There has been a rise in the prevalence of perniolike lesions—erythematous to violaceous, edematous papules or nodules on the fingers or toes—during the coronavirus disease 2019 (COVID-19) pandemic. These lesions are referred to as “COVID toes.” Although several studies have suggested an association with these lesions and COVID-19, and coronavirus particles have been identified in endothelial cells of biopsies of pernio lesions, questions remain on the management, pathophysiology, and implications of these lesions.¹ We provide a practical review for primary care clinicians and dermatologists on the current management, recommendations, and remaining questions, with particular attention to the distinctions for children vs adults presenting with pernio lesions.

Hypothetical Case of a Child Presenting With Acral Lesions

A 7-year-old boy presents with acute-onset, violaceous, mildly painful and pruritic macules on the distal toes that began 3 days earlier and have progressed to involve more toes and appear more purpuric. A review of symptoms reveals no fever, cough, fatigue, or viral symptoms. He has been staying at home for the last few weeks with his brother, mother, and father. His father is working in delivery services and is social distancing at work but not at home. His mother is concerned about the lesions, if they could be COVID toes, and if testing is needed for the patient or family. In your assessment and management of this patient, you consider the following questions.

What Is the Relationship Between These Clinical Findings and COVID-19?
Despite negative polymerase chain reaction (PCR) tests reported in cases of chilblains during the COVID-19 pandemic as well as the possibility that these lesions are an indirect result of environmental factors or behavioral changes during quarantine, the majority of studies favor an association between these chilblains lesions and COVID-19 infection.^2,3 Most compellingly, COVID-19 viral particles have been identified by immunohistochemistry and electron microscopy in the endothelial cells of biopsies of these lesions.¹ Additionally, there is evidence for possible associations of other viruses, including Epstein-Barr virus and parvovirus B19, with chilblains lesions.^4,5 In sum, with the lack of any large prospective study, the weight of current evidence suggests that these perniolike skin lesions are not specific markers of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).⁶

Published studies differ in reporting the coincidence of perniolike lesions with typical COVID-19 symptoms, including fever, dyspnea, cough, fatigue, myalgia, headache, and anosmia, among others. Some studies have reported that up to 63% of patients with reported perniolike lesions developed typical COVID-19 symptoms, but other studies found that no patients with these lesions developed symptoms.^6-11 Studies with younger cohorts tended to report lower prevalence of COVID-19 symptoms, and within cohorts, younger patients tended to have less severe symptoms. For example, 78.8% of patients in a cohort (n=58) with an average age of 14 years did not experience COVID-19–related symptoms.⁶ Based on these data, it has been hypothesized that patients with chilblainslike lesions may represent a subpopulation who will have a robust interferon response that is protective from more symptomatic and severe COVID-19.^12-14

Current evidence suggests that these lesions are most likely to occur between 9 days and 2 months after the onset of COVID-19 symptoms.^4,9,10 Most cases have been only mildly symptomatic, with an overall favorable prognosis of both lesions and any viral symptoms.^8,10 The lesions typically resolve without treatment within a few days of initial onset.^15,16

What Should Be the Workup and Management of These Lesions?
Given the currently available information and favorable prognosis, usually no further workup specific to the perniolike lesions is required in the case of an asymptomatic child presenting with acral lesions, and the majority of management will center around patient and parent/guardian education and reassurance. When asked by the patient’s parent, “What does it mean that my child has these lesions?”, clinicians can provide information on the possible association with COVID-19 and the excellent, self-resolving prognosis. An example of honest and reasonable phrasing with current understanding might be, “We are currently not certain if COVID-19 causes these lesions, although there are data to suggest that they are associated. There are a lot of data showing that children with these lesions either do not have any symptoms or have very mild symptoms that resolve without treatment.”

For management, important considerations include how painful the lesions are to the individual patient and how they affect quality of life. If less severe, clinicians can reassure patients and parents/guardians that the lesions will likely self-resolve without treatment. If worsening or symptomatic, clinicians can try typical treatments for chilblains, such as topical steroids, whole-body warming, and nifedipine.^17-19 Obtaining a review of symptoms, including COVID-19 symptoms and general viral symptoms, is important given the rare cases of children with severe COVID-19.^20,21

The question of COVID-19 testing as related to these lesions remains controversial, and currently there are still differing perspectives on the need for biopsy, PCR for COVID-19, or serologies for COVID-19 in patients presenting with these lesions. Some experts report that additional testing is not needed in the pediatric population because of the high frequency of negative testing reported to date.^22,23 However, these children may be silent carriers, and until more is known about their potential to transmit the virus, testing may be considered if resources allow, particularly if the patient has a known exposure.^10,12,16,24 The ultimate decision to pursue biopsy or serologic workup for COVID-19 remains up to clinical discretion with consideration of symptoms, severity, and immunocompromised household contacts. If lesions developed after infection, PCR likely will result negative, whereas serologic testing may reveal antibodies.

Hypothetical Case of an Adult Presenting With Acral Lesions and COVID-19 Symptoms

A 50-year-old man presents with acute-onset, violaceous, painful, edematous plaques on the distal toes that began 3 days earlier and have progressed to include the soles. A review of symptoms reveals fever (temperature, 38.4 °C [101 °F]), cough, dyspnea, diarrhea, and severe asthenia. He has had interactions with a coworker who recently tested positive for COVID-19.

How Should You Consider These Lesions in the Context of the Other Symptoms Concerning for COVID-19?
In contrast to the asymptomatic child above, this adult has chilblainslike lesions and viral symptoms. In adults, chilblainslike lesions have been associated with relatively mild COVID-19, and patients with these lesions who are otherwise asymptomatic have largely tested negative for COVID-19 by PCR and serologic antibody testing.^11,25,26

True acral ischemia, which is more severe and should be differentiated from chilblains, has been reported in critically ill patients.⁹ Additionally, studies have found that retiform purpura is the most common cutaneous finding in patients with severe COVID-19.²⁷ For this patient, who has an examination consistent with progressive and severe chilblainslike lesions and suspicion for COVID-19 infection, it is important to observe and monitor these lesions, as clinical progression suggestive of acral ischemia or retiform purpura should be taken seriously and may indicate worsening of the underlying disease. Early intervention with anticoagulation might be considered, though there currently is no evidence of successful treatment.²⁸

What Causes These Lesions in a Patient With COVID-19?
The underlying pathophysiology has been proposed to be a monocytic-macrophage–induced hyperinflammatory systemic state that damages the lungs, as well as the gastrointestinal, renal, and endothelial systems. The activation of the innate immune system triggers a cytokine storm that creates a hypercoagulable state that ultimately can manifest as superficial thromboses, leading to gangrene of the extremities. Additionally, interferon response and resulting hypercytokinemia may cause direct cytopathic damage to the endothelium of arterioles and capillaries, causing the development of papulovesicular lesions that resemble the chilblainslike lesions observed in children.²⁹ In contrast to children, who typically have no or mild COVID-19 symptoms, adults may have a delayed interferon response, which has been proposed to allow for more severe manifestations of infection.^12,30

How Should an Adult With Perniolike Lesions Be Managed?
Adults with chilblainslike lesions and no other signs or symptoms of COVID-19 infection do not necessarily need be tested for COVID-19, given the reports demonstrating most patients in this clinical situation will have negative PCRs and serologies for antibodies. However, there have been several reports of adults with acro-ischemic skin findings who also had severe COVID-19, with an observed incidence of 23% in intensive care unit patients with COVID-19.^27,28,31,32 If there is suspicion of infection with COVID-19, it is advisable to first obtain workup for COVID-19 and other viruses that can cause acral lesions, including Epstein-Barr virus and parvovirus. Other pertinent laboratory tests may include D-dimer, fibrinogen, prothrombin time, activated partial thromboplastin time, antithrombin activity, platelet count, neutrophil count, procalcitonin, triglycerides, ferritin, C-reactive protein, and hemoglobin. For patients with evidence of worsening acro-ischemia, regular monitoring of these values up to several times per week can allow for initiation of vascular intervention, including angiontensin-converting enzyme inhibitors, statins, or antiplatelet drugs.³² The presence of antiphospholipid antibodies also has been associated with critically ill patients who develop digit ischemia as part of the sequelae of COVID-19 infection and therefore may act as an important marker for the potential to develop disseminated intravascular coagulation in this patient.³³ Even if COVID-19 infection is not suspected, a thorough review of systems is important to look for an underlying connective tissue disease, such as systemic lupus erythematosus, which is associated with pernio. Associated symptoms may warrant workup with antinuclear antibodies and other appropriate autoimmune serologies.

If there is any doubt of the diagnosis, the patient is experiencing symptoms from the lesion, or the patient is experiencing other viral symptoms, it is appropriate to biopsy immediately to confirm the diagnosis. Prior studies have identified fibrin clots, angiocentric and eccrinotropic lymphocytic infiltrates, lymphocytic vasculopathy, and papillary dermal edema as the most common features in chilblainslike lesions during the COVID-19 pandemic.⁹

For COVID-19 testing, many studies have revealed adult patients with an acute hypercoagulable state testing positive by SARS-CoV-2 PCR. These same patients also experienced thromboembolic events shortly after testing positive for COVID-19, which suggests that patients with elevated D-dimer and fibrinogen likely will have a viral load that is sufficient to test positive for COVID-19.^32,34-36 It is appropriate to test all patients with suspected COVID-19, especially adults who are more likely to experience adverse complications secondary to infection.

This patient experiencing COVID-19 symptoms with signs of acral ischemia is likely to test positive by PCR, and additional testing for serologic antibodies is unlikely to be clinically meaningful in this patient’s state. Furthermore, there is little evidence that serology is reliable because of the markedly high levels of both false-negative and false-positive results when using the available antibody testing kits.³⁷ The latter evidence makes serology testing of little value for the general population, but particularly for patients with acute COVID-19.

Conclusion and Outstanding Questions

There is evidence suggesting an association between chilblainslike lesions and COVID-19.^11,22,38,39 Children presenting with these lesions have an excellent prognosis and only need a workup or treatment if there are other symptoms, as the lesions self-resolve in the majority of reported cases.^7-9 Adults presenting with these lesions and without symptoms likewise are unlikely to test positive for COVID-19, and the lesions typically resolve spontaneously or with first-line treatment. However, adults presenting with these lesions and COVID-19 symptoms should raise clinical concern for evolving skin manifestations of acro-ischemia. If the diagnosis is uncertain or systemic symptoms are concerning, biopsy, COVID-19 PCR, and other appropriate laboratory workup should be obtained.

There remains controversy and uncertainty over the relationship between these skin findings and SARS-CoV-2 infection, with clinical evidence to support both a direct relationship representing convalescent-phase cutaneous reaction as well as an indirect epiphenomenon. If there was a direct relationship, we would have expected to see a rise in the incidence of acral lesions proportionate to the rising caseload of COVID-19 after the reopening of many states in the summer of 2020. Similarly, because young adults represent the largest demographic of increasing cases and as some schools have remained open for in-person instruction during the current academic year, we also would have expected the incidence of chilblains-like lesions presenting to dermatologists and pediatricians to increase alongside these cases. Continued evaluation of emerging literature and ongoing efforts to understand the cause of this observed phenomenon will hopefully help us arrive at a future understanding of the pathophysiology of this puzzling skin manifestation.⁴⁰

There has been a rise in the prevalence of perniolike lesions—erythematous to violaceous, edematous papules or nodules on the fingers or toes—during the coronavirus disease 2019 (COVID-19) pandemic. These lesions are referred to as “COVID toes.” Although several studies have suggested an association with these lesions and COVID-19, and coronavirus particles have been identified in endothelial cells of biopsies of pernio lesions, questions remain on the management, pathophysiology, and implications of these lesions.¹ We provide a practical review for primary care clinicians and dermatologists on the current management, recommendations, and remaining questions, with particular attention to the distinctions for children vs adults presenting with pernio lesions.

Hypothetical Case of a Child Presenting With Acral Lesions

A 7-year-old boy presents with acute-onset, violaceous, mildly painful and pruritic macules on the distal toes that began 3 days earlier and have progressed to involve more toes and appear more purpuric. A review of symptoms reveals no fever, cough, fatigue, or viral symptoms. He has been staying at home for the last few weeks with his brother, mother, and father. His father is working in delivery services and is social distancing at work but not at home. His mother is concerned about the lesions, if they could be COVID toes, and if testing is needed for the patient or family. In your assessment and management of this patient, you consider the following questions.

What Is the Relationship Between These Clinical Findings and COVID-19?
Despite negative polymerase chain reaction (PCR) tests reported in cases of chilblains during the COVID-19 pandemic as well as the possibility that these lesions are an indirect result of environmental factors or behavioral changes during quarantine, the majority of studies favor an association between these chilblains lesions and COVID-19 infection.^2,3 Most compellingly, COVID-19 viral particles have been identified by immunohistochemistry and electron microscopy in the endothelial cells of biopsies of these lesions.¹ Additionally, there is evidence for possible associations of other viruses, including Epstein-Barr virus and parvovirus B19, with chilblains lesions.^4,5 In sum, with the lack of any large prospective study, the weight of current evidence suggests that these perniolike skin lesions are not specific markers of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).⁶

Published studies differ in reporting the coincidence of perniolike lesions with typical COVID-19 symptoms, including fever, dyspnea, cough, fatigue, myalgia, headache, and anosmia, among others. Some studies have reported that up to 63% of patients with reported perniolike lesions developed typical COVID-19 symptoms, but other studies found that no patients with these lesions developed symptoms.^6-11 Studies with younger cohorts tended to report lower prevalence of COVID-19 symptoms, and within cohorts, younger patients tended to have less severe symptoms. For example, 78.8% of patients in a cohort (n=58) with an average age of 14 years did not experience COVID-19–related symptoms.⁶ Based on these data, it has been hypothesized that patients with chilblainslike lesions may represent a subpopulation who will have a robust interferon response that is protective from more symptomatic and severe COVID-19.^12-14

Current evidence suggests that these lesions are most likely to occur between 9 days and 2 months after the onset of COVID-19 symptoms.^4,9,10 Most cases have been only mildly symptomatic, with an overall favorable prognosis of both lesions and any viral symptoms.^8,10 The lesions typically resolve without treatment within a few days of initial onset.^15,16

What Should Be the Workup and Management of These Lesions?
Given the currently available information and favorable prognosis, usually no further workup specific to the perniolike lesions is required in the case of an asymptomatic child presenting with acral lesions, and the majority of management will center around patient and parent/guardian education and reassurance. When asked by the patient’s parent, “What does it mean that my child has these lesions?”, clinicians can provide information on the possible association with COVID-19 and the excellent, self-resolving prognosis. An example of honest and reasonable phrasing with current understanding might be, “We are currently not certain if COVID-19 causes these lesions, although there are data to suggest that they are associated. There are a lot of data showing that children with these lesions either do not have any symptoms or have very mild symptoms that resolve without treatment.”

For management, important considerations include how painful the lesions are to the individual patient and how they affect quality of life. If less severe, clinicians can reassure patients and parents/guardians that the lesions will likely self-resolve without treatment. If worsening or symptomatic, clinicians can try typical treatments for chilblains, such as topical steroids, whole-body warming, and nifedipine.^17-19 Obtaining a review of symptoms, including COVID-19 symptoms and general viral symptoms, is important given the rare cases of children with severe COVID-19.^20,21

The question of COVID-19 testing as related to these lesions remains controversial, and currently there are still differing perspectives on the need for biopsy, PCR for COVID-19, or serologies for COVID-19 in patients presenting with these lesions. Some experts report that additional testing is not needed in the pediatric population because of the high frequency of negative testing reported to date.^22,23 However, these children may be silent carriers, and until more is known about their potential to transmit the virus, testing may be considered if resources allow, particularly if the patient has a known exposure.^10,12,16,24 The ultimate decision to pursue biopsy or serologic workup for COVID-19 remains up to clinical discretion with consideration of symptoms, severity, and immunocompromised household contacts. If lesions developed after infection, PCR likely will result negative, whereas serologic testing may reveal antibodies.

Hypothetical Case of an Adult Presenting With Acral Lesions and COVID-19 Symptoms

A 50-year-old man presents with acute-onset, violaceous, painful, edematous plaques on the distal toes that began 3 days earlier and have progressed to include the soles. A review of symptoms reveals fever (temperature, 38.4 °C [101 °F]), cough, dyspnea, diarrhea, and severe asthenia. He has had interactions with a coworker who recently tested positive for COVID-19.

How Should You Consider These Lesions in the Context of the Other Symptoms Concerning for COVID-19?
In contrast to the asymptomatic child above, this adult has chilblainslike lesions and viral symptoms. In adults, chilblainslike lesions have been associated with relatively mild COVID-19, and patients with these lesions who are otherwise asymptomatic have largely tested negative for COVID-19 by PCR and serologic antibody testing.^11,25,26

True acral ischemia, which is more severe and should be differentiated from chilblains, has been reported in critically ill patients.⁹ Additionally, studies have found that retiform purpura is the most common cutaneous finding in patients with severe COVID-19.²⁷ For this patient, who has an examination consistent with progressive and severe chilblainslike lesions and suspicion for COVID-19 infection, it is important to observe and monitor these lesions, as clinical progression suggestive of acral ischemia or retiform purpura should be taken seriously and may indicate worsening of the underlying disease. Early intervention with anticoagulation might be considered, though there currently is no evidence of successful treatment.²⁸

What Causes These Lesions in a Patient With COVID-19?
The underlying pathophysiology has been proposed to be a monocytic-macrophage–induced hyperinflammatory systemic state that damages the lungs, as well as the gastrointestinal, renal, and endothelial systems. The activation of the innate immune system triggers a cytokine storm that creates a hypercoagulable state that ultimately can manifest as superficial thromboses, leading to gangrene of the extremities. Additionally, interferon response and resulting hypercytokinemia may cause direct cytopathic damage to the endothelium of arterioles and capillaries, causing the development of papulovesicular lesions that resemble the chilblainslike lesions observed in children.²⁹ In contrast to children, who typically have no or mild COVID-19 symptoms, adults may have a delayed interferon response, which has been proposed to allow for more severe manifestations of infection.^12,30

How Should an Adult With Perniolike Lesions Be Managed?
Adults with chilblainslike lesions and no other signs or symptoms of COVID-19 infection do not necessarily need be tested for COVID-19, given the reports demonstrating most patients in this clinical situation will have negative PCRs and serologies for antibodies. However, there have been several reports of adults with acro-ischemic skin findings who also had severe COVID-19, with an observed incidence of 23% in intensive care unit patients with COVID-19.^27,28,31,32 If there is suspicion of infection with COVID-19, it is advisable to first obtain workup for COVID-19 and other viruses that can cause acral lesions, including Epstein-Barr virus and parvovirus. Other pertinent laboratory tests may include D-dimer, fibrinogen, prothrombin time, activated partial thromboplastin time, antithrombin activity, platelet count, neutrophil count, procalcitonin, triglycerides, ferritin, C-reactive protein, and hemoglobin. For patients with evidence of worsening acro-ischemia, regular monitoring of these values up to several times per week can allow for initiation of vascular intervention, including angiontensin-converting enzyme inhibitors, statins, or antiplatelet drugs.³² The presence of antiphospholipid antibodies also has been associated with critically ill patients who develop digit ischemia as part of the sequelae of COVID-19 infection and therefore may act as an important marker for the potential to develop disseminated intravascular coagulation in this patient.³³ Even if COVID-19 infection is not suspected, a thorough review of systems is important to look for an underlying connective tissue disease, such as systemic lupus erythematosus, which is associated with pernio. Associated symptoms may warrant workup with antinuclear antibodies and other appropriate autoimmune serologies.

If there is any doubt of the diagnosis, the patient is experiencing symptoms from the lesion, or the patient is experiencing other viral symptoms, it is appropriate to biopsy immediately to confirm the diagnosis. Prior studies have identified fibrin clots, angiocentric and eccrinotropic lymphocytic infiltrates, lymphocytic vasculopathy, and papillary dermal edema as the most common features in chilblainslike lesions during the COVID-19 pandemic.⁹

For COVID-19 testing, many studies have revealed adult patients with an acute hypercoagulable state testing positive by SARS-CoV-2 PCR. These same patients also experienced thromboembolic events shortly after testing positive for COVID-19, which suggests that patients with elevated D-dimer and fibrinogen likely will have a viral load that is sufficient to test positive for COVID-19.^32,34-36 It is appropriate to test all patients with suspected COVID-19, especially adults who are more likely to experience adverse complications secondary to infection.

This patient experiencing COVID-19 symptoms with signs of acral ischemia is likely to test positive by PCR, and additional testing for serologic antibodies is unlikely to be clinically meaningful in this patient’s state. Furthermore, there is little evidence that serology is reliable because of the markedly high levels of both false-negative and false-positive results when using the available antibody testing kits.³⁷ The latter evidence makes serology testing of little value for the general population, but particularly for patients with acute COVID-19.

Conclusion and Outstanding Questions

There is evidence suggesting an association between chilblainslike lesions and COVID-19.^11,22,38,39 Children presenting with these lesions have an excellent prognosis and only need a workup or treatment if there are other symptoms, as the lesions self-resolve in the majority of reported cases.^7-9 Adults presenting with these lesions and without symptoms likewise are unlikely to test positive for COVID-19, and the lesions typically resolve spontaneously or with first-line treatment. However, adults presenting with these lesions and COVID-19 symptoms should raise clinical concern for evolving skin manifestations of acro-ischemia. If the diagnosis is uncertain or systemic symptoms are concerning, biopsy, COVID-19 PCR, and other appropriate laboratory workup should be obtained.

There remains controversy and uncertainty over the relationship between these skin findings and SARS-CoV-2 infection, with clinical evidence to support both a direct relationship representing convalescent-phase cutaneous reaction as well as an indirect epiphenomenon. If there was a direct relationship, we would have expected to see a rise in the incidence of acral lesions proportionate to the rising caseload of COVID-19 after the reopening of many states in the summer of 2020. Similarly, because young adults represent the largest demographic of increasing cases and as some schools have remained open for in-person instruction during the current academic year, we also would have expected the incidence of chilblains-like lesions presenting to dermatologists and pediatricians to increase alongside these cases. Continued evaluation of emerging literature and ongoing efforts to understand the cause of this observed phenomenon will hopefully help us arrive at a future understanding of the pathophysiology of this puzzling skin manifestation.⁴⁰

There has been a rise in the prevalence of perniolike lesions—erythematous to violaceous, edematous papules or nodules on the fingers or toes—during the coronavirus disease 2019 (COVID-19) pandemic. These lesions are referred to as “COVID toes.” Although several studies have suggested an association with these lesions and COVID-19, and coronavirus particles have been identified in endothelial cells of biopsies of pernio lesions, questions remain on the management, pathophysiology, and implications of these lesions.¹ We provide a practical review for primary care clinicians and dermatologists on the current management, recommendations, and remaining questions, with particular attention to the distinctions for children vs adults presenting with pernio lesions.

Hypothetical Case of a Child Presenting With Acral Lesions

A 7-year-old boy presents with acute-onset, violaceous, mildly painful and pruritic macules on the distal toes that began 3 days earlier and have progressed to involve more toes and appear more purpuric. A review of symptoms reveals no fever, cough, fatigue, or viral symptoms. He has been staying at home for the last few weeks with his brother, mother, and father. His father is working in delivery services and is social distancing at work but not at home. His mother is concerned about the lesions, if they could be COVID toes, and if testing is needed for the patient or family. In your assessment and management of this patient, you consider the following questions.

What Is the Relationship Between These Clinical Findings and COVID-19?
Despite negative polymerase chain reaction (PCR) tests reported in cases of chilblains during the COVID-19 pandemic as well as the possibility that these lesions are an indirect result of environmental factors or behavioral changes during quarantine, the majority of studies favor an association between these chilblains lesions and COVID-19 infection.^2,3 Most compellingly, COVID-19 viral particles have been identified by immunohistochemistry and electron microscopy in the endothelial cells of biopsies of these lesions.¹ Additionally, there is evidence for possible associations of other viruses, including Epstein-Barr virus and parvovirus B19, with chilblains lesions.^4,5 In sum, with the lack of any large prospective study, the weight of current evidence suggests that these perniolike skin lesions are not specific markers of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).⁶

Published studies differ in reporting the coincidence of perniolike lesions with typical COVID-19 symptoms, including fever, dyspnea, cough, fatigue, myalgia, headache, and anosmia, among others. Some studies have reported that up to 63% of patients with reported perniolike lesions developed typical COVID-19 symptoms, but other studies found that no patients with these lesions developed symptoms.^6-11 Studies with younger cohorts tended to report lower prevalence of COVID-19 symptoms, and within cohorts, younger patients tended to have less severe symptoms. For example, 78.8% of patients in a cohort (n=58) with an average age of 14 years did not experience COVID-19–related symptoms.⁶ Based on these data, it has been hypothesized that patients with chilblainslike lesions may represent a subpopulation who will have a robust interferon response that is protective from more symptomatic and severe COVID-19.^12-14

Current evidence suggests that these lesions are most likely to occur between 9 days and 2 months after the onset of COVID-19 symptoms.^4,9,10 Most cases have been only mildly symptomatic, with an overall favorable prognosis of both lesions and any viral symptoms.^8,10 The lesions typically resolve without treatment within a few days of initial onset.^15,16

What Should Be the Workup and Management of These Lesions?
Given the currently available information and favorable prognosis, usually no further workup specific to the perniolike lesions is required in the case of an asymptomatic child presenting with acral lesions, and the majority of management will center around patient and parent/guardian education and reassurance. When asked by the patient’s parent, “What does it mean that my child has these lesions?”, clinicians can provide information on the possible association with COVID-19 and the excellent, self-resolving prognosis. An example of honest and reasonable phrasing with current understanding might be, “We are currently not certain if COVID-19 causes these lesions, although there are data to suggest that they are associated. There are a lot of data showing that children with these lesions either do not have any symptoms or have very mild symptoms that resolve without treatment.”

For management, important considerations include how painful the lesions are to the individual patient and how they affect quality of life. If less severe, clinicians can reassure patients and parents/guardians that the lesions will likely self-resolve without treatment. If worsening or symptomatic, clinicians can try typical treatments for chilblains, such as topical steroids, whole-body warming, and nifedipine.^17-19 Obtaining a review of symptoms, including COVID-19 symptoms and general viral symptoms, is important given the rare cases of children with severe COVID-19.^20,21

The question of COVID-19 testing as related to these lesions remains controversial, and currently there are still differing perspectives on the need for biopsy, PCR for COVID-19, or serologies for COVID-19 in patients presenting with these lesions. Some experts report that additional testing is not needed in the pediatric population because of the high frequency of negative testing reported to date.^22,23 However, these children may be silent carriers, and until more is known about their potential to transmit the virus, testing may be considered if resources allow, particularly if the patient has a known exposure.^10,12,16,24 The ultimate decision to pursue biopsy or serologic workup for COVID-19 remains up to clinical discretion with consideration of symptoms, severity, and immunocompromised household contacts. If lesions developed after infection, PCR likely will result negative, whereas serologic testing may reveal antibodies.

Hypothetical Case of an Adult Presenting With Acral Lesions and COVID-19 Symptoms

A 50-year-old man presents with acute-onset, violaceous, painful, edematous plaques on the distal toes that began 3 days earlier and have progressed to include the soles. A review of symptoms reveals fever (temperature, 38.4 °C [101 °F]), cough, dyspnea, diarrhea, and severe asthenia. He has had interactions with a coworker who recently tested positive for COVID-19.

How Should You Consider These Lesions in the Context of the Other Symptoms Concerning for COVID-19?
In contrast to the asymptomatic child above, this adult has chilblainslike lesions and viral symptoms. In adults, chilblainslike lesions have been associated with relatively mild COVID-19, and patients with these lesions who are otherwise asymptomatic have largely tested negative for COVID-19 by PCR and serologic antibody testing.^11,25,26

True acral ischemia, which is more severe and should be differentiated from chilblains, has been reported in critically ill patients.⁹ Additionally, studies have found that retiform purpura is the most common cutaneous finding in patients with severe COVID-19.²⁷ For this patient, who has an examination consistent with progressive and severe chilblainslike lesions and suspicion for COVID-19 infection, it is important to observe and monitor these lesions, as clinical progression suggestive of acral ischemia or retiform purpura should be taken seriously and may indicate worsening of the underlying disease. Early intervention with anticoagulation might be considered, though there currently is no evidence of successful treatment.²⁸

What Causes These Lesions in a Patient With COVID-19?
The underlying pathophysiology has been proposed to be a monocytic-macrophage–induced hyperinflammatory systemic state that damages the lungs, as well as the gastrointestinal, renal, and endothelial systems. The activation of the innate immune system triggers a cytokine storm that creates a hypercoagulable state that ultimately can manifest as superficial thromboses, leading to gangrene of the extremities. Additionally, interferon response and resulting hypercytokinemia may cause direct cytopathic damage to the endothelium of arterioles and capillaries, causing the development of papulovesicular lesions that resemble the chilblainslike lesions observed in children.²⁹ In contrast to children, who typically have no or mild COVID-19 symptoms, adults may have a delayed interferon response, which has been proposed to allow for more severe manifestations of infection.^12,30

How Should an Adult With Perniolike Lesions Be Managed?
Adults with chilblainslike lesions and no other signs or symptoms of COVID-19 infection do not necessarily need be tested for COVID-19, given the reports demonstrating most patients in this clinical situation will have negative PCRs and serologies for antibodies. However, there have been several reports of adults with acro-ischemic skin findings who also had severe COVID-19, with an observed incidence of 23% in intensive care unit patients with COVID-19.^27,28,31,32 If there is suspicion of infection with COVID-19, it is advisable to first obtain workup for COVID-19 and other viruses that can cause acral lesions, including Epstein-Barr virus and parvovirus. Other pertinent laboratory tests may include D-dimer, fibrinogen, prothrombin time, activated partial thromboplastin time, antithrombin activity, platelet count, neutrophil count, procalcitonin, triglycerides, ferritin, C-reactive protein, and hemoglobin. For patients with evidence of worsening acro-ischemia, regular monitoring of these values up to several times per week can allow for initiation of vascular intervention, including angiontensin-converting enzyme inhibitors, statins, or antiplatelet drugs.³² The presence of antiphospholipid antibodies also has been associated with critically ill patients who develop digit ischemia as part of the sequelae of COVID-19 infection and therefore may act as an important marker for the potential to develop disseminated intravascular coagulation in this patient.³³ Even if COVID-19 infection is not suspected, a thorough review of systems is important to look for an underlying connective tissue disease, such as systemic lupus erythematosus, which is associated with pernio. Associated symptoms may warrant workup with antinuclear antibodies and other appropriate autoimmune serologies.

If there is any doubt of the diagnosis, the patient is experiencing symptoms from the lesion, or the patient is experiencing other viral symptoms, it is appropriate to biopsy immediately to confirm the diagnosis. Prior studies have identified fibrin clots, angiocentric and eccrinotropic lymphocytic infiltrates, lymphocytic vasculopathy, and papillary dermal edema as the most common features in chilblainslike lesions during the COVID-19 pandemic.⁹

For COVID-19 testing, many studies have revealed adult patients with an acute hypercoagulable state testing positive by SARS-CoV-2 PCR. These same patients also experienced thromboembolic events shortly after testing positive for COVID-19, which suggests that patients with elevated D-dimer and fibrinogen likely will have a viral load that is sufficient to test positive for COVID-19.^32,34-36 It is appropriate to test all patients with suspected COVID-19, especially adults who are more likely to experience adverse complications secondary to infection.

This patient experiencing COVID-19 symptoms with signs of acral ischemia is likely to test positive by PCR, and additional testing for serologic antibodies is unlikely to be clinically meaningful in this patient’s state. Furthermore, there is little evidence that serology is reliable because of the markedly high levels of both false-negative and false-positive results when using the available antibody testing kits.³⁷ The latter evidence makes serology testing of little value for the general population, but particularly for patients with acute COVID-19.

Conclusion and Outstanding Questions

There is evidence suggesting an association between chilblainslike lesions and COVID-19.^11,22,38,39 Children presenting with these lesions have an excellent prognosis and only need a workup or treatment if there are other symptoms, as the lesions self-resolve in the majority of reported cases.^7-9 Adults presenting with these lesions and without symptoms likewise are unlikely to test positive for COVID-19, and the lesions typically resolve spontaneously or with first-line treatment. However, adults presenting with these lesions and COVID-19 symptoms should raise clinical concern for evolving skin manifestations of acro-ischemia. If the diagnosis is uncertain or systemic symptoms are concerning, biopsy, COVID-19 PCR, and other appropriate laboratory workup should be obtained.

There remains controversy and uncertainty over the relationship between these skin findings and SARS-CoV-2 infection, with clinical evidence to support both a direct relationship representing convalescent-phase cutaneous reaction as well as an indirect epiphenomenon. If there was a direct relationship, we would have expected to see a rise in the incidence of acral lesions proportionate to the rising caseload of COVID-19 after the reopening of many states in the summer of 2020. Similarly, because young adults represent the largest demographic of increasing cases and as some schools have remained open for in-person instruction during the current academic year, we also would have expected the incidence of chilblains-like lesions presenting to dermatologists and pediatricians to increase alongside these cases. Continued evaluation of emerging literature and ongoing efforts to understand the cause of this observed phenomenon will hopefully help us arrive at a future understanding of the pathophysiology of this puzzling skin manifestation.⁴⁰

Hidradenitis suppurativa (HS)(also known as acne inversa) is a chronic, recurrent, and debilitating inflammatory dermatologic disease of the hair follicle. It usually presents after puberty, with painful, deep-seated, inflamed lesions in apocrine gland–bearing areas of the body, most commonly the axillae and inguinal and anogenital regions.¹

Hidradenitis suppurativa patients have a high rate of psychologic and psychiatric comorbidities that often are interrelated and multidirectional. Approximately 1 in 4 adults with HS also experience depression (prevalence among all HS patients, 16.9%), and 1 in 5 experience anxiety (prevalence, 4.9%).^2,3 Hidradenitis suppurativa has been associated with bipolar disorder, schizophrenia, and suicidality.^2,4

These comorbidity factors have a remarkable impact on HS patients’ quality of life (QOL). Compared to other diseases, including psoriasis, stroke, and conditions that create candidacy for heart transplantation, HS was identified as the most impairing condition.^5,6 It is estimated that more than 50% of HS patients experience a very or extremely large effect on their QOL, as measured by the dermatology life quality index.⁶

Pain, a major component of low QOL in HS patients, has an adverse impact on emotional health. Hidradenitis suppurativa causes body image dissatisfaction, leading to shame, embarrassment, lack of self-confidence, stigmatization, and social isolation.^7-9 Furthermore, patients with HS have an increased risk for antidepressant drug use, completed suicide, and suicidal behavior compared to the general population.¹⁰

Focusing therapy on physical manifestations of HS only while ignoring the psychologic aspect could lead to a vicious cycle in which stress triggers flares, leading to worsening HS, leading to more stress, and so on.¹¹ Therefore, psychological support for HS patients is critical, and we believe it should be an integral part of managing the disease.

There is no evidence to support effective therapeutic intervention for psychological aspects of HS. We conducted a PubMed search of articles indexed for MEDLINE using the term hidradenitis in combination with psychology, psychological, mindfulness, and cognitive behavioral therapy. No relevant articles were found. Most articles on HS focused on the low QOL associated with the disease and patient coping mechanisms. However, there are a number of psychological therapies to consider and evaluate for the management of HS.

Psychological Therapies to Consider in HS

Cognitive Behavioral Treatment
Cognitive behavioral treatment has been successfully used to manage skin diseases other than HS.¹² Patients’ shame and stigmatization due to body dissatisfaction often cause social isolation, which might appear as social anxiety.^9,13 Cognitive behavioral treatment, or compassion-focused therapy, could increase patients’ self-acceptance and reduce shameful feelings.¹³

Group Therapy
Alternatively, group therapy might be beneficial for HS patients. Research has shown that most HS patients know others affected by the same disease or attend an HS support group, and patients value the support of peers with the disease.¹³ Therefore, group therapy meetings with HS patients that are directed by a health care professional might reduce feelings of shame and stigmatization and increase feelings of social acceptance.

Mindfulness
Another approach for managing psychological aspects of skin diseases that might be useful in HS is mindfulness-based stress reduction (MBSR), developed by Kabat-Zinn and colleagues,¹⁴ which helps patients develop mindfulness through training in meditation. It is an intensive, structured, patient-centered approach that has been successfully used in a variety of settings.^14,15

Current evidence supports the use of MBSR in the adjunct treatment of chronic pain, anxiety, and depression—symptoms that have a great impact on HS patients’ QOL.¹⁶ Furthermore, MBSR is offered in a group setting, which is potentially an opportunity for peer support and understanding; social support has been reported to be highly beneficial for HS patients.¹⁷

Can the Placebo Effect Aid in Managing HS?

A recent review that assessed the placebo effect in randomized clinical trials (RCTs) of treatments for cutaneous disease demonstrated that the placebo effect in HS therapy trials is higher than in RCTs of therapies for psoriasis and eczema. This finding highlights the importance of the physician-patient relationship when managing HS, which can result in greater treatment adherence and more patient education, empowerment, and encouragement toward beneficial lifestyle changes.¹⁸

Complementary psychological interventions for managing HS might maximize the placebo effect in clinical practice.¹⁸ The placebo effect in RCTs is higher for HS treatments than for psoriasis treatments, and if patients with psoriasis improved with psychological interventions,¹² it would be reasonable to expect an improvement in QOL with psychological interventions for HS.

Final Thoughts

Although a number of studies have been published in the medical literature regarding psychological intervention in psoriasis management,¹² we found no clinical studies assessing the psychological management of HS. We conclude that more research is necessary to develop psychological interventions targeting HS patients because a multidisciplinary and patient-centered approach is essential for the management of HS.

Hidradenitis suppurativa (HS)(also known as acne inversa) is a chronic, recurrent, and debilitating inflammatory dermatologic disease of the hair follicle. It usually presents after puberty, with painful, deep-seated, inflamed lesions in apocrine gland–bearing areas of the body, most commonly the axillae and inguinal and anogenital regions.¹

Hidradenitis suppurativa patients have a high rate of psychologic and psychiatric comorbidities that often are interrelated and multidirectional. Approximately 1 in 4 adults with HS also experience depression (prevalence among all HS patients, 16.9%), and 1 in 5 experience anxiety (prevalence, 4.9%).^2,3 Hidradenitis suppurativa has been associated with bipolar disorder, schizophrenia, and suicidality.^2,4

These comorbidity factors have a remarkable impact on HS patients’ quality of life (QOL). Compared to other diseases, including psoriasis, stroke, and conditions that create candidacy for heart transplantation, HS was identified as the most impairing condition.^5,6 It is estimated that more than 50% of HS patients experience a very or extremely large effect on their QOL, as measured by the dermatology life quality index.⁶

Pain, a major component of low QOL in HS patients, has an adverse impact on emotional health. Hidradenitis suppurativa causes body image dissatisfaction, leading to shame, embarrassment, lack of self-confidence, stigmatization, and social isolation.^7-9 Furthermore, patients with HS have an increased risk for antidepressant drug use, completed suicide, and suicidal behavior compared to the general population.¹⁰

Focusing therapy on physical manifestations of HS only while ignoring the psychologic aspect could lead to a vicious cycle in which stress triggers flares, leading to worsening HS, leading to more stress, and so on.¹¹ Therefore, psychological support for HS patients is critical, and we believe it should be an integral part of managing the disease.

There is no evidence to support effective therapeutic intervention for psychological aspects of HS. We conducted a PubMed search of articles indexed for MEDLINE using the term hidradenitis in combination with psychology, psychological, mindfulness, and cognitive behavioral therapy. No relevant articles were found. Most articles on HS focused on the low QOL associated with the disease and patient coping mechanisms. However, there are a number of psychological therapies to consider and evaluate for the management of HS.

Psychological Therapies to Consider in HS

Cognitive Behavioral Treatment
Cognitive behavioral treatment has been successfully used to manage skin diseases other than HS.¹² Patients’ shame and stigmatization due to body dissatisfaction often cause social isolation, which might appear as social anxiety.^9,13 Cognitive behavioral treatment, or compassion-focused therapy, could increase patients’ self-acceptance and reduce shameful feelings.¹³

Group Therapy
Alternatively, group therapy might be beneficial for HS patients. Research has shown that most HS patients know others affected by the same disease or attend an HS support group, and patients value the support of peers with the disease.¹³ Therefore, group therapy meetings with HS patients that are directed by a health care professional might reduce feelings of shame and stigmatization and increase feelings of social acceptance.

Mindfulness
Another approach for managing psychological aspects of skin diseases that might be useful in HS is mindfulness-based stress reduction (MBSR), developed by Kabat-Zinn and colleagues,¹⁴ which helps patients develop mindfulness through training in meditation. It is an intensive, structured, patient-centered approach that has been successfully used in a variety of settings.^14,15

Current evidence supports the use of MBSR in the adjunct treatment of chronic pain, anxiety, and depression—symptoms that have a great impact on HS patients’ QOL.¹⁶ Furthermore, MBSR is offered in a group setting, which is potentially an opportunity for peer support and understanding; social support has been reported to be highly beneficial for HS patients.¹⁷

Can the Placebo Effect Aid in Managing HS?

A recent review that assessed the placebo effect in randomized clinical trials (RCTs) of treatments for cutaneous disease demonstrated that the placebo effect in HS therapy trials is higher than in RCTs of therapies for psoriasis and eczema. This finding highlights the importance of the physician-patient relationship when managing HS, which can result in greater treatment adherence and more patient education, empowerment, and encouragement toward beneficial lifestyle changes.¹⁸

Complementary psychological interventions for managing HS might maximize the placebo effect in clinical practice.¹⁸ The placebo effect in RCTs is higher for HS treatments than for psoriasis treatments, and if patients with psoriasis improved with psychological interventions,¹² it would be reasonable to expect an improvement in QOL with psychological interventions for HS.

Final Thoughts

Although a number of studies have been published in the medical literature regarding psychological intervention in psoriasis management,¹² we found no clinical studies assessing the psychological management of HS. We conclude that more research is necessary to develop psychological interventions targeting HS patients because a multidisciplinary and patient-centered approach is essential for the management of HS.

Hidradenitis suppurativa (HS)(also known as acne inversa) is a chronic, recurrent, and debilitating inflammatory dermatologic disease of the hair follicle. It usually presents after puberty, with painful, deep-seated, inflamed lesions in apocrine gland–bearing areas of the body, most commonly the axillae and inguinal and anogenital regions.¹

Hidradenitis suppurativa patients have a high rate of psychologic and psychiatric comorbidities that often are interrelated and multidirectional. Approximately 1 in 4 adults with HS also experience depression (prevalence among all HS patients, 16.9%), and 1 in 5 experience anxiety (prevalence, 4.9%).^2,3 Hidradenitis suppurativa has been associated with bipolar disorder, schizophrenia, and suicidality.^2,4

These comorbidity factors have a remarkable impact on HS patients’ quality of life (QOL). Compared to other diseases, including psoriasis, stroke, and conditions that create candidacy for heart transplantation, HS was identified as the most impairing condition.^5,6 It is estimated that more than 50% of HS patients experience a very or extremely large effect on their QOL, as measured by the dermatology life quality index.⁶

Pain, a major component of low QOL in HS patients, has an adverse impact on emotional health. Hidradenitis suppurativa causes body image dissatisfaction, leading to shame, embarrassment, lack of self-confidence, stigmatization, and social isolation.^7-9 Furthermore, patients with HS have an increased risk for antidepressant drug use, completed suicide, and suicidal behavior compared to the general population.¹⁰

Focusing therapy on physical manifestations of HS only while ignoring the psychologic aspect could lead to a vicious cycle in which stress triggers flares, leading to worsening HS, leading to more stress, and so on.¹¹ Therefore, psychological support for HS patients is critical, and we believe it should be an integral part of managing the disease.

There is no evidence to support effective therapeutic intervention for psychological aspects of HS. We conducted a PubMed search of articles indexed for MEDLINE using the term hidradenitis in combination with psychology, psychological, mindfulness, and cognitive behavioral therapy. No relevant articles were found. Most articles on HS focused on the low QOL associated with the disease and patient coping mechanisms. However, there are a number of psychological therapies to consider and evaluate for the management of HS.

Psychological Therapies to Consider in HS

Cognitive Behavioral Treatment
Cognitive behavioral treatment has been successfully used to manage skin diseases other than HS.¹² Patients’ shame and stigmatization due to body dissatisfaction often cause social isolation, which might appear as social anxiety.^9,13 Cognitive behavioral treatment, or compassion-focused therapy, could increase patients’ self-acceptance and reduce shameful feelings.¹³

Group Therapy
Alternatively, group therapy might be beneficial for HS patients. Research has shown that most HS patients know others affected by the same disease or attend an HS support group, and patients value the support of peers with the disease.¹³ Therefore, group therapy meetings with HS patients that are directed by a health care professional might reduce feelings of shame and stigmatization and increase feelings of social acceptance.

Mindfulness
Another approach for managing psychological aspects of skin diseases that might be useful in HS is mindfulness-based stress reduction (MBSR), developed by Kabat-Zinn and colleagues,¹⁴ which helps patients develop mindfulness through training in meditation. It is an intensive, structured, patient-centered approach that has been successfully used in a variety of settings.^14,15

Current evidence supports the use of MBSR in the adjunct treatment of chronic pain, anxiety, and depression—symptoms that have a great impact on HS patients’ QOL.¹⁶ Furthermore, MBSR is offered in a group setting, which is potentially an opportunity for peer support and understanding; social support has been reported to be highly beneficial for HS patients.¹⁷

Can the Placebo Effect Aid in Managing HS?

A recent review that assessed the placebo effect in randomized clinical trials (RCTs) of treatments for cutaneous disease demonstrated that the placebo effect in HS therapy trials is higher than in RCTs of therapies for psoriasis and eczema. This finding highlights the importance of the physician-patient relationship when managing HS, which can result in greater treatment adherence and more patient education, empowerment, and encouragement toward beneficial lifestyle changes.¹⁸

Complementary psychological interventions for managing HS might maximize the placebo effect in clinical practice.¹⁸ The placebo effect in RCTs is higher for HS treatments than for psoriasis treatments, and if patients with psoriasis improved with psychological interventions,¹² it would be reasonable to expect an improvement in QOL with psychological interventions for HS.

Final Thoughts

Although a number of studies have been published in the medical literature regarding psychological intervention in psoriasis management,¹² we found no clinical studies assessing the psychological management of HS. We conclude that more research is necessary to develop psychological interventions targeting HS patients because a multidisciplinary and patient-centered approach is essential for the management of HS.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

The use of mobile devices in health care settings has enhanced clinical practice through real-time communication and direct patient monitoring.¹ With advancements in technology, improving the accessibility and quality of patient care using mobile devices is a hot topic. In 2018, 261.34 million people worldwide used smartphones compared to 280.54 million in 2021—a 7.3% increase.² Revenue from sales of mobile applications (apps) is projected to reach $693 billion in 2021.³

A range of apps targeted to patients is available for acne, melanoma, and teledermatology.^4-6 Nail disorders are a common concern, representing 21.1 million outpatient visits in 2007 to 2016,⁷ but, to date, the availability of apps related to nail disorders has not been explored. In this study, we investigated iOS (Apple’s iPhone Operating System) and Android apps to determine the types of nail health apps that are available, using psoriasis and hair loss apps as comparator groups.

Methods

A standard app analytics and market data tool (App Annie; https://www.appannie.com/en/) was utilized to search for iOS and Android nail mobile apps.^4,5 The analysis was performed on a single day (March 23, 2020), given that app searches can change on a daily basis. Our search included the following keywords: nail, nail health, toenail fungus, nail tumor, brittle nails, onychomycosis, onycholysis, subungual melanoma, nail melanoma, paronychia, and nail squamous cell carcinoma. App Annie app descriptions were assessed to determine the type of each app (Lifestyle, Medical, Health & Fitness) and target audience (patient, physician, or both). Psoriasis and hair loss topics were chosen as controls for comparison, based on a prior study.⁸ For psoriasis, the keywords psoriasis and chronic skin disease were searched. Hair loss was searched using the keywords alopecia, hair loss, hair health, and scalp.

Results

Nail-Related Apps
Using keywords for nail-related terms on iOS and Android platforms, our search returned few specific and informative apps related to nail disorders (Table 1). When the terms brittle nails, nail, nail health, nail squamous cell carcinoma, and nail tumor were searched, all available nail apps were either nail games or virtual nail salons for entertainment purposes. For the terms nail melanoma and subungual melanoma, there were no specific nail apps that appeared in the search results; rather, the App Annie search yielded only general dermatology and melanoma apps. The terms onycholysis and paronychia both yielded 0 hits for iOS and Android.

The only search terms that returned specific nail apps were onychomycosis and toenail fungus. Initially, when onychomycosis was searched, only 1 Google Play Medical category app was found: “Nail fungal infection (model onychomycosis).” Although this app recently was removed from the app store, it previously allowed the user to upload a nail photograph, with which a computing algorithm assessed whether the presentation was a fungal nail infection. Toenail fungus returned 1 iOS Medical category app and 5 Android Health & Fitness category apps with reference material for patients. Neither of the 2 medical apps for onychomycosis and toenail fungus referenced a physician involved in the app development.

Psoriasis Comparator
On the contrary, a search for psoriasis yielded 22 hits for iOS and 34 hits for Android within the Health & Fitness, Medical, and Social Networking categories (Table 2). The search term chronic skin disease returned 18 apps for iOS and 60 apps for Android related to psoriasis; 100% were classified as Medical apps.

Other Findings
Most apps for psoriasis and hair health were identified as patient focused. Although iOS and Android are different operating systems, some health apps overlapped: subungual melanoma and toenail fungus had a 20% overlap; psoriasis, 19%; chronic skin disease, 2%; alopecia, 0%; hair loss and hair health, 10%; and scalp, 18%. iOS and Android nail entertainment games had approximately a 30% overlap. Tables 1 and 2 also compare the number of free and paid apps; most available apps were free.

Comment

With continued growth in mobile device ownership and app development has been parallel growth in the creation and use of apps to enhance medical care.¹ In a study analyzing the most popular dermatology apps, 62% (18/29) and 38% (11/29) of apps targeted patients and physicians, respectively.⁶ Our study showed that (1) there are few nail disorder apps available for patient education and (2) there is no evidence that a physician was consulted for content input. Because patients who can effectively communicate their health concerns before and after seeing a physician have better self-reported clinical outcomes,⁹ it is important to have nail disorder apps available to patients for referencing. The nail health app options differ notably from psoriasis and hair loss apps, with apps for the latter 2 topics found in Medical and Health & Fitness categories—targeting patients who seek immediate access to health care and education.

Although there are several general dermatology apps that contain reference information for patients pertaining to nail conditions,⁶ using any of those apps would require a patient to have prior knowledge that dermatologists specialize in nail disorders and necessitate several steps to find nail-relevant information. For example, the patient would have to search dermatology in the iOS and Android app stores, select the available app (eg, Dermatology Database), and then search within that app for nail disorders. Therefore, a patient who is concerned about a possible subungual melanoma would not be able to easily find clinical images and explanations using an app.

Study Limitations
This study was subject to several limitations. Android and iOS app stores have undisclosed computing algorithms that might have filtered apps based on specific word inquiry. Also, our queries were based on specific relevant keywords for nail conditions, psoriasis, and hair loss; use of different keywords might have yielded different results. Additionally, app options change on a daily basis, so a search today (ie, any given day) might yield slightly different results than it did on March 23, 2020.

Conclusion

Specific nail disorder apps available for patient reference are limited. App developers should consider accessibility (ie, clear language, ease of use, cost-effectiveness, usability on iOS- and Android-operated devices) and content (accurate medical information from experts) when considering new apps. A solution to this problem is for established medical organizations to create nail disorder apps specifically for patients.¹⁰ For example, the American Academy of Dermatology has iOS and Android apps that are relevant to physicians (MyDermPath+, Dialogues in Dermatology, Mohs Surgery Appropriate Use Criteria) but no comparable apps for patients; patient-appropriate nail apps are necessary.¹¹ In addition, it would be beneficial to patients if established app companies consulted with dermatologists on pertinent nail content.

In sum, we found few available nail health apps on the iOS or Android platforms that provided accessible and timely information to patients regarding nail disorders. There is an immediate need to produce apps related to nail health for appropriate patient education.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Adding andecaliximab (ADX) to first-line treatment with modified oxaliplatin, leucovorin, and fluorouracil (mFOLFOX6) provided no survival benefit in patients with advanced HER2-negative gastric or gastroesophageal junction adenocarcinoma in the phase 3 GAMMA-1 study.

Objective response rates were 50.5% in the ADX arm and 41.1% in the placebo arm (stratified odds ratio, 1.47; P = .049), but this did not translate to improved survival.

The median overall survival (OS) was 12.5 months in the ADX arm and 11.8 months in the placebo arm (stratified hazard ratio, 0.93; P = .56). The median progression-free survival (PFS) was 7.5 months and 7.1 months, respectively (stratified HR, 0.84; P = .10).

Manish A. Shah, MD, of Weill Cornell Medicine, New York, and colleagues reported these results in the Journal of Clinical Oncology.

The lack of improvement when ADX was added to mFOLFOX6 was despite encouraging antitumor activity seen with the combination in a phase 1 and phase 1b study, the authors noted.

“Despite compelling early-phase data, the addition of ADX did not improve outcomes in an unselected patient population,” the authors wrote. “Tissue or blood samples were not available for correlative analyses to understand why ADX was less active than expected or to identify any gastric cancer subset that may derive greater benefit with ADX.”

The researchers did note, however, that subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older.
 

Study details

Participants in the double-blind GAMMA-1 trial were adults with confirmed locally advanced or metastatic adenocarcinoma of the stomach or gastroesophageal junction. They were enrolled at 132 centers worldwide between Oct. 13, 2015, and May 15, 2019.

There were 432 patients randomized to receive mFOLFOX6 plus either 800 mg of ADX (n = 218) or placebo (n = 214) infused on days 1 and 15 of each 28-day cycle until disease progression or intolerance.

As noted before, there was a significant improvement in response rate with the addition of ADX (P = .049) but no significant improvements in PFS (P = .10) or OS (P = .56).

On the other hand, subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older. The authors said this result is intriguing and warrants further study.

Among patients aged 65 and older, the median OS was 13.9 months in the ADX arm and 10.5 months in the placebo arm (stratified HR, 0.64; P = .03). The median PFS was 8.7 months and 5.6 months, respectively (stratified HR, 0.50; P < .001). However, the P values were not adjusted for multiplicity.

No significant differences were seen between the groups with respect to safety outcomes. Serious adverse events occurred in 47.7% of patients in the ADX arm and 51.4% of those in the placebo arm. Nine patients in the ADX arm and 13 in the placebo arm discontinued the study because of adverse events.

The GAMMA-1 trial was sponsored by Gilead Sciences. The authors disclosed relationships with Gilead and many other companies.

[email protected]

Adding andecaliximab (ADX) to first-line treatment with modified oxaliplatin, leucovorin, and fluorouracil (mFOLFOX6) provided no survival benefit in patients with advanced HER2-negative gastric or gastroesophageal junction adenocarcinoma in the phase 3 GAMMA-1 study.

Objective response rates were 50.5% in the ADX arm and 41.1% in the placebo arm (stratified odds ratio, 1.47; P = .049), but this did not translate to improved survival.

The median overall survival (OS) was 12.5 months in the ADX arm and 11.8 months in the placebo arm (stratified hazard ratio, 0.93; P = .56). The median progression-free survival (PFS) was 7.5 months and 7.1 months, respectively (stratified HR, 0.84; P = .10).

Manish A. Shah, MD, of Weill Cornell Medicine, New York, and colleagues reported these results in the Journal of Clinical Oncology.

The lack of improvement when ADX was added to mFOLFOX6 was despite encouraging antitumor activity seen with the combination in a phase 1 and phase 1b study, the authors noted.

“Despite compelling early-phase data, the addition of ADX did not improve outcomes in an unselected patient population,” the authors wrote. “Tissue or blood samples were not available for correlative analyses to understand why ADX was less active than expected or to identify any gastric cancer subset that may derive greater benefit with ADX.”

The researchers did note, however, that subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older.
 

Study details

Participants in the double-blind GAMMA-1 trial were adults with confirmed locally advanced or metastatic adenocarcinoma of the stomach or gastroesophageal junction. They were enrolled at 132 centers worldwide between Oct. 13, 2015, and May 15, 2019.

There were 432 patients randomized to receive mFOLFOX6 plus either 800 mg of ADX (n = 218) or placebo (n = 214) infused on days 1 and 15 of each 28-day cycle until disease progression or intolerance.

As noted before, there was a significant improvement in response rate with the addition of ADX (P = .049) but no significant improvements in PFS (P = .10) or OS (P = .56).

On the other hand, subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older. The authors said this result is intriguing and warrants further study.

Among patients aged 65 and older, the median OS was 13.9 months in the ADX arm and 10.5 months in the placebo arm (stratified HR, 0.64; P = .03). The median PFS was 8.7 months and 5.6 months, respectively (stratified HR, 0.50; P < .001). However, the P values were not adjusted for multiplicity.

No significant differences were seen between the groups with respect to safety outcomes. Serious adverse events occurred in 47.7% of patients in the ADX arm and 51.4% of those in the placebo arm. Nine patients in the ADX arm and 13 in the placebo arm discontinued the study because of adverse events.

The GAMMA-1 trial was sponsored by Gilead Sciences. The authors disclosed relationships with Gilead and many other companies.

[email protected]

Adding andecaliximab (ADX) to first-line treatment with modified oxaliplatin, leucovorin, and fluorouracil (mFOLFOX6) provided no survival benefit in patients with advanced HER2-negative gastric or gastroesophageal junction adenocarcinoma in the phase 3 GAMMA-1 study.

Objective response rates were 50.5% in the ADX arm and 41.1% in the placebo arm (stratified odds ratio, 1.47; P = .049), but this did not translate to improved survival.

The median overall survival (OS) was 12.5 months in the ADX arm and 11.8 months in the placebo arm (stratified hazard ratio, 0.93; P = .56). The median progression-free survival (PFS) was 7.5 months and 7.1 months, respectively (stratified HR, 0.84; P = .10).

Manish A. Shah, MD, of Weill Cornell Medicine, New York, and colleagues reported these results in the Journal of Clinical Oncology.

The lack of improvement when ADX was added to mFOLFOX6 was despite encouraging antitumor activity seen with the combination in a phase 1 and phase 1b study, the authors noted.

“Despite compelling early-phase data, the addition of ADX did not improve outcomes in an unselected patient population,” the authors wrote. “Tissue or blood samples were not available for correlative analyses to understand why ADX was less active than expected or to identify any gastric cancer subset that may derive greater benefit with ADX.”

The researchers did note, however, that subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older.
 

Study details

Participants in the double-blind GAMMA-1 trial were adults with confirmed locally advanced or metastatic adenocarcinoma of the stomach or gastroesophageal junction. They were enrolled at 132 centers worldwide between Oct. 13, 2015, and May 15, 2019.

There were 432 patients randomized to receive mFOLFOX6 plus either 800 mg of ADX (n = 218) or placebo (n = 214) infused on days 1 and 15 of each 28-day cycle until disease progression or intolerance.

As noted before, there was a significant improvement in response rate with the addition of ADX (P = .049) but no significant improvements in PFS (P = .10) or OS (P = .56).

On the other hand, subgroup analyses suggested survival benefits with ADX in patients aged 65 years and older. The authors said this result is intriguing and warrants further study.

Among patients aged 65 and older, the median OS was 13.9 months in the ADX arm and 10.5 months in the placebo arm (stratified HR, 0.64; P = .03). The median PFS was 8.7 months and 5.6 months, respectively (stratified HR, 0.50; P < .001). However, the P values were not adjusted for multiplicity.

No significant differences were seen between the groups with respect to safety outcomes. Serious adverse events occurred in 47.7% of patients in the ADX arm and 51.4% of those in the placebo arm. Nine patients in the ADX arm and 13 in the placebo arm discontinued the study because of adverse events.

The GAMMA-1 trial was sponsored by Gilead Sciences. The authors disclosed relationships with Gilead and many other companies.

[email protected]

Diagnosis of bleeding disorders in girls and women can lag behind diagnosis in boys and men by more than a decade, meaning needless delays in treatment and poor quality of life for many with hemophilia or related conditions.

“There is increasing awareness about issues faced by women and girls with inherited bleeding disorders, but disparities still exist both in both access to diagnosis and treatment,” said Roseline D’Oiron, MD, from Hôpital Bicêtre in Paris.

“Diagnosis, when it is made, is often made late, particularly in women. Indeed, a recent study from the European Hemophilia Consortium including more than 700 women with bleeding disorders showed that the median age at diagnosis was 16 years old,” she said during the annual congress of the European Association for Haemophilia and Allied Disorders.

She said that delayed diagnosis of bleeding disorders in women and girls may be caused by a lack of knowledge by patients, families, and general practitioners about family history of bleeding disorders, abnormal bleeding events, and heavy menstrual bleeding. In addition, despite the frequency and severity of heavy bleeding events, patients, their families, and caregivers may underestimate the effect on the patient’s quality of life.
 

Disparities documented

Dr. D’Oiron pointed to several studies showing clear sex-based disparities in time to diagnosis. For example, a study published in Haemophilia showed that in 22 girls with hemophilia A or hemophilia B, the diagnosis of severe hemophilia was delayed by a median of 6.5 months compared with the diagnosis in boys, and a diagnosis of moderate hemophilia in girls was delayed by a median of 39 months.

In a second, single-center study comparing 44 women and girls with mild hemophilia (factor VIII or factor XI levels from 5 to 50 IU/dL) with 77 men and boys with mild hemophilia, the mean age at diagnosis was 31.63 years versus 19.18 years, respectively – a delay of 12.45 years.

A third study comparing 442 girls/women and 442 boys/men with mild hemophilia in France showed a difference of 6.07 years in diagnosis: the median age for girls/women at diagnosis was 16.91 years versus10.84 years for boys/men.
 

Why it matters

Dr. D’Oiron described the case of a patient named Clare, who first experienced, at age 8, 12 hours of bleeding following a dental procedure. At age 12.5, she began having heavy menstrual bleeding, causing her to miss school for a few days each month, to be feel tired, and have poor-quality sleep.

Despite repeated bleeding episodes, severe anemia, and iron deficiency, her hemophilia was not suspected until after her 16th birthday, and a definitive diagnosis of hemophilia in both Clare and her mother was finally made when Clare was past 17, when a nonsense variant factor in F8, the gene encoding for factor VIII, was detected.

“For Clare, it took more the 8 years after the first bleeding symptoms, and nearly 4 years after presenting with heavy menstrual bleeding to recognize that she had a bleeding problem,” she said.

In total, Clare had about 450 days of heavy menstrual bleeding, causing her to miss an estimated 140 days of school because of the delayed diagnosis and treatment.

“In my view, this is the main argument why it is urgent for these patients to achieve diagnosis early: this is to reduce the duration [of] a very poor quality of life,” Dr. D’Oiron said.
 

Barriers to diagnosis

Patients and families have reported difficulty distinguishing normal bleeding from abnormal symptoms, and girls may be reluctant to discuss their symptoms with their family or peers. In addition, primary care practitioners may not recognize the severity of the symptoms and therefore may not refer patients to hematologists for further workup.

These findings emphasize the need for improved tools to help patients differentiate between normal and abnormal bleeding, using symptom recognition–based language tools that can lead to early testing and application of accurate diagnostic tools, she said.

Standardization of definitions can help to improve screening and diagnosis, Dr. D’Oiron said, pointing to a recent study in Blood Advances proposing definitions for future research in von Willebrand disease.

For example, the authors of that study proposed a definition of heavy menstrual bleeding to include any of the following:

• Bleeding lasting 8 or more days
• Bleeding that consistently soaks through one or more sanitary protections every 2 hours on multiple days
• Requires use of more than one sanitary protection item at a time
• Requires changing sanitary protection during the night
• Is associated with repeat passing of blood clots
• Has a Pictorial Blood Assessment Chart score greater than 100.
•  

Problem and solutions

Answering the question posed in the title of her talk, Dr. D’Oiron said: “Yes, we do have a problem with the diagnosis of bleeding disorders in women and girls, but we also have solutions.”

The solutions include family and patient outreach efforts; communication to improve awareness; inclusion of general practitioners in the circle of care; and early screening, diagnosis, and treatment.

A bleeding disorders specialist who was not involved in the study said that Dr. D’Oiron’s report closely reflects what she sees in the clinic.

“I do pediatrics, and usually what happens is that I see a teenager with heavy menstrual bleeding and we take her history, and we find out that Mom and multiple female family members have had horrible menstrual bleeding, possibly many of whom have had hysterectomies for it, and then diagnosing the parents and other family members after diagnosing the girl that we’re seeing” said Veronica H. Flood, MD, from the Medical College of Wisconsin, Milwaukee.

“It is unfortunately a very real thing,” she added.

Reasons for the delay likely include lack of awareness of bleeding disorders.

“If you present to a hematologist, we think about bleeding disorders, but if you present to a primary care physician, they don’t always have that on their radar,” she said.

Additionally, a girl from a family with a history of heavy menstrual bleeding may just assume that what she is experiencing is “normal,” despite the serious affect it has on her quality of life, Dr. Flood said.

Dr. D’Oiron’s research is supported by her institution, the French Hemophilia Association, FranceCoag and Mhemon, the European Hemophilia Consortium, and the World Federation of Hemophilia. She reported advisory board or invited speaker activities for multiple companies. Dr. Flood reported having no conflicts of interest to disclose.

Diagnosis of bleeding disorders in girls and women can lag behind diagnosis in boys and men by more than a decade, meaning needless delays in treatment and poor quality of life for many with hemophilia or related conditions.

“There is increasing awareness about issues faced by women and girls with inherited bleeding disorders, but disparities still exist both in both access to diagnosis and treatment,” said Roseline D’Oiron, MD, from Hôpital Bicêtre in Paris.

“Diagnosis, when it is made, is often made late, particularly in women. Indeed, a recent study from the European Hemophilia Consortium including more than 700 women with bleeding disorders showed that the median age at diagnosis was 16 years old,” she said during the annual congress of the European Association for Haemophilia and Allied Disorders.

She said that delayed diagnosis of bleeding disorders in women and girls may be caused by a lack of knowledge by patients, families, and general practitioners about family history of bleeding disorders, abnormal bleeding events, and heavy menstrual bleeding. In addition, despite the frequency and severity of heavy bleeding events, patients, their families, and caregivers may underestimate the effect on the patient’s quality of life.
 

Disparities documented

Dr. D’Oiron pointed to several studies showing clear sex-based disparities in time to diagnosis. For example, a study published in Haemophilia showed that in 22 girls with hemophilia A or hemophilia B, the diagnosis of severe hemophilia was delayed by a median of 6.5 months compared with the diagnosis in boys, and a diagnosis of moderate hemophilia in girls was delayed by a median of 39 months.

In a second, single-center study comparing 44 women and girls with mild hemophilia (factor VIII or factor XI levels from 5 to 50 IU/dL) with 77 men and boys with mild hemophilia, the mean age at diagnosis was 31.63 years versus 19.18 years, respectively – a delay of 12.45 years.

A third study comparing 442 girls/women and 442 boys/men with mild hemophilia in France showed a difference of 6.07 years in diagnosis: the median age for girls/women at diagnosis was 16.91 years versus10.84 years for boys/men.
 

Why it matters

Dr. D’Oiron described the case of a patient named Clare, who first experienced, at age 8, 12 hours of bleeding following a dental procedure. At age 12.5, she began having heavy menstrual bleeding, causing her to miss school for a few days each month, to be feel tired, and have poor-quality sleep.

Despite repeated bleeding episodes, severe anemia, and iron deficiency, her hemophilia was not suspected until after her 16th birthday, and a definitive diagnosis of hemophilia in both Clare and her mother was finally made when Clare was past 17, when a nonsense variant factor in F8, the gene encoding for factor VIII, was detected.

“For Clare, it took more the 8 years after the first bleeding symptoms, and nearly 4 years after presenting with heavy menstrual bleeding to recognize that she had a bleeding problem,” she said.

In total, Clare had about 450 days of heavy menstrual bleeding, causing her to miss an estimated 140 days of school because of the delayed diagnosis and treatment.

“In my view, this is the main argument why it is urgent for these patients to achieve diagnosis early: this is to reduce the duration [of] a very poor quality of life,” Dr. D’Oiron said.
 

Barriers to diagnosis

Patients and families have reported difficulty distinguishing normal bleeding from abnormal symptoms, and girls may be reluctant to discuss their symptoms with their family or peers. In addition, primary care practitioners may not recognize the severity of the symptoms and therefore may not refer patients to hematologists for further workup.

These findings emphasize the need for improved tools to help patients differentiate between normal and abnormal bleeding, using symptom recognition–based language tools that can lead to early testing and application of accurate diagnostic tools, she said.

Standardization of definitions can help to improve screening and diagnosis, Dr. D’Oiron said, pointing to a recent study in Blood Advances proposing definitions for future research in von Willebrand disease.

For example, the authors of that study proposed a definition of heavy menstrual bleeding to include any of the following:

• Bleeding lasting 8 or more days
• Bleeding that consistently soaks through one or more sanitary protections every 2 hours on multiple days
• Requires use of more than one sanitary protection item at a time
• Requires changing sanitary protection during the night
• Is associated with repeat passing of blood clots
• Has a Pictorial Blood Assessment Chart score greater than 100.
•  

Problem and solutions

Answering the question posed in the title of her talk, Dr. D’Oiron said: “Yes, we do have a problem with the diagnosis of bleeding disorders in women and girls, but we also have solutions.”

The solutions include family and patient outreach efforts; communication to improve awareness; inclusion of general practitioners in the circle of care; and early screening, diagnosis, and treatment.

A bleeding disorders specialist who was not involved in the study said that Dr. D’Oiron’s report closely reflects what she sees in the clinic.

“I do pediatrics, and usually what happens is that I see a teenager with heavy menstrual bleeding and we take her history, and we find out that Mom and multiple female family members have had horrible menstrual bleeding, possibly many of whom have had hysterectomies for it, and then diagnosing the parents and other family members after diagnosing the girl that we’re seeing” said Veronica H. Flood, MD, from the Medical College of Wisconsin, Milwaukee.

“It is unfortunately a very real thing,” she added.

Reasons for the delay likely include lack of awareness of bleeding disorders.

“If you present to a hematologist, we think about bleeding disorders, but if you present to a primary care physician, they don’t always have that on their radar,” she said.

Additionally, a girl from a family with a history of heavy menstrual bleeding may just assume that what she is experiencing is “normal,” despite the serious affect it has on her quality of life, Dr. Flood said.

Dr. D’Oiron’s research is supported by her institution, the French Hemophilia Association, FranceCoag and Mhemon, the European Hemophilia Consortium, and the World Federation of Hemophilia. She reported advisory board or invited speaker activities for multiple companies. Dr. Flood reported having no conflicts of interest to disclose.

Diagnosis of bleeding disorders in girls and women can lag behind diagnosis in boys and men by more than a decade, meaning needless delays in treatment and poor quality of life for many with hemophilia or related conditions.

“There is increasing awareness about issues faced by women and girls with inherited bleeding disorders, but disparities still exist both in both access to diagnosis and treatment,” said Roseline D’Oiron, MD, from Hôpital Bicêtre in Paris.

“Diagnosis, when it is made, is often made late, particularly in women. Indeed, a recent study from the European Hemophilia Consortium including more than 700 women with bleeding disorders showed that the median age at diagnosis was 16 years old,” she said during the annual congress of the European Association for Haemophilia and Allied Disorders.

She said that delayed diagnosis of bleeding disorders in women and girls may be caused by a lack of knowledge by patients, families, and general practitioners about family history of bleeding disorders, abnormal bleeding events, and heavy menstrual bleeding. In addition, despite the frequency and severity of heavy bleeding events, patients, their families, and caregivers may underestimate the effect on the patient’s quality of life.
 

Disparities documented

Dr. D’Oiron pointed to several studies showing clear sex-based disparities in time to diagnosis. For example, a study published in Haemophilia showed that in 22 girls with hemophilia A or hemophilia B, the diagnosis of severe hemophilia was delayed by a median of 6.5 months compared with the diagnosis in boys, and a diagnosis of moderate hemophilia in girls was delayed by a median of 39 months.

In a second, single-center study comparing 44 women and girls with mild hemophilia (factor VIII or factor XI levels from 5 to 50 IU/dL) with 77 men and boys with mild hemophilia, the mean age at diagnosis was 31.63 years versus 19.18 years, respectively – a delay of 12.45 years.

A third study comparing 442 girls/women and 442 boys/men with mild hemophilia in France showed a difference of 6.07 years in diagnosis: the median age for girls/women at diagnosis was 16.91 years versus10.84 years for boys/men.
 

Why it matters

Dr. D’Oiron described the case of a patient named Clare, who first experienced, at age 8, 12 hours of bleeding following a dental procedure. At age 12.5, she began having heavy menstrual bleeding, causing her to miss school for a few days each month, to be feel tired, and have poor-quality sleep.

Despite repeated bleeding episodes, severe anemia, and iron deficiency, her hemophilia was not suspected until after her 16th birthday, and a definitive diagnosis of hemophilia in both Clare and her mother was finally made when Clare was past 17, when a nonsense variant factor in F8, the gene encoding for factor VIII, was detected.

“For Clare, it took more the 8 years after the first bleeding symptoms, and nearly 4 years after presenting with heavy menstrual bleeding to recognize that she had a bleeding problem,” she said.

In total, Clare had about 450 days of heavy menstrual bleeding, causing her to miss an estimated 140 days of school because of the delayed diagnosis and treatment.

“In my view, this is the main argument why it is urgent for these patients to achieve diagnosis early: this is to reduce the duration [of] a very poor quality of life,” Dr. D’Oiron said.
 

Barriers to diagnosis

Patients and families have reported difficulty distinguishing normal bleeding from abnormal symptoms, and girls may be reluctant to discuss their symptoms with their family or peers. In addition, primary care practitioners may not recognize the severity of the symptoms and therefore may not refer patients to hematologists for further workup.

These findings emphasize the need for improved tools to help patients differentiate between normal and abnormal bleeding, using symptom recognition–based language tools that can lead to early testing and application of accurate diagnostic tools, she said.

Standardization of definitions can help to improve screening and diagnosis, Dr. D’Oiron said, pointing to a recent study in Blood Advances proposing definitions for future research in von Willebrand disease.

For example, the authors of that study proposed a definition of heavy menstrual bleeding to include any of the following:

• Bleeding lasting 8 or more days
• Bleeding that consistently soaks through one or more sanitary protections every 2 hours on multiple days
• Requires use of more than one sanitary protection item at a time
• Requires changing sanitary protection during the night
• Is associated with repeat passing of blood clots
• Has a Pictorial Blood Assessment Chart score greater than 100.
•  

Problem and solutions

Answering the question posed in the title of her talk, Dr. D’Oiron said: “Yes, we do have a problem with the diagnosis of bleeding disorders in women and girls, but we also have solutions.”

The solutions include family and patient outreach efforts; communication to improve awareness; inclusion of general practitioners in the circle of care; and early screening, diagnosis, and treatment.

A bleeding disorders specialist who was not involved in the study said that Dr. D’Oiron’s report closely reflects what she sees in the clinic.

“I do pediatrics, and usually what happens is that I see a teenager with heavy menstrual bleeding and we take her history, and we find out that Mom and multiple female family members have had horrible menstrual bleeding, possibly many of whom have had hysterectomies for it, and then diagnosing the parents and other family members after diagnosing the girl that we’re seeing” said Veronica H. Flood, MD, from the Medical College of Wisconsin, Milwaukee.

“It is unfortunately a very real thing,” she added.

Reasons for the delay likely include lack of awareness of bleeding disorders.

“If you present to a hematologist, we think about bleeding disorders, but if you present to a primary care physician, they don’t always have that on their radar,” she said.

Additionally, a girl from a family with a history of heavy menstrual bleeding may just assume that what she is experiencing is “normal,” despite the serious affect it has on her quality of life, Dr. Flood said.

Dr. D’Oiron’s research is supported by her institution, the French Hemophilia Association, FranceCoag and Mhemon, the European Hemophilia Consortium, and the World Federation of Hemophilia. She reported advisory board or invited speaker activities for multiple companies. Dr. Flood reported having no conflicts of interest to disclose.

People who are fully vaccinated against COVID-19 can safely gather unmasked and inside with nonvulnerable people who are not yet immunized, according to long-awaited guidance released by the CDC.

“Today’s action represents an important first step. It is not our final destination,” CDC Director Rochelle Walensky, MD, said March 8 at a White House briefing. “As more people get vaccinated, levels of COVID-19 infection decline in communities, and as our understanding of COVID immunity improves, we look forward to updating these recommendations to the public.”

According to the new guidance, people who are at least 2 weeks out from their last dose can:

• Visit with other fully vaccinated people indoors without wearing masks or physical distancing.
• Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
• Avoid quarantine and testing following exposure to someone if they remain asymptomatic.

However, there are still restrictions that will remain until further data are collected. Those who are fully vaccinated must still:

• Wear masks and physically distance in public settings and around people at high risk for severe disease.
• Wear masks and physically distance when visiting unvaccinated people from more than one household.
• Avoid medium- and large-sized gatherings.
• Avoid travel.

People considered at high risk for severe disease include older adults and those with cancer, chronic kidney disease, COPD, Down syndrome, heart disease, heart failure, a weakened immune system, obesity, sickle cell disease, and type 2 diabetes. The category also includes pregnant women and smokers.

“In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace or school guidance,” the guidance says. “Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19.”

Respecting travel restrictions is still crucial, Dr. Walensky said, given past surges and variants that have emerged after periods of increased travel.

"We would like to give the opportunity for vaccinated grandparents to visit children and grandchildren who are healthy and local,” Dr. Walensky said.

But, she said, “It’s important to realize as we’re working through this that over 90% of the population is not yet vaccinated.”

For now, there are not enough data on transmission rates from those who are vaccinated to the rest of the public. However, Anthony Fauci, MD, said at a briefing last month that preliminary data are “pointing in a very favorable direction.”

Studies from Spain and Israel published last month showed the amount of viral load – or the amount of the COVID-19 virus in someone’s body – is significantly lower if someone gets infected after they’ve been vaccinated, compared with people who get infected and didn’t have the vaccine. Lower viral load means much lower chances of passing the virus to someone else, Dr. Fauci said.

“The science of COVID-19 is complex,” Dr. Walensky said, “and our understanding of it continues to evolve.”

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

People who are fully vaccinated against COVID-19 can safely gather unmasked and inside with nonvulnerable people who are not yet immunized, according to long-awaited guidance released by the CDC.

“Today’s action represents an important first step. It is not our final destination,” CDC Director Rochelle Walensky, MD, said March 8 at a White House briefing. “As more people get vaccinated, levels of COVID-19 infection decline in communities, and as our understanding of COVID immunity improves, we look forward to updating these recommendations to the public.”

According to the new guidance, people who are at least 2 weeks out from their last dose can:

• Visit with other fully vaccinated people indoors without wearing masks or physical distancing.
• Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
• Avoid quarantine and testing following exposure to someone if they remain asymptomatic.

However, there are still restrictions that will remain until further data are collected. Those who are fully vaccinated must still:

• Wear masks and physically distance in public settings and around people at high risk for severe disease.
• Wear masks and physically distance when visiting unvaccinated people from more than one household.
• Avoid medium- and large-sized gatherings.
• Avoid travel.

People considered at high risk for severe disease include older adults and those with cancer, chronic kidney disease, COPD, Down syndrome, heart disease, heart failure, a weakened immune system, obesity, sickle cell disease, and type 2 diabetes. The category also includes pregnant women and smokers.

“In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace or school guidance,” the guidance says. “Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19.”

Respecting travel restrictions is still crucial, Dr. Walensky said, given past surges and variants that have emerged after periods of increased travel.

"We would like to give the opportunity for vaccinated grandparents to visit children and grandchildren who are healthy and local,” Dr. Walensky said.

But, she said, “It’s important to realize as we’re working through this that over 90% of the population is not yet vaccinated.”

For now, there are not enough data on transmission rates from those who are vaccinated to the rest of the public. However, Anthony Fauci, MD, said at a briefing last month that preliminary data are “pointing in a very favorable direction.”

Studies from Spain and Israel published last month showed the amount of viral load – or the amount of the COVID-19 virus in someone’s body – is significantly lower if someone gets infected after they’ve been vaccinated, compared with people who get infected and didn’t have the vaccine. Lower viral load means much lower chances of passing the virus to someone else, Dr. Fauci said.

“The science of COVID-19 is complex,” Dr. Walensky said, “and our understanding of it continues to evolve.”

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

People who are fully vaccinated against COVID-19 can safely gather unmasked and inside with nonvulnerable people who are not yet immunized, according to long-awaited guidance released by the CDC.

“Today’s action represents an important first step. It is not our final destination,” CDC Director Rochelle Walensky, MD, said March 8 at a White House briefing. “As more people get vaccinated, levels of COVID-19 infection decline in communities, and as our understanding of COVID immunity improves, we look forward to updating these recommendations to the public.”

According to the new guidance, people who are at least 2 weeks out from their last dose can:

• Visit with other fully vaccinated people indoors without wearing masks or physical distancing.
• Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
• Avoid quarantine and testing following exposure to someone if they remain asymptomatic.

However, there are still restrictions that will remain until further data are collected. Those who are fully vaccinated must still:

• Wear masks and physically distance in public settings and around people at high risk for severe disease.
• Wear masks and physically distance when visiting unvaccinated people from more than one household.
• Avoid medium- and large-sized gatherings.
• Avoid travel.

People considered at high risk for severe disease include older adults and those with cancer, chronic kidney disease, COPD, Down syndrome, heart disease, heart failure, a weakened immune system, obesity, sickle cell disease, and type 2 diabetes. The category also includes pregnant women and smokers.

“In public spaces, fully vaccinated people should continue to follow guidance to protect themselves and others, including wearing a well-fitted mask, physical distancing (at least 6 feet), avoiding crowds, avoiding poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following any applicable workplace or school guidance,” the guidance says. “Fully vaccinated people should still watch for symptoms of COVID-19, especially following an exposure to someone with suspected or confirmed COVID-19.”

Respecting travel restrictions is still crucial, Dr. Walensky said, given past surges and variants that have emerged after periods of increased travel.

"We would like to give the opportunity for vaccinated grandparents to visit children and grandchildren who are healthy and local,” Dr. Walensky said.

But, she said, “It’s important to realize as we’re working through this that over 90% of the population is not yet vaccinated.”

For now, there are not enough data on transmission rates from those who are vaccinated to the rest of the public. However, Anthony Fauci, MD, said at a briefing last month that preliminary data are “pointing in a very favorable direction.”

Studies from Spain and Israel published last month showed the amount of viral load – or the amount of the COVID-19 virus in someone’s body – is significantly lower if someone gets infected after they’ve been vaccinated, compared with people who get infected and didn’t have the vaccine. Lower viral load means much lower chances of passing the virus to someone else, Dr. Fauci said.

“The science of COVID-19 is complex,” Dr. Walensky said, “and our understanding of it continues to evolve.”

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

The development and worsening of overlapping asthma and chronic obstructive pulmonary disease (COPD) can be affected by pollutants found in rural and urban environments, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Urban-rural-occupational air pollutants or respiratory sensitizers impact asthma and the asthma-COPD overlap features,” Jill A. Poole, MD, division chief of allergy and immunology at the University of Nebraska Medical Center, Omaha, said in her presentation.

The Global Initiative for Asthma (GINA) first outlined a syndrome in 2015 described as “persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD” and called asthma-COPD overlap syndrome. In 2017, a joint American Thoracic Society/National Heart, Lung, and Blood Institute workshop outlined knowledge gaps about asthma-COPD overlap, noting it “does not represent a single discrete disease entity.”

“This is not a single disease and should be thought of as being heterogeneous and used as a descriptive label for patients commonly seen in clinical practice,” Dr. Poole said. “Both asthma and COPD definitions are not mutually exclusive because each disease includes several phenotypes with different underlining mechanisms.” An example of how asthma-COPD overlap might present is through a patient with allergic asthma who has a history of smoking who develops airflow obstruction that isn’t fully reversible, or a patient with COPD “with high reversible airflow, obstruction, type 2 inflammation, and perhaps the presence of peripheral blood eosinophils or sputum eosinophils.”

A patient’s interaction with urban, rural, and occupational environments may additionally impact their disease, Dr. Poole explained. “The environmental factors of an urban versus rural environment may not be necessarily mutually exclusive,” she said. “It’s also important to recognize occupational exposures that can be both seen in an urban or rural environment [can] contribute to asthma-COPD overlap.”

In a study of 6,040 men and women with asthma living in Canada, 630 (10.4%) had asthma-COPD overlap, with increased air pollution raising the likelihood of developing asthma-COPD overlap (odds ratio, 2.78; 95% confidence interval, 1.62-4.78). These people experienced later onset asthma, increased emergency department visits before a diagnosis of COPD, and increased mortality. Another study in Canada of women from Ontario in the Breast Cancer Screening Study found 1,705 of 4,051 women with asthma also had COPD. While air pollution did not increase the risk of developing asthma-COPD overlap, there was an association between body mass index, low level of education, living in a rural area, and smoking status.

Among farmers in rural areas, “it has been recognized that there is something called the asthma-like syndrome that’s been reported in adult farming communities,” Dr. Poole said, which includes “some degree of airflow obstruction and reversibility” that can be worsened by smoking and could be an overlap of asthma and COPD. Farmers can also experience asthma exacerbations while working, and “livestock farmers appear more at risk of developing [chronic bronchitis and/or COPD] than do the crop farmers,” she noted.

Occupational environments outside of agriculture exposure can cause incident asthma, with high-molecular-weight antigens such as flour cereal, animal dander, latex, psyllium, crab processing products, and enzymes as well as low-molecular-weight antigens such as isocyanates, woods, antibiotics, glues, epoxies colophony products, and dyes presenting a risk. In food processing, main allergen sources can include raw and processed animal and plant products, additives and preservatives, contaminants from microbes or insects, inhaled dust particles or aerosols, which can be “IgE mediated, mixed IgE-mediated and non-lgE mediated.”

While some studies have been conducted on the prevalence of work-related asthma and asthma-COPD overlap, “in general, the prevalence and clinical features have been scarcely investigated,” Dr. Poole said. One survey of 23,137 patients found 52.9% of adults with work-related asthma also had COPD, compared with 25.6% of participants whose asthma was not work related.

To prevent asthma-COPD overlap, Dr. Poole recommended tobacco cessation, reducing indoor biomass fuel use, medical surveillance programs such as preplacement questionnaires, and considering “reducing exposure to the respiratory sensitizers with ideally monitoring the levels to keep the levels below the permissible limits.”

Dr. Poole noted there is currently no unique treatment for asthma-COPD overlap, but it is “important to fully characterize and phenotype your individual patients, looking for eosinophilia or seeing if they have more neutrophil features and whether or not the allergy features are prevalent and can be treated,” she said. “[A]wareness is really required such that counseling is encouraged for prevention and or interventional strategies as we move forward.”

For patients with features of both asthma and COPD where there is a high likelihood of asthma, treat the disease as if it were asthma, Dr. Poole said, but clinicians should follow GINA GOLD COPD treatment recommendations, adding on long-acting beta-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) when needed, but avoiding LABAs and/or LAMAs without use of inhaled corticosteroids, and avoiding oral corticosteroids entirely. Clinicians should be reviewing the treatments of patients with asthma and COPD features “every 2-3 months to see how their response is to it, and what additional therapies could be used,” she said.

Dr. Poole reports receiving grant support from National Institute of Environmental Health Sciences, National Institute for Occupational Safety and Health, and the Central States Center for Agricultural Safety and Health at the University of Nebraska Medical Center.

The development and worsening of overlapping asthma and chronic obstructive pulmonary disease (COPD) can be affected by pollutants found in rural and urban environments, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Urban-rural-occupational air pollutants or respiratory sensitizers impact asthma and the asthma-COPD overlap features,” Jill A. Poole, MD, division chief of allergy and immunology at the University of Nebraska Medical Center, Omaha, said in her presentation.

The Global Initiative for Asthma (GINA) first outlined a syndrome in 2015 described as “persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD” and called asthma-COPD overlap syndrome. In 2017, a joint American Thoracic Society/National Heart, Lung, and Blood Institute workshop outlined knowledge gaps about asthma-COPD overlap, noting it “does not represent a single discrete disease entity.”

“This is not a single disease and should be thought of as being heterogeneous and used as a descriptive label for patients commonly seen in clinical practice,” Dr. Poole said. “Both asthma and COPD definitions are not mutually exclusive because each disease includes several phenotypes with different underlining mechanisms.” An example of how asthma-COPD overlap might present is through a patient with allergic asthma who has a history of smoking who develops airflow obstruction that isn’t fully reversible, or a patient with COPD “with high reversible airflow, obstruction, type 2 inflammation, and perhaps the presence of peripheral blood eosinophils or sputum eosinophils.”

A patient’s interaction with urban, rural, and occupational environments may additionally impact their disease, Dr. Poole explained. “The environmental factors of an urban versus rural environment may not be necessarily mutually exclusive,” she said. “It’s also important to recognize occupational exposures that can be both seen in an urban or rural environment [can] contribute to asthma-COPD overlap.”

In a study of 6,040 men and women with asthma living in Canada, 630 (10.4%) had asthma-COPD overlap, with increased air pollution raising the likelihood of developing asthma-COPD overlap (odds ratio, 2.78; 95% confidence interval, 1.62-4.78). These people experienced later onset asthma, increased emergency department visits before a diagnosis of COPD, and increased mortality. Another study in Canada of women from Ontario in the Breast Cancer Screening Study found 1,705 of 4,051 women with asthma also had COPD. While air pollution did not increase the risk of developing asthma-COPD overlap, there was an association between body mass index, low level of education, living in a rural area, and smoking status.

Among farmers in rural areas, “it has been recognized that there is something called the asthma-like syndrome that’s been reported in adult farming communities,” Dr. Poole said, which includes “some degree of airflow obstruction and reversibility” that can be worsened by smoking and could be an overlap of asthma and COPD. Farmers can also experience asthma exacerbations while working, and “livestock farmers appear more at risk of developing [chronic bronchitis and/or COPD] than do the crop farmers,” she noted.

Occupational environments outside of agriculture exposure can cause incident asthma, with high-molecular-weight antigens such as flour cereal, animal dander, latex, psyllium, crab processing products, and enzymes as well as low-molecular-weight antigens such as isocyanates, woods, antibiotics, glues, epoxies colophony products, and dyes presenting a risk. In food processing, main allergen sources can include raw and processed animal and plant products, additives and preservatives, contaminants from microbes or insects, inhaled dust particles or aerosols, which can be “IgE mediated, mixed IgE-mediated and non-lgE mediated.”

While some studies have been conducted on the prevalence of work-related asthma and asthma-COPD overlap, “in general, the prevalence and clinical features have been scarcely investigated,” Dr. Poole said. One survey of 23,137 patients found 52.9% of adults with work-related asthma also had COPD, compared with 25.6% of participants whose asthma was not work related.

To prevent asthma-COPD overlap, Dr. Poole recommended tobacco cessation, reducing indoor biomass fuel use, medical surveillance programs such as preplacement questionnaires, and considering “reducing exposure to the respiratory sensitizers with ideally monitoring the levels to keep the levels below the permissible limits.”

Dr. Poole noted there is currently no unique treatment for asthma-COPD overlap, but it is “important to fully characterize and phenotype your individual patients, looking for eosinophilia or seeing if they have more neutrophil features and whether or not the allergy features are prevalent and can be treated,” she said. “[A]wareness is really required such that counseling is encouraged for prevention and or interventional strategies as we move forward.”

For patients with features of both asthma and COPD where there is a high likelihood of asthma, treat the disease as if it were asthma, Dr. Poole said, but clinicians should follow GINA GOLD COPD treatment recommendations, adding on long-acting beta-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) when needed, but avoiding LABAs and/or LAMAs without use of inhaled corticosteroids, and avoiding oral corticosteroids entirely. Clinicians should be reviewing the treatments of patients with asthma and COPD features “every 2-3 months to see how their response is to it, and what additional therapies could be used,” she said.

Dr. Poole reports receiving grant support from National Institute of Environmental Health Sciences, National Institute for Occupational Safety and Health, and the Central States Center for Agricultural Safety and Health at the University of Nebraska Medical Center.

The development and worsening of overlapping asthma and chronic obstructive pulmonary disease (COPD) can be affected by pollutants found in rural and urban environments, according to a recent presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, held virtually this year.

“Urban-rural-occupational air pollutants or respiratory sensitizers impact asthma and the asthma-COPD overlap features,” Jill A. Poole, MD, division chief of allergy and immunology at the University of Nebraska Medical Center, Omaha, said in her presentation.

The Global Initiative for Asthma (GINA) first outlined a syndrome in 2015 described as “persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD” and called asthma-COPD overlap syndrome. In 2017, a joint American Thoracic Society/National Heart, Lung, and Blood Institute workshop outlined knowledge gaps about asthma-COPD overlap, noting it “does not represent a single discrete disease entity.”

“This is not a single disease and should be thought of as being heterogeneous and used as a descriptive label for patients commonly seen in clinical practice,” Dr. Poole said. “Both asthma and COPD definitions are not mutually exclusive because each disease includes several phenotypes with different underlining mechanisms.” An example of how asthma-COPD overlap might present is through a patient with allergic asthma who has a history of smoking who develops airflow obstruction that isn’t fully reversible, or a patient with COPD “with high reversible airflow, obstruction, type 2 inflammation, and perhaps the presence of peripheral blood eosinophils or sputum eosinophils.”

A patient’s interaction with urban, rural, and occupational environments may additionally impact their disease, Dr. Poole explained. “The environmental factors of an urban versus rural environment may not be necessarily mutually exclusive,” she said. “It’s also important to recognize occupational exposures that can be both seen in an urban or rural environment [can] contribute to asthma-COPD overlap.”

In a study of 6,040 men and women with asthma living in Canada, 630 (10.4%) had asthma-COPD overlap, with increased air pollution raising the likelihood of developing asthma-COPD overlap (odds ratio, 2.78; 95% confidence interval, 1.62-4.78). These people experienced later onset asthma, increased emergency department visits before a diagnosis of COPD, and increased mortality. Another study in Canada of women from Ontario in the Breast Cancer Screening Study found 1,705 of 4,051 women with asthma also had COPD. While air pollution did not increase the risk of developing asthma-COPD overlap, there was an association between body mass index, low level of education, living in a rural area, and smoking status.

Among farmers in rural areas, “it has been recognized that there is something called the asthma-like syndrome that’s been reported in adult farming communities,” Dr. Poole said, which includes “some degree of airflow obstruction and reversibility” that can be worsened by smoking and could be an overlap of asthma and COPD. Farmers can also experience asthma exacerbations while working, and “livestock farmers appear more at risk of developing [chronic bronchitis and/or COPD] than do the crop farmers,” she noted.

Occupational environments outside of agriculture exposure can cause incident asthma, with high-molecular-weight antigens such as flour cereal, animal dander, latex, psyllium, crab processing products, and enzymes as well as low-molecular-weight antigens such as isocyanates, woods, antibiotics, glues, epoxies colophony products, and dyes presenting a risk. In food processing, main allergen sources can include raw and processed animal and plant products, additives and preservatives, contaminants from microbes or insects, inhaled dust particles or aerosols, which can be “IgE mediated, mixed IgE-mediated and non-lgE mediated.”

While some studies have been conducted on the prevalence of work-related asthma and asthma-COPD overlap, “in general, the prevalence and clinical features have been scarcely investigated,” Dr. Poole said. One survey of 23,137 patients found 52.9% of adults with work-related asthma also had COPD, compared with 25.6% of participants whose asthma was not work related.

To prevent asthma-COPD overlap, Dr. Poole recommended tobacco cessation, reducing indoor biomass fuel use, medical surveillance programs such as preplacement questionnaires, and considering “reducing exposure to the respiratory sensitizers with ideally monitoring the levels to keep the levels below the permissible limits.”

Dr. Poole noted there is currently no unique treatment for asthma-COPD overlap, but it is “important to fully characterize and phenotype your individual patients, looking for eosinophilia or seeing if they have more neutrophil features and whether or not the allergy features are prevalent and can be treated,” she said. “[A]wareness is really required such that counseling is encouraged for prevention and or interventional strategies as we move forward.”

For patients with features of both asthma and COPD where there is a high likelihood of asthma, treat the disease as if it were asthma, Dr. Poole said, but clinicians should follow GINA GOLD COPD treatment recommendations, adding on long-acting beta-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) when needed, but avoiding LABAs and/or LAMAs without use of inhaled corticosteroids, and avoiding oral corticosteroids entirely. Clinicians should be reviewing the treatments of patients with asthma and COPD features “every 2-3 months to see how their response is to it, and what additional therapies could be used,” she said.

Dr. Poole reports receiving grant support from National Institute of Environmental Health Sciences, National Institute for Occupational Safety and Health, and the Central States Center for Agricultural Safety and Health at the University of Nebraska Medical Center.

Sarah Sofka, MD, FACP, noticed a pattern. As program director for the internal medicine (IM) residency at West Virginia University, Morgantown, she was informed when residents were sent to counseling because they were affected by burnout, depression, or anxiety. When trainees returned from these visits, many told her the same thing: They wished they had sought help sooner.

IM residents and their families had access to free counseling at WVU, but few used the resource, says Dr. Sofka. “So, we thought, let’s just schedule all of our residents for a therapy visit so they can go and see what it’s like,” she said. “This will hopefully decrease the stigma for seeking mental health care. If everybody’s going, it’s not a big deal.”

In July 2015, Dr. Sofka and her colleagues launched a universal well-being assessment program for the IM residents at WVU. The program leaders automatically scheduled first- and second-year residents for a visit to the faculty staff assistance program counselors. The visits were not mandatory, and residents could choose not to go; but if they did go, they received the entire day of their visit off from work.

Five and a half years after launching their program, Dr. Sofka and her colleagues conducted one of the first studies of the efficacy of an opt-out approach for resident mental wellness. They found that the program led to more counseling visits that were resident initiated and fewer that were mandated, suggesting that residents were seeking help proactively after having to at least consider it.

Opt-out counseling is a recent concept in residency programs – one that’s attracting interest from training programs across the country. Brown University, Providence, R.I.; the University of Colorado at Denver, Aurora; University of Pennsylvania, Philadelphia; and the University of California, San Francisco have at least one residency program that uses the approach.

No time, no access, plenty of stigma

Burnout and mental health are known to be major concerns for health care workers, especially trainees. College graduates starting medical education have lower rates of burnout and depression, compared with demographically matched peers; however, once they’ve started training, medical students, residents, and fellows are more likely to be burned out and exhibit symptoms of depression. The ongoing COVID-19 pandemic is further fraying the well-being of overworked and traumatized health care professionals, and experts predict a mental health crisis will follow the viral crisis.

The Accreditation Council for Graduate Medical Education recently mandated that programs offer wellness services to trainees. Yet this doesn’t mean they are always used; well-known barriers stand between residents, medical students, and physicians and their receiving effective mental health treatment.

“A lack of transparency and clear messaging around what is available, who provides the services, and how to access these services can be a major barrier,” says Erene Stergiopoulos, MD, a second-year psychiatry resident at the University of Toronto. In addition, there can be considerable lag between when a resident realizes they need help and when they manage to find a provider and schedule an appointment, says Dr. Meeks.

How the opt-out approach works

“The idea is by making it opt-out, you really normalize it,” says Maneesh Batra, MD, MPH, associate director of the University of Washington, Seattle, Children’s Hospital residency program. Similar approaches have proven effective at shaping human behavior in other health care settings, including boosting testing rates for HIV and increasing immunization rates for childhood vaccines, Dr. Batra says.

In general, opt-out programs acknowledge that people are busy and won’t take that extra step or click that extra button if they don’t have to, says Oana Tomescu, MD, PhD, associate professor of clinical medicine and pediatrics at the University of Pennsylvania, Philadelphia.

In 2018, Dr. Sofka and her colleagues at WVU conducted a survey that showed that a majority of residents thought favorably of their opt-out program and said they would return to counseling for follow-up care. In their most recent study, published in the Journal of Graduate Medical Education in 2021, Dr. Sofka and her colleagues found that residents did just that – only 8 of 239 opted out of universally scheduled visits. Resident-initiated visits increased significantly from zero during the 2014-2015 academic year to 23 in 2018-2019. Between those periods, program-mandated visits decreased significantly from 12 to 3.

The initiative has succeeded in creating a culture of openness and caring at WVU, says 2nd-year internal medicine resident Nistha Modi, MD. “It sets the tone for the program – we talk about mental health openly,” says Dr. Modi.

Crucially, the counselors work out of a different building than the hospital where Dr. Modi and her fellow residents work and use a separate electronic medical record system to protect resident privacy. This is hugely important for medical trainees, note Dr. Tomescu, Dr. Gold, and many other experts. The therapists understand residency and medical education, and there is no limit to the number of visits a resident or fellow can make with the program counselors, says Dr. Modi.

Opt-out programs offer a counterbalance to many negative tendencies in residency, says Dr. Meeks. “We’ve normalized so many things that are not healthy and productive. ... We need to counterbalance that with normalizing help seeking. And it’s really difficult to normalize something that’s not part of a system.”
 

Costs, concerns, and systematic support

Providing unlimited, free counseling for trainees can be very beneficial, but it requires adequate funding and personnel resources. Offering unlimited access means that an institution has to follow through in making this degree of care available while also ensuring that the system doesn’t get overwhelmed or is unable to accommodate very sick individuals, says Dr. Gold.

Another concern that experts like Dr. Batra, Dr. Moffit, and Dr. Gold share is that residents who go to their scheduled appointments may not completely buy into the experience because it wasn’t their idea in the first place. Participation alone doesn’t necessarily indicate full acceptance. Program personnel don’t intend for these appointments to be thought of as mandatory, yet residents may still experience them that way. Several leading resident well-being programs instead emphasize outreach to trainees, institutional support, and accessible mental health resources that are – and feel – entirely voluntary.

“If I tell someone that they have to do something, it’s very different than if they arrive at that conclusion for themselves,” says Dr. Batra. “That’s how life works.”

When it comes to cost, a recent study published in Academic Medicine provides encouraging data. At the University of Colorado, an opt-out pilot program for IM and pediatrics interns during the 2017-2018 academic year cost just $940 total, equal to $11.75 per intern. As in West Virginia, the program in Colorado covered the cost of the visit, interns were provided a half day off (whether they attended their appointment or not), and the visits and surveys were entirely optional and confidential. During the 1-year pilot program, 29% of 80 interns attended the scheduled appointment, 56% opted out in advance, and 15% didn’t show up. The majority of interns who were surveyed (85%), however, thought the program should continue and that it had a positive effect on their wellness even if they didn’t attend their appointment.

In West Virginia, program costs are higher. The program has $20,000 in annual funding to cover the opt-out program and unlimited counseling visits for residents and fellows. With that funding, Dr. Sofka and her colleagues were also able to expand the program slightly last year to schedule all the critical care faculty for counseling visits. Cost is a barrier to expanding these services to the entire institution, which Dr. Sofka says she hopes to do one day.

Research in this area is still preliminary. The WVU and Colorado studies provide some of the first evidence in support of an opt-out approach. Eventually, it would be beneficial for multicenter studies and longitudinal research to track the effects of such programs over time, say Dr. Sofka and Ajay Major, MD, MBA, one of the study’s coauthors and a hematology/oncology fellow at the University of Chicago.

Whether a program goes with an opt-out approach or not, the systematic supports – protecting resident privacy, providing flexible scheduling, and more – are crucial.

As Dr. Tomescu notes, wellness shouldn’t be just something trainees have to do. “The key with really working on burnout at a huge level is for all programs and schools to recognize that it’s a shared responsibility.”

“I felt very fortunate that I was able to get some help throughout residency,” says Dr. Modi. “About how to be a better daughter. How to be content with things I have in life. How to be happy, and grateful. With the kind of job we have, I think we sometimes forget to be grateful.”

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

Sarah Sofka, MD, FACP, noticed a pattern. As program director for the internal medicine (IM) residency at West Virginia University, Morgantown, she was informed when residents were sent to counseling because they were affected by burnout, depression, or anxiety. When trainees returned from these visits, many told her the same thing: They wished they had sought help sooner.

IM residents and their families had access to free counseling at WVU, but few used the resource, says Dr. Sofka. “So, we thought, let’s just schedule all of our residents for a therapy visit so they can go and see what it’s like,” she said. “This will hopefully decrease the stigma for seeking mental health care. If everybody’s going, it’s not a big deal.”

In July 2015, Dr. Sofka and her colleagues launched a universal well-being assessment program for the IM residents at WVU. The program leaders automatically scheduled first- and second-year residents for a visit to the faculty staff assistance program counselors. The visits were not mandatory, and residents could choose not to go; but if they did go, they received the entire day of their visit off from work.

Five and a half years after launching their program, Dr. Sofka and her colleagues conducted one of the first studies of the efficacy of an opt-out approach for resident mental wellness. They found that the program led to more counseling visits that were resident initiated and fewer that were mandated, suggesting that residents were seeking help proactively after having to at least consider it.

Opt-out counseling is a recent concept in residency programs – one that’s attracting interest from training programs across the country. Brown University, Providence, R.I.; the University of Colorado at Denver, Aurora; University of Pennsylvania, Philadelphia; and the University of California, San Francisco have at least one residency program that uses the approach.

No time, no access, plenty of stigma

Burnout and mental health are known to be major concerns for health care workers, especially trainees. College graduates starting medical education have lower rates of burnout and depression, compared with demographically matched peers; however, once they’ve started training, medical students, residents, and fellows are more likely to be burned out and exhibit symptoms of depression. The ongoing COVID-19 pandemic is further fraying the well-being of overworked and traumatized health care professionals, and experts predict a mental health crisis will follow the viral crisis.

The Accreditation Council for Graduate Medical Education recently mandated that programs offer wellness services to trainees. Yet this doesn’t mean they are always used; well-known barriers stand between residents, medical students, and physicians and their receiving effective mental health treatment.

“A lack of transparency and clear messaging around what is available, who provides the services, and how to access these services can be a major barrier,” says Erene Stergiopoulos, MD, a second-year psychiatry resident at the University of Toronto. In addition, there can be considerable lag between when a resident realizes they need help and when they manage to find a provider and schedule an appointment, says Dr. Meeks.

How the opt-out approach works

“The idea is by making it opt-out, you really normalize it,” says Maneesh Batra, MD, MPH, associate director of the University of Washington, Seattle, Children’s Hospital residency program. Similar approaches have proven effective at shaping human behavior in other health care settings, including boosting testing rates for HIV and increasing immunization rates for childhood vaccines, Dr. Batra says.

In general, opt-out programs acknowledge that people are busy and won’t take that extra step or click that extra button if they don’t have to, says Oana Tomescu, MD, PhD, associate professor of clinical medicine and pediatrics at the University of Pennsylvania, Philadelphia.

In 2018, Dr. Sofka and her colleagues at WVU conducted a survey that showed that a majority of residents thought favorably of their opt-out program and said they would return to counseling for follow-up care. In their most recent study, published in the Journal of Graduate Medical Education in 2021, Dr. Sofka and her colleagues found that residents did just that – only 8 of 239 opted out of universally scheduled visits. Resident-initiated visits increased significantly from zero during the 2014-2015 academic year to 23 in 2018-2019. Between those periods, program-mandated visits decreased significantly from 12 to 3.

The initiative has succeeded in creating a culture of openness and caring at WVU, says 2nd-year internal medicine resident Nistha Modi, MD. “It sets the tone for the program – we talk about mental health openly,” says Dr. Modi.

Crucially, the counselors work out of a different building than the hospital where Dr. Modi and her fellow residents work and use a separate electronic medical record system to protect resident privacy. This is hugely important for medical trainees, note Dr. Tomescu, Dr. Gold, and many other experts. The therapists understand residency and medical education, and there is no limit to the number of visits a resident or fellow can make with the program counselors, says Dr. Modi.

Opt-out programs offer a counterbalance to many negative tendencies in residency, says Dr. Meeks. “We’ve normalized so many things that are not healthy and productive. ... We need to counterbalance that with normalizing help seeking. And it’s really difficult to normalize something that’s not part of a system.”
 

Costs, concerns, and systematic support

Providing unlimited, free counseling for trainees can be very beneficial, but it requires adequate funding and personnel resources. Offering unlimited access means that an institution has to follow through in making this degree of care available while also ensuring that the system doesn’t get overwhelmed or is unable to accommodate very sick individuals, says Dr. Gold.

Another concern that experts like Dr. Batra, Dr. Moffit, and Dr. Gold share is that residents who go to their scheduled appointments may not completely buy into the experience because it wasn’t their idea in the first place. Participation alone doesn’t necessarily indicate full acceptance. Program personnel don’t intend for these appointments to be thought of as mandatory, yet residents may still experience them that way. Several leading resident well-being programs instead emphasize outreach to trainees, institutional support, and accessible mental health resources that are – and feel – entirely voluntary.

“If I tell someone that they have to do something, it’s very different than if they arrive at that conclusion for themselves,” says Dr. Batra. “That’s how life works.”

When it comes to cost, a recent study published in Academic Medicine provides encouraging data. At the University of Colorado, an opt-out pilot program for IM and pediatrics interns during the 2017-2018 academic year cost just $940 total, equal to $11.75 per intern. As in West Virginia, the program in Colorado covered the cost of the visit, interns were provided a half day off (whether they attended their appointment or not), and the visits and surveys were entirely optional and confidential. During the 1-year pilot program, 29% of 80 interns attended the scheduled appointment, 56% opted out in advance, and 15% didn’t show up. The majority of interns who were surveyed (85%), however, thought the program should continue and that it had a positive effect on their wellness even if they didn’t attend their appointment.

In West Virginia, program costs are higher. The program has $20,000 in annual funding to cover the opt-out program and unlimited counseling visits for residents and fellows. With that funding, Dr. Sofka and her colleagues were also able to expand the program slightly last year to schedule all the critical care faculty for counseling visits. Cost is a barrier to expanding these services to the entire institution, which Dr. Sofka says she hopes to do one day.

Research in this area is still preliminary. The WVU and Colorado studies provide some of the first evidence in support of an opt-out approach. Eventually, it would be beneficial for multicenter studies and longitudinal research to track the effects of such programs over time, say Dr. Sofka and Ajay Major, MD, MBA, one of the study’s coauthors and a hematology/oncology fellow at the University of Chicago.

Whether a program goes with an opt-out approach or not, the systematic supports – protecting resident privacy, providing flexible scheduling, and more – are crucial.

As Dr. Tomescu notes, wellness shouldn’t be just something trainees have to do. “The key with really working on burnout at a huge level is for all programs and schools to recognize that it’s a shared responsibility.”

“I felt very fortunate that I was able to get some help throughout residency,” says Dr. Modi. “About how to be a better daughter. How to be content with things I have in life. How to be happy, and grateful. With the kind of job we have, I think we sometimes forget to be grateful.”

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

Sarah Sofka, MD, FACP, noticed a pattern. As program director for the internal medicine (IM) residency at West Virginia University, Morgantown, she was informed when residents were sent to counseling because they were affected by burnout, depression, or anxiety. When trainees returned from these visits, many told her the same thing: They wished they had sought help sooner.

IM residents and their families had access to free counseling at WVU, but few used the resource, says Dr. Sofka. “So, we thought, let’s just schedule all of our residents for a therapy visit so they can go and see what it’s like,” she said. “This will hopefully decrease the stigma for seeking mental health care. If everybody’s going, it’s not a big deal.”

In July 2015, Dr. Sofka and her colleagues launched a universal well-being assessment program for the IM residents at WVU. The program leaders automatically scheduled first- and second-year residents for a visit to the faculty staff assistance program counselors. The visits were not mandatory, and residents could choose not to go; but if they did go, they received the entire day of their visit off from work.

Five and a half years after launching their program, Dr. Sofka and her colleagues conducted one of the first studies of the efficacy of an opt-out approach for resident mental wellness. They found that the program led to more counseling visits that were resident initiated and fewer that were mandated, suggesting that residents were seeking help proactively after having to at least consider it.

Opt-out counseling is a recent concept in residency programs – one that’s attracting interest from training programs across the country. Brown University, Providence, R.I.; the University of Colorado at Denver, Aurora; University of Pennsylvania, Philadelphia; and the University of California, San Francisco have at least one residency program that uses the approach.

No time, no access, plenty of stigma

Burnout and mental health are known to be major concerns for health care workers, especially trainees. College graduates starting medical education have lower rates of burnout and depression, compared with demographically matched peers; however, once they’ve started training, medical students, residents, and fellows are more likely to be burned out and exhibit symptoms of depression. The ongoing COVID-19 pandemic is further fraying the well-being of overworked and traumatized health care professionals, and experts predict a mental health crisis will follow the viral crisis.

The Accreditation Council for Graduate Medical Education recently mandated that programs offer wellness services to trainees. Yet this doesn’t mean they are always used; well-known barriers stand between residents, medical students, and physicians and their receiving effective mental health treatment.

“A lack of transparency and clear messaging around what is available, who provides the services, and how to access these services can be a major barrier,” says Erene Stergiopoulos, MD, a second-year psychiatry resident at the University of Toronto. In addition, there can be considerable lag between when a resident realizes they need help and when they manage to find a provider and schedule an appointment, says Dr. Meeks.

How the opt-out approach works

“The idea is by making it opt-out, you really normalize it,” says Maneesh Batra, MD, MPH, associate director of the University of Washington, Seattle, Children’s Hospital residency program. Similar approaches have proven effective at shaping human behavior in other health care settings, including boosting testing rates for HIV and increasing immunization rates for childhood vaccines, Dr. Batra says.

In general, opt-out programs acknowledge that people are busy and won’t take that extra step or click that extra button if they don’t have to, says Oana Tomescu, MD, PhD, associate professor of clinical medicine and pediatrics at the University of Pennsylvania, Philadelphia.

In 2018, Dr. Sofka and her colleagues at WVU conducted a survey that showed that a majority of residents thought favorably of their opt-out program and said they would return to counseling for follow-up care. In their most recent study, published in the Journal of Graduate Medical Education in 2021, Dr. Sofka and her colleagues found that residents did just that – only 8 of 239 opted out of universally scheduled visits. Resident-initiated visits increased significantly from zero during the 2014-2015 academic year to 23 in 2018-2019. Between those periods, program-mandated visits decreased significantly from 12 to 3.

The initiative has succeeded in creating a culture of openness and caring at WVU, says 2nd-year internal medicine resident Nistha Modi, MD. “It sets the tone for the program – we talk about mental health openly,” says Dr. Modi.

Crucially, the counselors work out of a different building than the hospital where Dr. Modi and her fellow residents work and use a separate electronic medical record system to protect resident privacy. This is hugely important for medical trainees, note Dr. Tomescu, Dr. Gold, and many other experts. The therapists understand residency and medical education, and there is no limit to the number of visits a resident or fellow can make with the program counselors, says Dr. Modi.

Opt-out programs offer a counterbalance to many negative tendencies in residency, says Dr. Meeks. “We’ve normalized so many things that are not healthy and productive. ... We need to counterbalance that with normalizing help seeking. And it’s really difficult to normalize something that’s not part of a system.”
 

Costs, concerns, and systematic support

Providing unlimited, free counseling for trainees can be very beneficial, but it requires adequate funding and personnel resources. Offering unlimited access means that an institution has to follow through in making this degree of care available while also ensuring that the system doesn’t get overwhelmed or is unable to accommodate very sick individuals, says Dr. Gold.

Another concern that experts like Dr. Batra, Dr. Moffit, and Dr. Gold share is that residents who go to their scheduled appointments may not completely buy into the experience because it wasn’t their idea in the first place. Participation alone doesn’t necessarily indicate full acceptance. Program personnel don’t intend for these appointments to be thought of as mandatory, yet residents may still experience them that way. Several leading resident well-being programs instead emphasize outreach to trainees, institutional support, and accessible mental health resources that are – and feel – entirely voluntary.

“If I tell someone that they have to do something, it’s very different than if they arrive at that conclusion for themselves,” says Dr. Batra. “That’s how life works.”

When it comes to cost, a recent study published in Academic Medicine provides encouraging data. At the University of Colorado, an opt-out pilot program for IM and pediatrics interns during the 2017-2018 academic year cost just $940 total, equal to $11.75 per intern. As in West Virginia, the program in Colorado covered the cost of the visit, interns were provided a half day off (whether they attended their appointment or not), and the visits and surveys were entirely optional and confidential. During the 1-year pilot program, 29% of 80 interns attended the scheduled appointment, 56% opted out in advance, and 15% didn’t show up. The majority of interns who were surveyed (85%), however, thought the program should continue and that it had a positive effect on their wellness even if they didn’t attend their appointment.

In West Virginia, program costs are higher. The program has $20,000 in annual funding to cover the opt-out program and unlimited counseling visits for residents and fellows. With that funding, Dr. Sofka and her colleagues were also able to expand the program slightly last year to schedule all the critical care faculty for counseling visits. Cost is a barrier to expanding these services to the entire institution, which Dr. Sofka says she hopes to do one day.

Research in this area is still preliminary. The WVU and Colorado studies provide some of the first evidence in support of an opt-out approach. Eventually, it would be beneficial for multicenter studies and longitudinal research to track the effects of such programs over time, say Dr. Sofka and Ajay Major, MD, MBA, one of the study’s coauthors and a hematology/oncology fellow at the University of Chicago.

Whether a program goes with an opt-out approach or not, the systematic supports – protecting resident privacy, providing flexible scheduling, and more – are crucial.

As Dr. Tomescu notes, wellness shouldn’t be just something trainees have to do. “The key with really working on burnout at a huge level is for all programs and schools to recognize that it’s a shared responsibility.”

“I felt very fortunate that I was able to get some help throughout residency,” says Dr. Modi. “About how to be a better daughter. How to be content with things I have in life. How to be happy, and grateful. With the kind of job we have, I think we sometimes forget to be grateful.”

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