single, asymptomatic, slow-growing, firm lesion most commonly manifesting on the face and back. Histopathologically, the cyst wall may show acanthosis, papillomatosis, hypergranulosis with coarse keratohyalin granules, and koilocytic changes (eFigure 3). These histopathologic features are believed to be induced by secondary HPV infection. While HPV-related change, characterized by koilocytic alteration, papillomatosis, and verruciform hyperplasia, more commonly affects epidermal cysts, occasionally trichilemmal (pilar) cysts are involved. In these cases, verrucous cysts should be distinguished from MPTT. Verrucous cysts may contain rare normal mitotic figures, but do not contain atypical mitosis, marked cellular pleomorphism, or an infiltrating pattern similar to MPTT.¹⁵

THE DIAGNOSIS: Malignant Proliferating Trichilemmal Tumor

Biopsy revealed a squamous epithelium with cystic changes, trichilemmal differentiation, squamous eddy formation, keratinocyte atypia, focal necrotic changes, and a focus of atypical keratinocytes invading the dermis (Figure 1). Based on these findings, a diagnosis of malignant proliferating trichilemmal tumor (MPTT) was made.

Malignant proliferating trichilemmal tumor is a rare adnexal tumor that develops from the outer root sheath of the hair follicle. It often arises due to malignant transformation of pre-existing trichilemmal cysts, but some cases occur de novo.¹ Malignant transformation is thought to start from a trichilemmal cyst in an adenomatous histologic stage, progressing to a proliferating trichilemmal cyst (PTC) in an epitheliomatous phase, ultimately becoming carcinomatous with MPTT.^2-4 This transformation has been categorized into 3 morphologic groups to predict tumor behavior, including benign PTCs (curable by excision), low-grade malignant PTCs (minor risk for local recurrence), and high-grade malignant PTCs (risk for regional spread and metastasis with cytologic atypical features and potential for aggressive growth).¹

More commonly observed in women in the fourth to eighth decades of life, MPTT may manifest as a fast- growing, painless, solitary nodule or as a progressively enlarging nodule at the site of a previously stable, long-standing lesion. Malignant proliferating trichilemmal tumor manifests frequently on the scalp, face, or neck, but there are reports of MPTT manifesting on the trunk and even as multiple concurrent lesions.^1-4 The variability in clinical presentation and the potential to be mistaken for benign conditions makes excisional biopsy essential for diagnosis of MPTT. Histopathology classically demonstrates trichilemmal keratinization, a high mitotic index, and cellular atypia with invasion into the dermis.⁴ Malignant transformation frequently follows a prior history of trauma to the area or local inflammation.

Given the locally aggressive nature of MPTT, our patient was referred to a Mohs micrographic surgeon. While both wide excision with tumor-free margins and Mohs micrographic surgery are accepted surgical procedures for MPTT, there is no consensus in the literature on a standard treatment recommendation. Following surgery, close monitoring is needed for potential recurrence and metastases intracranially to the dura and muscles,⁵ as well as to the lungs.⁶ Further imaging using computed tomography or positron emission tomography can be ordered to rule out metastatic disease.⁴

Pilomatrixomas are benign neoplasms that arise from hair matrix cells and have been associated with catenin beta-1 gene mutations, as well as genetic syndromes and trauma.⁷ Clinically, pilomatrixomas manifest as solitary, firm, painless, slow-growing nodules that commonly are found in the head and neck region. This tumor has a slight predominance in women and occurs frequently in adolescent years. The overlying skin may appear normal or show grey-bluish discoloration.⁸ Histopathology shows basaloid cells resembling primitive hair matrix cells with an abrupt transition to shadow cells composed of transformed keratinocytes without nuclei and calcification.^7-8 This tumor can be differentiated by the presence of basaloid and shadow cells with calcification on histopathology, while MPTT will show atypical, mitotically active squamous cells with trichilemmal keratinization (Figure 2).

Proliferating trichilemmal cyst is a variant of trichilemmal cyst (TC) arising from the outer root sheath cells of the hair follicle. While TCs usually are slow growing and benign, the proliferating variant can be more aggressive with malignant potential. Patients often present with a solitary, well-circumscribed, rapidly growing nodule on the scalp. The lesion may be painful, and ulceration can occur, exposing the cystic contents. Histopathologically, PTCs resemble TCs with trichilemmal keratinization but also exhibit notable epithelial proliferation within the cystic space.⁹ While there can be considerable histopathologic overlap between PTC and MPTT—including extensive trichilemmal keratinization, variable atypia, and mitotic activity—PTC typically should not demonstrate invasion into the surrounding soft tissue or the degree of high-grade atypia, brisk mitoses, or necrosis seen in MPTT (eFigure 1).¹ Immunohistochemistry may help distinguish PTC from MPTT and squamous cell carcinoma (SCC).^10-11 The pattern of Ki-67 and p53 expression may be helpful with classification of PTC/MPTT into the 3 groups (benign, low-grade malignant, and high-grade malignant) proposed by Ye et al.¹ Other investigators have suggested that Ki-67 expression may correlate potential for recurrence and clinical prognosis.¹² Expression of CD34 (a marker that supports outer root sheath origin) might favor PTC/MPTT over SCC; however, cases of CD34- negative MPTT have been reported, particularly those with poorly differentiated histopathology.

Squamous cell carcinoma with cystic features is a histologic variant of SCC characterized by cystlike spaces containing malignant squamous epithelial cells.¹³ Squamous cell carcinoma with cystic features can manifest as a firm nodule with ulceration similar to MPTT or PTC but also can mimic a benign cyst.¹⁴ The diagnosis of invasive SCC with cystic features typically is straightforward and characterized by cords and nests of atypical keratinocytes extending into the dermis with areas of cystic architecture (eFigure 2). While both SCC with cystic features and MPTT may show cystic histopathologic architecture, MPTT typically shows areas of PTC, whereas SCC with cystic features lacks such areas.

Verrucous cysts refer to infundibular cysts or less commonly pilar cysts or hybrid pilar-epidermoid cysts that exhibit superimposed human papillomavirus (HPV) cytopathic changes. Clinically, a verrucous cyst manifests as a single, asymptomatic, slow-growing, firm lesion most commonly manifesting on the face and back. Histopathologically, the cyst wall may show acanthosis, papillomatosis, hypergranulosis with coarse keratohyalin granules, and koilocytic changes (eFigure 3). These histopathologic features are believed to be induced by secondary HPV infection. While HPV-related change, characterized by koilocytic alteration, papillomatosis, and verruciform hyperplasia, more commonly affects epidermal cysts, occasionally trichilemmal (pilar) cysts are involved. In these cases, verrucous cysts should be distinguished from MPTT. Verrucous cysts may contain rare normal mitotic figures, but do not contain atypical mitosis, marked cellular pleomorphism, or an infiltrating pattern similar to MPTT.¹⁵

THE DIAGNOSIS: Malignant Proliferating Trichilemmal Tumor

Biopsy revealed a squamous epithelium with cystic changes, trichilemmal differentiation, squamous eddy formation, keratinocyte atypia, focal necrotic changes, and a focus of atypical keratinocytes invading the dermis (Figure 1). Based on these findings, a diagnosis of malignant proliferating trichilemmal tumor (MPTT) was made.

Malignant proliferating trichilemmal tumor is a rare adnexal tumor that develops from the outer root sheath of the hair follicle. It often arises due to malignant transformation of pre-existing trichilemmal cysts, but some cases occur de novo.¹ Malignant transformation is thought to start from a trichilemmal cyst in an adenomatous histologic stage, progressing to a proliferating trichilemmal cyst (PTC) in an epitheliomatous phase, ultimately becoming carcinomatous with MPTT.^2-4 This transformation has been categorized into 3 morphologic groups to predict tumor behavior, including benign PTCs (curable by excision), low-grade malignant PTCs (minor risk for local recurrence), and high-grade malignant PTCs (risk for regional spread and metastasis with cytologic atypical features and potential for aggressive growth).¹

More commonly observed in women in the fourth to eighth decades of life, MPTT may manifest as a fast- growing, painless, solitary nodule or as a progressively enlarging nodule at the site of a previously stable, long-standing lesion. Malignant proliferating trichilemmal tumor manifests frequently on the scalp, face, or neck, but there are reports of MPTT manifesting on the trunk and even as multiple concurrent lesions.^1-4 The variability in clinical presentation and the potential to be mistaken for benign conditions makes excisional biopsy essential for diagnosis of MPTT. Histopathology classically demonstrates trichilemmal keratinization, a high mitotic index, and cellular atypia with invasion into the dermis.⁴ Malignant transformation frequently follows a prior history of trauma to the area or local inflammation.

Given the locally aggressive nature of MPTT, our patient was referred to a Mohs micrographic surgeon. While both wide excision with tumor-free margins and Mohs micrographic surgery are accepted surgical procedures for MPTT, there is no consensus in the literature on a standard treatment recommendation. Following surgery, close monitoring is needed for potential recurrence and metastases intracranially to the dura and muscles,⁵ as well as to the lungs.⁶ Further imaging using computed tomography or positron emission tomography can be ordered to rule out metastatic disease.⁴

Pilomatrixomas are benign neoplasms that arise from hair matrix cells and have been associated with catenin beta-1 gene mutations, as well as genetic syndromes and trauma.⁷ Clinically, pilomatrixomas manifest as solitary, firm, painless, slow-growing nodules that commonly are found in the head and neck region. This tumor has a slight predominance in women and occurs frequently in adolescent years. The overlying skin may appear normal or show grey-bluish discoloration.⁸ Histopathology shows basaloid cells resembling primitive hair matrix cells with an abrupt transition to shadow cells composed of transformed keratinocytes without nuclei and calcification.^7-8 This tumor can be differentiated by the presence of basaloid and shadow cells with calcification on histopathology, while MPTT will show atypical, mitotically active squamous cells with trichilemmal keratinization (Figure 2).

Proliferating trichilemmal cyst is a variant of trichilemmal cyst (TC) arising from the outer root sheath cells of the hair follicle. While TCs usually are slow growing and benign, the proliferating variant can be more aggressive with malignant potential. Patients often present with a solitary, well-circumscribed, rapidly growing nodule on the scalp. The lesion may be painful, and ulceration can occur, exposing the cystic contents. Histopathologically, PTCs resemble TCs with trichilemmal keratinization but also exhibit notable epithelial proliferation within the cystic space.⁹ While there can be considerable histopathologic overlap between PTC and MPTT—including extensive trichilemmal keratinization, variable atypia, and mitotic activity—PTC typically should not demonstrate invasion into the surrounding soft tissue or the degree of high-grade atypia, brisk mitoses, or necrosis seen in MPTT (eFigure 1).¹ Immunohistochemistry may help distinguish PTC from MPTT and squamous cell carcinoma (SCC).^10-11 The pattern of Ki-67 and p53 expression may be helpful with classification of PTC/MPTT into the 3 groups (benign, low-grade malignant, and high-grade malignant) proposed by Ye et al.¹ Other investigators have suggested that Ki-67 expression may correlate potential for recurrence and clinical prognosis.¹² Expression of CD34 (a marker that supports outer root sheath origin) might favor PTC/MPTT over SCC; however, cases of CD34- negative MPTT have been reported, particularly those with poorly differentiated histopathology.

Squamous cell carcinoma with cystic features is a histologic variant of SCC characterized by cystlike spaces containing malignant squamous epithelial cells.¹³ Squamous cell carcinoma with cystic features can manifest as a firm nodule with ulceration similar to MPTT or PTC but also can mimic a benign cyst.¹⁴ The diagnosis of invasive SCC with cystic features typically is straightforward and characterized by cords and nests of atypical keratinocytes extending into the dermis with areas of cystic architecture (eFigure 2). While both SCC with cystic features and MPTT may show cystic histopathologic architecture, MPTT typically shows areas of PTC, whereas SCC with cystic features lacks such areas.

Verrucous cysts refer to infundibular cysts or less commonly pilar cysts or hybrid pilar-epidermoid cysts that exhibit superimposed human papillomavirus (HPV) cytopathic changes. Clinically, a verrucous cyst manifests as a single, asymptomatic, slow-growing, firm lesion most commonly manifesting on the face and back. Histopathologically, the cyst wall may show acanthosis, papillomatosis, hypergranulosis with coarse keratohyalin granules, and koilocytic changes (eFigure 3). These histopathologic features are believed to be induced by secondary HPV infection. While HPV-related change, characterized by koilocytic alteration, papillomatosis, and verruciform hyperplasia, more commonly affects epidermal cysts, occasionally trichilemmal (pilar) cysts are involved. In these cases, verrucous cysts should be distinguished from MPTT. Verrucous cysts may contain rare normal mitotic figures, but do not contain atypical mitosis, marked cellular pleomorphism, or an infiltrating pattern similar to MPTT.¹⁵