Exercise and a hypocaloric, Mediterranean-style diet remain first-line interventions that can benefit all patients with nonalcoholic fatty liver disease (NAFLD), according to a clinical practice update from the American Gastroenterological Association.

“[W]eight loss is associated with a reduction in liver fat, which provides a potential for reversal of disease progression,” wrote Zobair M. Younossi, MD, MPH, of Inova Fairfax Medical Campus in Falls Church, Va., with his associates. Lifestyle modifications remain “the cornerstone for management” because, even though NAFLD affects approximately 25% of individuals worldwide according to one meta-analytic assessment, interventions such as medications, bariatric endoscopy, and surgery are usually reserved for the subset of patients with severe obesity, comorbid diabetes, or nonalcoholic steatohepatitis (NASH) with at least stage 2 fibrosis, the experts wrote in Gastroenterology.

They note that clinically significant weight loss typically requires a hypocaloric diet of 1,200-1,500 kilocalories/day or a decrease of 500-1,000 kilocalories/day from baseline. A Mediterranean diet of fresh vegetables, fruits, legumes, minimally processed whole grains, fish, olive oil, nuts, and seeds is recommended because its antioxidant, anti-inflammatory effects may slow NAFLD progression. This diet minimizes or eliminates sweets, refined grains, and red and processed meats. Fructose from fruit is not associated with NAFLD, but patients should consume little or no commercially prepared fructose, which has been linked to visceral adiposity, insulin resistance, hepatic inflammation, and fibrosis progression. Other hypocaloric diets have not been studied enough to support their routine use in NAFLD treatment, according to the clinical practice update.

For patients with NASH, which is the more severe form of NAFLD and is associated with significant morbidity and mortality caused by complications from cirrhosis, hepatic decompensation, and hepatocellular carcinoma, weight loss also has a big impact: Losing at least 5% of total body weight can decrease hepatic steatosis, losing at least 7% can resolve NASH, and losing at least 10% can lessen or stabilize hepatic fibrosis, according to level 1 evidence cited by the update. Weight loss “can significantly impact all aspects of NAFLD histology including fibrosis, but a goal of 10% total body weight loss should be considered for patients with overweight or obese NAFLD,” the authors wrote. Fat loss also improves liver histology in patients with lean NAFLD (body mass index, 26 kg/m² in non-Asian patients or 24 in Asians), for whom a hypocaloric diet targeting a more modest 3%-5% total body weight loss is recommended.

Because aerobic exercise reduces hepatic fat levels independently of hypocaloric diet, patients with NAFLD should consider a weekly regimen of 150-300 minutes of moderate-intensity exercise or 75-150 minutes of vigorous activity. Resistance training can complement aerobic exercise “but [is] not a replacement,” the authors noted. In addition, patients with NAFLD should restrict alcohol consumption to reduce the risk for liver-related events, and those with advanced hepatic fibrosis should “avoid alcohol entirely.” These recommendations reflect the findings of a large prospective study in which the consumption of even low amounts of alcohol led to worse liver-related outcomes among patients with NAFLD.

Clinicians should screen for and “aggressively” manage common NAFLD comorbidities, including diabetes mellitus, hypertension, and obstructive sleep apnea, according to the clinical practice update. Patients with coexisting metabolic conditions should be risk-stratified for cardiovascular disease and treated based on guidelines from the American College of Cardiology and the American Heart Association.

It is believed that sarcopenia affects patients with NASH cirrhosis because their livers cannot effectively store, metabolize, or mobilize carbohydrates, which leads to a catabolic state in which protein and fat are used as energy sources, according to the update. To avoid exacerbations, these patients may need to optimize their protein intake – a minimum of 1.2-1.5 g/kg of body weight is recommended – from sources of branched-chain amino acids, such as chicken, fish, eggs, nuts, lentils, or soy. Patients with sarcopenic NAFLD also should consume small, frequent meals spaced no more than 4-6 hours apart. When possible, they should consult with a specialized nutritionist. Moderate-intensity exercise may also benefit patients experiencing sarcopenia.

The researchers disclosed ties to Gilead Sciences, Intercept, Bristol Myers Squibb, Novo Nordisk, and several other companies. The review was commissioned and approved by the AGA Institute’s Clinical Practice Updates Committee and the AGA Governing Board.

SOURCE: Younossi ZM et al. Gastroenterology. 2020 Dec 8. doi: 10.1053/j.gastro.2020.11.051.

This article was updated Feb. 10, 2021.

Exercise and a hypocaloric, Mediterranean-style diet remain first-line interventions that can benefit all patients with nonalcoholic fatty liver disease (NAFLD), according to a clinical practice update from the American Gastroenterological Association.

“[W]eight loss is associated with a reduction in liver fat, which provides a potential for reversal of disease progression,” wrote Zobair M. Younossi, MD, MPH, of Inova Fairfax Medical Campus in Falls Church, Va., with his associates. Lifestyle modifications remain “the cornerstone for management” because, even though NAFLD affects approximately 25% of individuals worldwide according to one meta-analytic assessment, interventions such as medications, bariatric endoscopy, and surgery are usually reserved for the subset of patients with severe obesity, comorbid diabetes, or nonalcoholic steatohepatitis (NASH) with at least stage 2 fibrosis, the experts wrote in Gastroenterology.

They note that clinically significant weight loss typically requires a hypocaloric diet of 1,200-1,500 kilocalories/day or a decrease of 500-1,000 kilocalories/day from baseline. A Mediterranean diet of fresh vegetables, fruits, legumes, minimally processed whole grains, fish, olive oil, nuts, and seeds is recommended because its antioxidant, anti-inflammatory effects may slow NAFLD progression. This diet minimizes or eliminates sweets, refined grains, and red and processed meats. Fructose from fruit is not associated with NAFLD, but patients should consume little or no commercially prepared fructose, which has been linked to visceral adiposity, insulin resistance, hepatic inflammation, and fibrosis progression. Other hypocaloric diets have not been studied enough to support their routine use in NAFLD treatment, according to the clinical practice update.

For patients with NASH, which is the more severe form of NAFLD and is associated with significant morbidity and mortality caused by complications from cirrhosis, hepatic decompensation, and hepatocellular carcinoma, weight loss also has a big impact: Losing at least 5% of total body weight can decrease hepatic steatosis, losing at least 7% can resolve NASH, and losing at least 10% can lessen or stabilize hepatic fibrosis, according to level 1 evidence cited by the update. Weight loss “can significantly impact all aspects of NAFLD histology including fibrosis, but a goal of 10% total body weight loss should be considered for patients with overweight or obese NAFLD,” the authors wrote. Fat loss also improves liver histology in patients with lean NAFLD (body mass index, 26 kg/m² in non-Asian patients or 24 in Asians), for whom a hypocaloric diet targeting a more modest 3%-5% total body weight loss is recommended.

Because aerobic exercise reduces hepatic fat levels independently of hypocaloric diet, patients with NAFLD should consider a weekly regimen of 150-300 minutes of moderate-intensity exercise or 75-150 minutes of vigorous activity. Resistance training can complement aerobic exercise “but [is] not a replacement,” the authors noted. In addition, patients with NAFLD should restrict alcohol consumption to reduce the risk for liver-related events, and those with advanced hepatic fibrosis should “avoid alcohol entirely.” These recommendations reflect the findings of a large prospective study in which the consumption of even low amounts of alcohol led to worse liver-related outcomes among patients with NAFLD.

Clinicians should screen for and “aggressively” manage common NAFLD comorbidities, including diabetes mellitus, hypertension, and obstructive sleep apnea, according to the clinical practice update. Patients with coexisting metabolic conditions should be risk-stratified for cardiovascular disease and treated based on guidelines from the American College of Cardiology and the American Heart Association.

It is believed that sarcopenia affects patients with NASH cirrhosis because their livers cannot effectively store, metabolize, or mobilize carbohydrates, which leads to a catabolic state in which protein and fat are used as energy sources, according to the update. To avoid exacerbations, these patients may need to optimize their protein intake – a minimum of 1.2-1.5 g/kg of body weight is recommended – from sources of branched-chain amino acids, such as chicken, fish, eggs, nuts, lentils, or soy. Patients with sarcopenic NAFLD also should consume small, frequent meals spaced no more than 4-6 hours apart. When possible, they should consult with a specialized nutritionist. Moderate-intensity exercise may also benefit patients experiencing sarcopenia.

The researchers disclosed ties to Gilead Sciences, Intercept, Bristol Myers Squibb, Novo Nordisk, and several other companies. The review was commissioned and approved by the AGA Institute’s Clinical Practice Updates Committee and the AGA Governing Board.

SOURCE: Younossi ZM et al. Gastroenterology. 2020 Dec 8. doi: 10.1053/j.gastro.2020.11.051.

This article was updated Feb. 10, 2021.

Exercise and a hypocaloric, Mediterranean-style diet remain first-line interventions that can benefit all patients with nonalcoholic fatty liver disease (NAFLD), according to a clinical practice update from the American Gastroenterological Association.

“[W]eight loss is associated with a reduction in liver fat, which provides a potential for reversal of disease progression,” wrote Zobair M. Younossi, MD, MPH, of Inova Fairfax Medical Campus in Falls Church, Va., with his associates. Lifestyle modifications remain “the cornerstone for management” because, even though NAFLD affects approximately 25% of individuals worldwide according to one meta-analytic assessment, interventions such as medications, bariatric endoscopy, and surgery are usually reserved for the subset of patients with severe obesity, comorbid diabetes, or nonalcoholic steatohepatitis (NASH) with at least stage 2 fibrosis, the experts wrote in Gastroenterology.

They note that clinically significant weight loss typically requires a hypocaloric diet of 1,200-1,500 kilocalories/day or a decrease of 500-1,000 kilocalories/day from baseline. A Mediterranean diet of fresh vegetables, fruits, legumes, minimally processed whole grains, fish, olive oil, nuts, and seeds is recommended because its antioxidant, anti-inflammatory effects may slow NAFLD progression. This diet minimizes or eliminates sweets, refined grains, and red and processed meats. Fructose from fruit is not associated with NAFLD, but patients should consume little or no commercially prepared fructose, which has been linked to visceral adiposity, insulin resistance, hepatic inflammation, and fibrosis progression. Other hypocaloric diets have not been studied enough to support their routine use in NAFLD treatment, according to the clinical practice update.

For patients with NASH, which is the more severe form of NAFLD and is associated with significant morbidity and mortality caused by complications from cirrhosis, hepatic decompensation, and hepatocellular carcinoma, weight loss also has a big impact: Losing at least 5% of total body weight can decrease hepatic steatosis, losing at least 7% can resolve NASH, and losing at least 10% can lessen or stabilize hepatic fibrosis, according to level 1 evidence cited by the update. Weight loss “can significantly impact all aspects of NAFLD histology including fibrosis, but a goal of 10% total body weight loss should be considered for patients with overweight or obese NAFLD,” the authors wrote. Fat loss also improves liver histology in patients with lean NAFLD (body mass index, 26 kg/m² in non-Asian patients or 24 in Asians), for whom a hypocaloric diet targeting a more modest 3%-5% total body weight loss is recommended.

Because aerobic exercise reduces hepatic fat levels independently of hypocaloric diet, patients with NAFLD should consider a weekly regimen of 150-300 minutes of moderate-intensity exercise or 75-150 minutes of vigorous activity. Resistance training can complement aerobic exercise “but [is] not a replacement,” the authors noted. In addition, patients with NAFLD should restrict alcohol consumption to reduce the risk for liver-related events, and those with advanced hepatic fibrosis should “avoid alcohol entirely.” These recommendations reflect the findings of a large prospective study in which the consumption of even low amounts of alcohol led to worse liver-related outcomes among patients with NAFLD.

Clinicians should screen for and “aggressively” manage common NAFLD comorbidities, including diabetes mellitus, hypertension, and obstructive sleep apnea, according to the clinical practice update. Patients with coexisting metabolic conditions should be risk-stratified for cardiovascular disease and treated based on guidelines from the American College of Cardiology and the American Heart Association.

It is believed that sarcopenia affects patients with NASH cirrhosis because their livers cannot effectively store, metabolize, or mobilize carbohydrates, which leads to a catabolic state in which protein and fat are used as energy sources, according to the update. To avoid exacerbations, these patients may need to optimize their protein intake – a minimum of 1.2-1.5 g/kg of body weight is recommended – from sources of branched-chain amino acids, such as chicken, fish, eggs, nuts, lentils, or soy. Patients with sarcopenic NAFLD also should consume small, frequent meals spaced no more than 4-6 hours apart. When possible, they should consult with a specialized nutritionist. Moderate-intensity exercise may also benefit patients experiencing sarcopenia.

The researchers disclosed ties to Gilead Sciences, Intercept, Bristol Myers Squibb, Novo Nordisk, and several other companies. The review was commissioned and approved by the AGA Institute’s Clinical Practice Updates Committee and the AGA Governing Board.

SOURCE: Younossi ZM et al. Gastroenterology. 2020 Dec 8. doi: 10.1053/j.gastro.2020.11.051.

This article was updated Feb. 10, 2021.

Nickel is unrivaled as the most common cause of contact allergy worldwide.¹ Nickel is commonly used as a hardening agent in metal products, and complete avoidance is challenging due to numerous potential exposures (eg, direct contact, airborne, dietary, medical implantation). Allergic contact dermatitis to nickel (Ni-ACD) can lead to decreased quality of life, inability to work, and considerable health care expenses.¹ Here, we review the epidemiology of nickel allergy, regulation of nickel in the United States and Europe, common clinical presentations, and pearls on avoidance.

Epidemiology

Nickel continues to be the most common cause of contact allergy worldwide. Data from the 2015-2016 North American Contact Dermatitis Group patch test cycle (N=5597) showed nickel sulfate to be positive in 17.5% of patients patch tested to nickel.² The prevalence of nickel allergy has been relatively stable in North America since 2005 (Figure 1). Although Ni-ACD historically was identified as an occupational disease of the hands in male nickel platers, the epidemiology of nickel allergy has shifted.¹ Today, most cases are nonoccupational and affect women more often than men,³ in part due to improved industrial hygiene, pervasive incorporation of nickel in consumer items, and differences in cultural practices such as piercings.^1,3 Piercings in particular have been implicated as important sources of nickel exposure, as this practice disrupts normal skin barrier function and is a potentially sensitizing event. Multiple studies including a large-scale epidemiologic analysis from 2017 have found piercings to be associated with an increased frequency of Ni-ACD (24.4% with piercing vs 9.6% without piercing). Interestingly, the degree of nickel sensitivity also was found to increase with the number of piercings (14.3% with 1 piercing vs 34.0% with ≥5 piercings).⁴

Regulation

Nickel content has been regulated in parts of the European Union (EU) since the 1990s, but regulation in the United States is lacking. In an attempt to reduce the prevalence of nickel allergy, the EU limits the level of nickel release from consumer items intended to be in direct and prolonged contact with the skin. These limits were first introduced in Denmark in 1990, followed closely by the EU Nickel Directive in 1994, which has resulted in consistent patterns of decreasing prevalence of Ni-ACD in multiple European countries.⁵ Notably, a Danish study comparing the prevalence of sensitization between girls with ears pierced before vs after implementation of nickel regulation found a decrease in prevalence from 17.1% to 3.9%.⁶ Additionally, this initiative has greatly reduced the economic burden of nickel dermatitis. It is estimated that Denmark alone has saved US $2 billion over a 20-year period in both direct and indirect health care costs.⁷

However, a policy is only effective if it is enforced, and it has been reported in the EU that 8% to 32% of tested jewelry exceeds the limit placed on nickel release, with imported jewelry being especially problematic.⁵ Also of interest, the 1 and 2 euro coins are known to release more nickel than pure nickel itself, releasing 240 to 320 times more than is allowed under the EU Nickel Directive (Figure 2).⁸ Although coins are not explicitly mentioned as items having prolonged contact with the skin, they can and do exacerbate allergic contact dermatitis of the hands, especially in occupational groups such as cashiers.⁹ Unsurprisingly, during the discussions to determine the composition of coins prior to the mass adoption of the euro in the EU in 2002, dermatologists and nickel industry experts remained divided in their recommendations.¹⁰ However, the EU regulation is considered a public health success overall, and the trends of Ni-ACD and economic burden are opposite of the United States, where legislation has yet to be adopted.

Patch Testing to Nickel

In North America, the 2 available patch test systems are the chamber method and the Thin-layer Rapid Use Epicutaneous (T.R.U.E.) test (SmartPractice). In the T.R.U.E. test, nickel sulfate is used to formulate the patch at 200 µg/cm² using hydroxypropyl cellulose as the gel vehicle. In the chamber method, nickel sulfate is used on either an aluminum or plastic chamber, most commonly at concentrations of 2.5% or 5% in petrolatum. Nickel sulfate 2.5% is most frequently used in US-based patch test clinics. A 2018 study (N=205) comparing the sensitivities of the 2.5% and 5% concentrations of nickel found 5% to be more sensitive; 31% of the cohort tested positive at 5% but only 20% at 2.5%, suggesting the 5% formulation is superior at detecting nickel allergy.¹¹

Similar to other metals, nickel may react later than other allergens. A 2019 analysis of the prevalence of new patch test reactions on day 7 showed that 17% of 607 patients were negative on day 3 but were positive on day 7, further emphasizing the importance of a properly timed delayed reading.¹²

Clinical Presentation

Localized
The classic presentation of Ni-ACD is a scaly erythematous dermatitis in a typical distribution (eg, earlobes [earrings], wrists [watch], periumbilical [belt]). These scenarios usually can be diagnosed by the astute clinician without patch testing; however, the source of exposure may be less obvious if the nickel-releasing item has intermittent contact with the skin (eg, coins in the pocket, furniture hardware, personal grooming devices).¹³ Other reported exposures include facial dermatitis from mobile phones, dermatitis of the ulnar hands from laptop use, and hand dermatitis from gaming controllers,^14-16 perhaps another reason for some to unplug.

Systemic
Sensitized individuals also may present with systemic contact dermatitis after airborne, oral, mucosal, or intravenous exposure. Presentations vary but have been reported to manifest as flare-up reactions in previously affected areas, pompholyx, diffuse dermatitis, flexural dermatitis, and baboon syndrome.¹⁷ Although it is unknown if airborne exposure alone is sufficient for sensitization, cases have been reported in occupational settings.¹⁸ One report described a man presenting with widespread dermatitis involving the extremities, chest, and genital area after his first day working at an electroplating plant.¹⁹

Systemic contact dermatitis from foods high in nickel (eg, chocolate, sunflower seeds, whole-grain flour, dried beans) and occasionally nonfood items (eg, coins) also has occurred. The so-called Easter egg hunt dermatitis has been described in children with Ni-ACD after candy ingestion.²⁰ Another case described an 8-year-old girl and budding illusionist with severe diffuse dermatitis; a thorough history revealed the dermatitis began after she ingested a coin while performing a magic trick.²¹

Cases of nickel systemic contact dermatitis have been reported following medical device implantation, including reactions to cardiac devices, orthopedic implants, neurosurgery materials, and others.²² In addition, both intraoral and extraoral manifestations following application of orthodontic materials and dental implants have been reported.^23,24 Although nickel-containing medical devices generally are well tolerated even in nickel-sensitive individuals, the development of systemic Ni-ACD has at times required device or hardware removal.^22,23

After the Patch Test: Avoidance of Nickel

Counseling patients on nickel avoidance is critical to clinical improvement. Common nickel-containing items include jewelry, metal on clothing (eg, zippers, clasps, grommets), belt buckles, watches, glasses, furniture, coins, and keys. Numerous personal care products may also contain nickel, including nail clippers, eyelash curlers, tweezers, mascara tubes, and razors.^25,26 Patients should be made aware that nickel-free alternatives are available for the majority of these products. Internet-based tips such as painting nail polish on products or iron-on patches tend to be of limited use in our experience. Patients may consider purchasing a nickel spot test to detect nickel in their environment; the dimethylglyoxime nickel spot test is inexpensive, rapid, and easy-to-use. To use the test, a small amount of the chemical is rubbed on the metal item using a cotton swab; a pink color indicates nickel release. Patients can be reassured that dimethylglyoxime does not harm jewelry.

Some general advice for patients regarding jewelry, the most common source of nickel exposure, is to only wear jewelry that is made from metals such as surgical-grade stainless steel, pure sterling silver, or platinum. If yellow gold is the preferred metal, it is prudent to be aware that lower karat items could potentially contain nickel. White gold should be avoided, as it often contains nickel to contribute to its color. Finally, gold-plated jewelry should be avoided, as the plating can wear off and expose a possibly nickel-containing base.

A low-nickel diet may be of benefit in select patients. A meta-analysis assessing systemic contact dermatitis from nickel ingestion found that 1% of nickel-sensitive individuals may be expected to react to nickel found in a normal diet.²⁷ However, as with any diet, adherence can be difficult. Thankfully, Mislankar and Zirwas²⁸ have developed a simple point-based system to help increase compliance. Additionally, a free mobile application is now available; Nickel Navigator can be used to track daily nickel intake and may be especially convenient for our more tech-savvy patients. In conjunction with a low-nickel diet, some authors also recommend eating meals high in vitamin C or supplementation with vitamin C, as co-ingestion has been shown to reduce nickel absorption.²⁹

Final Interpretation

Nickel allergy remains common, found in up to 17.5% of patch tested patients. Despite regulation in the EU, nickel continues to have high prevalence of positive patch test reactions around the world. Nickel is not only found in jewelry and belt buckles but also in personal care products, electronics, and food. Allergen avoidance is key and requires knowledge of common items containing nickel and a low nickel diet for select patients.

Nickel is unrivaled as the most common cause of contact allergy worldwide.¹ Nickel is commonly used as a hardening agent in metal products, and complete avoidance is challenging due to numerous potential exposures (eg, direct contact, airborne, dietary, medical implantation). Allergic contact dermatitis to nickel (Ni-ACD) can lead to decreased quality of life, inability to work, and considerable health care expenses.¹ Here, we review the epidemiology of nickel allergy, regulation of nickel in the United States and Europe, common clinical presentations, and pearls on avoidance.

Epidemiology

Nickel continues to be the most common cause of contact allergy worldwide. Data from the 2015-2016 North American Contact Dermatitis Group patch test cycle (N=5597) showed nickel sulfate to be positive in 17.5% of patients patch tested to nickel.² The prevalence of nickel allergy has been relatively stable in North America since 2005 (Figure 1). Although Ni-ACD historically was identified as an occupational disease of the hands in male nickel platers, the epidemiology of nickel allergy has shifted.¹ Today, most cases are nonoccupational and affect women more often than men,³ in part due to improved industrial hygiene, pervasive incorporation of nickel in consumer items, and differences in cultural practices such as piercings.^1,3 Piercings in particular have been implicated as important sources of nickel exposure, as this practice disrupts normal skin barrier function and is a potentially sensitizing event. Multiple studies including a large-scale epidemiologic analysis from 2017 have found piercings to be associated with an increased frequency of Ni-ACD (24.4% with piercing vs 9.6% without piercing). Interestingly, the degree of nickel sensitivity also was found to increase with the number of piercings (14.3% with 1 piercing vs 34.0% with ≥5 piercings).⁴

Regulation

Nickel content has been regulated in parts of the European Union (EU) since the 1990s, but regulation in the United States is lacking. In an attempt to reduce the prevalence of nickel allergy, the EU limits the level of nickel release from consumer items intended to be in direct and prolonged contact with the skin. These limits were first introduced in Denmark in 1990, followed closely by the EU Nickel Directive in 1994, which has resulted in consistent patterns of decreasing prevalence of Ni-ACD in multiple European countries.⁵ Notably, a Danish study comparing the prevalence of sensitization between girls with ears pierced before vs after implementation of nickel regulation found a decrease in prevalence from 17.1% to 3.9%.⁶ Additionally, this initiative has greatly reduced the economic burden of nickel dermatitis. It is estimated that Denmark alone has saved US $2 billion over a 20-year period in both direct and indirect health care costs.⁷

However, a policy is only effective if it is enforced, and it has been reported in the EU that 8% to 32% of tested jewelry exceeds the limit placed on nickel release, with imported jewelry being especially problematic.⁵ Also of interest, the 1 and 2 euro coins are known to release more nickel than pure nickel itself, releasing 240 to 320 times more than is allowed under the EU Nickel Directive (Figure 2).⁸ Although coins are not explicitly mentioned as items having prolonged contact with the skin, they can and do exacerbate allergic contact dermatitis of the hands, especially in occupational groups such as cashiers.⁹ Unsurprisingly, during the discussions to determine the composition of coins prior to the mass adoption of the euro in the EU in 2002, dermatologists and nickel industry experts remained divided in their recommendations.¹⁰ However, the EU regulation is considered a public health success overall, and the trends of Ni-ACD and economic burden are opposite of the United States, where legislation has yet to be adopted.

Patch Testing to Nickel

In North America, the 2 available patch test systems are the chamber method and the Thin-layer Rapid Use Epicutaneous (T.R.U.E.) test (SmartPractice). In the T.R.U.E. test, nickel sulfate is used to formulate the patch at 200 µg/cm² using hydroxypropyl cellulose as the gel vehicle. In the chamber method, nickel sulfate is used on either an aluminum or plastic chamber, most commonly at concentrations of 2.5% or 5% in petrolatum. Nickel sulfate 2.5% is most frequently used in US-based patch test clinics. A 2018 study (N=205) comparing the sensitivities of the 2.5% and 5% concentrations of nickel found 5% to be more sensitive; 31% of the cohort tested positive at 5% but only 20% at 2.5%, suggesting the 5% formulation is superior at detecting nickel allergy.¹¹

Similar to other metals, nickel may react later than other allergens. A 2019 analysis of the prevalence of new patch test reactions on day 7 showed that 17% of 607 patients were negative on day 3 but were positive on day 7, further emphasizing the importance of a properly timed delayed reading.¹²

Clinical Presentation

Localized
The classic presentation of Ni-ACD is a scaly erythematous dermatitis in a typical distribution (eg, earlobes [earrings], wrists [watch], periumbilical [belt]). These scenarios usually can be diagnosed by the astute clinician without patch testing; however, the source of exposure may be less obvious if the nickel-releasing item has intermittent contact with the skin (eg, coins in the pocket, furniture hardware, personal grooming devices).¹³ Other reported exposures include facial dermatitis from mobile phones, dermatitis of the ulnar hands from laptop use, and hand dermatitis from gaming controllers,^14-16 perhaps another reason for some to unplug.

Systemic
Sensitized individuals also may present with systemic contact dermatitis after airborne, oral, mucosal, or intravenous exposure. Presentations vary but have been reported to manifest as flare-up reactions in previously affected areas, pompholyx, diffuse dermatitis, flexural dermatitis, and baboon syndrome.¹⁷ Although it is unknown if airborne exposure alone is sufficient for sensitization, cases have been reported in occupational settings.¹⁸ One report described a man presenting with widespread dermatitis involving the extremities, chest, and genital area after his first day working at an electroplating plant.¹⁹

Systemic contact dermatitis from foods high in nickel (eg, chocolate, sunflower seeds, whole-grain flour, dried beans) and occasionally nonfood items (eg, coins) also has occurred. The so-called Easter egg hunt dermatitis has been described in children with Ni-ACD after candy ingestion.²⁰ Another case described an 8-year-old girl and budding illusionist with severe diffuse dermatitis; a thorough history revealed the dermatitis began after she ingested a coin while performing a magic trick.²¹

Cases of nickel systemic contact dermatitis have been reported following medical device implantation, including reactions to cardiac devices, orthopedic implants, neurosurgery materials, and others.²² In addition, both intraoral and extraoral manifestations following application of orthodontic materials and dental implants have been reported.^23,24 Although nickel-containing medical devices generally are well tolerated even in nickel-sensitive individuals, the development of systemic Ni-ACD has at times required device or hardware removal.^22,23

After the Patch Test: Avoidance of Nickel

Counseling patients on nickel avoidance is critical to clinical improvement. Common nickel-containing items include jewelry, metal on clothing (eg, zippers, clasps, grommets), belt buckles, watches, glasses, furniture, coins, and keys. Numerous personal care products may also contain nickel, including nail clippers, eyelash curlers, tweezers, mascara tubes, and razors.^25,26 Patients should be made aware that nickel-free alternatives are available for the majority of these products. Internet-based tips such as painting nail polish on products or iron-on patches tend to be of limited use in our experience. Patients may consider purchasing a nickel spot test to detect nickel in their environment; the dimethylglyoxime nickel spot test is inexpensive, rapid, and easy-to-use. To use the test, a small amount of the chemical is rubbed on the metal item using a cotton swab; a pink color indicates nickel release. Patients can be reassured that dimethylglyoxime does not harm jewelry.

Some general advice for patients regarding jewelry, the most common source of nickel exposure, is to only wear jewelry that is made from metals such as surgical-grade stainless steel, pure sterling silver, or platinum. If yellow gold is the preferred metal, it is prudent to be aware that lower karat items could potentially contain nickel. White gold should be avoided, as it often contains nickel to contribute to its color. Finally, gold-plated jewelry should be avoided, as the plating can wear off and expose a possibly nickel-containing base.

A low-nickel diet may be of benefit in select patients. A meta-analysis assessing systemic contact dermatitis from nickel ingestion found that 1% of nickel-sensitive individuals may be expected to react to nickel found in a normal diet.²⁷ However, as with any diet, adherence can be difficult. Thankfully, Mislankar and Zirwas²⁸ have developed a simple point-based system to help increase compliance. Additionally, a free mobile application is now available; Nickel Navigator can be used to track daily nickel intake and may be especially convenient for our more tech-savvy patients. In conjunction with a low-nickel diet, some authors also recommend eating meals high in vitamin C or supplementation with vitamin C, as co-ingestion has been shown to reduce nickel absorption.²⁹

Final Interpretation

Nickel allergy remains common, found in up to 17.5% of patch tested patients. Despite regulation in the EU, nickel continues to have high prevalence of positive patch test reactions around the world. Nickel is not only found in jewelry and belt buckles but also in personal care products, electronics, and food. Allergen avoidance is key and requires knowledge of common items containing nickel and a low nickel diet for select patients.

Nickel is unrivaled as the most common cause of contact allergy worldwide.¹ Nickel is commonly used as a hardening agent in metal products, and complete avoidance is challenging due to numerous potential exposures (eg, direct contact, airborne, dietary, medical implantation). Allergic contact dermatitis to nickel (Ni-ACD) can lead to decreased quality of life, inability to work, and considerable health care expenses.¹ Here, we review the epidemiology of nickel allergy, regulation of nickel in the United States and Europe, common clinical presentations, and pearls on avoidance.

Epidemiology

Nickel continues to be the most common cause of contact allergy worldwide. Data from the 2015-2016 North American Contact Dermatitis Group patch test cycle (N=5597) showed nickel sulfate to be positive in 17.5% of patients patch tested to nickel.² The prevalence of nickel allergy has been relatively stable in North America since 2005 (Figure 1). Although Ni-ACD historically was identified as an occupational disease of the hands in male nickel platers, the epidemiology of nickel allergy has shifted.¹ Today, most cases are nonoccupational and affect women more often than men,³ in part due to improved industrial hygiene, pervasive incorporation of nickel in consumer items, and differences in cultural practices such as piercings.^1,3 Piercings in particular have been implicated as important sources of nickel exposure, as this practice disrupts normal skin barrier function and is a potentially sensitizing event. Multiple studies including a large-scale epidemiologic analysis from 2017 have found piercings to be associated with an increased frequency of Ni-ACD (24.4% with piercing vs 9.6% without piercing). Interestingly, the degree of nickel sensitivity also was found to increase with the number of piercings (14.3% with 1 piercing vs 34.0% with ≥5 piercings).⁴

Regulation

Nickel content has been regulated in parts of the European Union (EU) since the 1990s, but regulation in the United States is lacking. In an attempt to reduce the prevalence of nickel allergy, the EU limits the level of nickel release from consumer items intended to be in direct and prolonged contact with the skin. These limits were first introduced in Denmark in 1990, followed closely by the EU Nickel Directive in 1994, which has resulted in consistent patterns of decreasing prevalence of Ni-ACD in multiple European countries.⁵ Notably, a Danish study comparing the prevalence of sensitization between girls with ears pierced before vs after implementation of nickel regulation found a decrease in prevalence from 17.1% to 3.9%.⁶ Additionally, this initiative has greatly reduced the economic burden of nickel dermatitis. It is estimated that Denmark alone has saved US $2 billion over a 20-year period in both direct and indirect health care costs.⁷

However, a policy is only effective if it is enforced, and it has been reported in the EU that 8% to 32% of tested jewelry exceeds the limit placed on nickel release, with imported jewelry being especially problematic.⁵ Also of interest, the 1 and 2 euro coins are known to release more nickel than pure nickel itself, releasing 240 to 320 times more than is allowed under the EU Nickel Directive (Figure 2).⁸ Although coins are not explicitly mentioned as items having prolonged contact with the skin, they can and do exacerbate allergic contact dermatitis of the hands, especially in occupational groups such as cashiers.⁹ Unsurprisingly, during the discussions to determine the composition of coins prior to the mass adoption of the euro in the EU in 2002, dermatologists and nickel industry experts remained divided in their recommendations.¹⁰ However, the EU regulation is considered a public health success overall, and the trends of Ni-ACD and economic burden are opposite of the United States, where legislation has yet to be adopted.

Patch Testing to Nickel

In North America, the 2 available patch test systems are the chamber method and the Thin-layer Rapid Use Epicutaneous (T.R.U.E.) test (SmartPractice). In the T.R.U.E. test, nickel sulfate is used to formulate the patch at 200 µg/cm² using hydroxypropyl cellulose as the gel vehicle. In the chamber method, nickel sulfate is used on either an aluminum or plastic chamber, most commonly at concentrations of 2.5% or 5% in petrolatum. Nickel sulfate 2.5% is most frequently used in US-based patch test clinics. A 2018 study (N=205) comparing the sensitivities of the 2.5% and 5% concentrations of nickel found 5% to be more sensitive; 31% of the cohort tested positive at 5% but only 20% at 2.5%, suggesting the 5% formulation is superior at detecting nickel allergy.¹¹

Similar to other metals, nickel may react later than other allergens. A 2019 analysis of the prevalence of new patch test reactions on day 7 showed that 17% of 607 patients were negative on day 3 but were positive on day 7, further emphasizing the importance of a properly timed delayed reading.¹²

Clinical Presentation

Localized
The classic presentation of Ni-ACD is a scaly erythematous dermatitis in a typical distribution (eg, earlobes [earrings], wrists [watch], periumbilical [belt]). These scenarios usually can be diagnosed by the astute clinician without patch testing; however, the source of exposure may be less obvious if the nickel-releasing item has intermittent contact with the skin (eg, coins in the pocket, furniture hardware, personal grooming devices).¹³ Other reported exposures include facial dermatitis from mobile phones, dermatitis of the ulnar hands from laptop use, and hand dermatitis from gaming controllers,^14-16 perhaps another reason for some to unplug.

Systemic
Sensitized individuals also may present with systemic contact dermatitis after airborne, oral, mucosal, or intravenous exposure. Presentations vary but have been reported to manifest as flare-up reactions in previously affected areas, pompholyx, diffuse dermatitis, flexural dermatitis, and baboon syndrome.¹⁷ Although it is unknown if airborne exposure alone is sufficient for sensitization, cases have been reported in occupational settings.¹⁸ One report described a man presenting with widespread dermatitis involving the extremities, chest, and genital area after his first day working at an electroplating plant.¹⁹

Systemic contact dermatitis from foods high in nickel (eg, chocolate, sunflower seeds, whole-grain flour, dried beans) and occasionally nonfood items (eg, coins) also has occurred. The so-called Easter egg hunt dermatitis has been described in children with Ni-ACD after candy ingestion.²⁰ Another case described an 8-year-old girl and budding illusionist with severe diffuse dermatitis; a thorough history revealed the dermatitis began after she ingested a coin while performing a magic trick.²¹

Cases of nickel systemic contact dermatitis have been reported following medical device implantation, including reactions to cardiac devices, orthopedic implants, neurosurgery materials, and others.²² In addition, both intraoral and extraoral manifestations following application of orthodontic materials and dental implants have been reported.^23,24 Although nickel-containing medical devices generally are well tolerated even in nickel-sensitive individuals, the development of systemic Ni-ACD has at times required device or hardware removal.^22,23

After the Patch Test: Avoidance of Nickel

Counseling patients on nickel avoidance is critical to clinical improvement. Common nickel-containing items include jewelry, metal on clothing (eg, zippers, clasps, grommets), belt buckles, watches, glasses, furniture, coins, and keys. Numerous personal care products may also contain nickel, including nail clippers, eyelash curlers, tweezers, mascara tubes, and razors.^25,26 Patients should be made aware that nickel-free alternatives are available for the majority of these products. Internet-based tips such as painting nail polish on products or iron-on patches tend to be of limited use in our experience. Patients may consider purchasing a nickel spot test to detect nickel in their environment; the dimethylglyoxime nickel spot test is inexpensive, rapid, and easy-to-use. To use the test, a small amount of the chemical is rubbed on the metal item using a cotton swab; a pink color indicates nickel release. Patients can be reassured that dimethylglyoxime does not harm jewelry.

Some general advice for patients regarding jewelry, the most common source of nickel exposure, is to only wear jewelry that is made from metals such as surgical-grade stainless steel, pure sterling silver, or platinum. If yellow gold is the preferred metal, it is prudent to be aware that lower karat items could potentially contain nickel. White gold should be avoided, as it often contains nickel to contribute to its color. Finally, gold-plated jewelry should be avoided, as the plating can wear off and expose a possibly nickel-containing base.

A low-nickel diet may be of benefit in select patients. A meta-analysis assessing systemic contact dermatitis from nickel ingestion found that 1% of nickel-sensitive individuals may be expected to react to nickel found in a normal diet.²⁷ However, as with any diet, adherence can be difficult. Thankfully, Mislankar and Zirwas²⁸ have developed a simple point-based system to help increase compliance. Additionally, a free mobile application is now available; Nickel Navigator can be used to track daily nickel intake and may be especially convenient for our more tech-savvy patients. In conjunction with a low-nickel diet, some authors also recommend eating meals high in vitamin C or supplementation with vitamin C, as co-ingestion has been shown to reduce nickel absorption.²⁹

Final Interpretation

Nickel allergy remains common, found in up to 17.5% of patch tested patients. Despite regulation in the EU, nickel continues to have high prevalence of positive patch test reactions around the world. Nickel is not only found in jewelry and belt buckles but also in personal care products, electronics, and food. Allergen avoidance is key and requires knowledge of common items containing nickel and a low nickel diet for select patients.

The management of delusional infestation (DI), also known as Morgellons disease or delusional parasitosis, can lead to some of the most difficult and stressful patient encounters in dermatology. As a specialty, dermatology providers are trained to respect scientific objectivity and pride themselves on their visual diagnostic acumen. Therefore, having to accommodate a patient’s erroneous ideations and potentially treat a psychiatric pathology poses a challenge for many dermatology providers because it requires shifting their mindset to where the subjective reality becomes the primary issue during the visit. This disconnect may lead to strife between the patient and the provider. All of these issues may make it difficult for dermatologists to connect with DI patients with the usual courtesy and consideration given to other patients. Moreover, some dermatologists find it difficult to respect the chief concern, which often is seen as purely psychological because there may be some lingering bias where psychological concerns perhaps are not seen as bona fide or legitimate disorders.

Is There a Biologic Basis for DI? A New Theory on the Etiology of Delusional Parasitosis

It is important to distinguish DI phenomenology into primary and secondary causes. Primary DI refers to cases where the delusion and formication occur spontaneously. In contrast, in secondary DI the delusion and other manifestations (eg, formication) happen secondarily to underlying broader diagnoses such as illicit substance abuse, primary psychiatric conditions including schizophrenia, organic brain syndrome, and vitamin B₁₂ deficiency.

It is well known that primary DI overwhelmingly occurs in older women, whereas secondary DI does not show this same predilection. It has been a big unanswered question as to why primary DI so often occurs not only in women but specifically in older women. The latest theory that has been advancing in Europe and is supported by some data, including magnetic resonance imaging of the brain, involves the dopamine transporter (DAT) system, which is important in making sure the dopamine level in the intersynaptic space is not excessive.¹ The DAT system is much more prominent in woman vs men and deteriorates with age due to declining estrogen levels. This age-related loss of striatal DAT is thought to be one possible etiology of DI. It has been hypothesized that decreased DAT functioning may cause an increase in extracellular striatal dopamine levels in the synapse that can lead to tactile hallucinations and delusions, which are hallmark symptoms seen in DI. Given that women experience a greater age-related DAT decline in striatal subregions than men, it is thought that primary DI mainly affects older women due to the decline of neuroprotective effects of estrogen on DAT activity with age.² Further studies should evaluate the possibility of estrogen replacement therapy for treatment of DI.

Improving Care of Psychodermatology Patients in Clinic

There are several medications that are known to be effective for the treatment of DI, including pimozide, risperidone, aripiprazole, and olanzapine, among others. Pimozide is uniquely accepted by DI patients because it has no official psychiatric indication from the US Food and Drug Administration (FDA); it is only indicated in the United States for Tourette syndrome, which is a neurologic disorder. Therefore, pimozide arguably can be disregarded as a true antipsychotic agent. The fact that its chemical structure is similar to those of bona fide antipsychotic medications does not necessarily put it in this same category, as there also are antiemetic and antitussive medications (eg, prochlorperazine, promethazine) with chemical structures similar to antipsychotics, but clinicians generally do not think of these drugs as antipsychotics despite the similarities. This nuanced and admittedly somewhat arbitrary categorization is critical to patient care; in our clinic, we have found that patients who categorically refuse to consider all psychiatric medications are much more willing to try pimozide for this very reason, that this medication can uniquely be presented to the DI patient as an agent not used in psychiatry. We have found great success in treatment with pimozide, even with relatively low doses.^3,4

One of the main reasons dermatologists are reluctant to prescribe antipsychotic medications or even pimozide is the concern for side effects, especially tardive dyskinesia (TD), which is thought to be irreversible and untreatable. However, after a half century of worldwide use of pimozide in dermatology, a PubMed search of English-language articles indexed for MEDLINE using the terms pimozide and tardive dyskinesia, tardive dyskinesia and delusions of parasitosis, tardive dyskinesia and dermatology, and tardive dyskinesia and delusional infestation/Morgellons disease yielded only 1 known case of TD reported in dermatologic use for DI.⁵ In this particular case, TD-like symptoms did not appear until after pimozide had been discontinued for 1 month. Therefore, it is not clear if this case was true TD or a condition known as withdrawal dyskinesia, which mimics TD and usually is self-limiting.⁵

The senior author (J.K.) has been using pimozide for treatment of DI for more than 30 years and has not encountered TD or any other notable side effects. The reason for this extremely low incidence of side effects may be due to its high efficacy in treating DI; hence, only a low dose of pimozide usually is needed. At the University of California, San Francisco, Psychodermatology Clinic, pimozide typically is used to treat DI at a low dose of 3 mg or less daily, starting with 0.5 or 1 mg and slowly titrating upward until a clinically effective dose is reached. Pimozide rarely is used long-term; after the resolution of symptoms, the dose usually is continued at the clinically effective dose for a few months and then is slowly tapered off. In contrast, for a condition such as schizophrenia, an antipsychotic medication often is needed at high doses for life, resulting in higher TD occurrences being reported. Therefore, even though the newer antipsychotic agents are preferable to pimozide because of their somewhat lower risk for TD, in actual clinical practice many, if not most, DI patients detest any suggestion of taking a medication for “crazy people.” Thus, we find that pimozide’s inherent superior acceptability among DI patients often is critical to enabling any effective treatment to occur at all due to the fact that the provider can honestly say that pimozide has no FDA psychiatric indication.

Still, one of the biggest apprehensions with initiating and continuing these medications in dermatology is fear of TD. Now, dermatologists can be made aware that if this very rare side effect occurs, there are medications approved to treat TD, even if the anti-TD therapy is administered by a neurologist. For the first time, 2 medications were approved by the FDA for treatment of TD in 2017, namely valbenazine and deutetrabenazine. These medications represent a class known as vesicular monoamine transporter type 2 inhibitors and function by ultimately reducing the amount of dopamine released from the presynaptic dopaminergic neurons. In phase 3 trials for valbenazine and deutetrabenazine, 40% (N=234) and 34% (N=222) of patients, respectively, achieved a response, which was defined as at least a 50% decrease from baseline on the abnormal involuntary movement scale dyskinesia score in 6 to 12 weeks compared to 9% and 12%, respectively, with placebo.Discontinuation because of an adverse event was seldom encountered with both medications.⁶

Conclusion

The recent developments in psychodermatology with regard to DI are encouraging. The advent of new evidence and theories suggestive of an organic basis for DI could help this condition become more respected in the eyes of the dermatologist as a bona fide disorder. Moreover, the new developments and availability of medications that can treat TD can further make it easier for dermatologists to consider offering DI patients truly meaningful treatment that they desperately need. Therefore, both of these developments are welcomed for our specialty.

The management of delusional infestation (DI), also known as Morgellons disease or delusional parasitosis, can lead to some of the most difficult and stressful patient encounters in dermatology. As a specialty, dermatology providers are trained to respect scientific objectivity and pride themselves on their visual diagnostic acumen. Therefore, having to accommodate a patient’s erroneous ideations and potentially treat a psychiatric pathology poses a challenge for many dermatology providers because it requires shifting their mindset to where the subjective reality becomes the primary issue during the visit. This disconnect may lead to strife between the patient and the provider. All of these issues may make it difficult for dermatologists to connect with DI patients with the usual courtesy and consideration given to other patients. Moreover, some dermatologists find it difficult to respect the chief concern, which often is seen as purely psychological because there may be some lingering bias where psychological concerns perhaps are not seen as bona fide or legitimate disorders.

Is There a Biologic Basis for DI? A New Theory on the Etiology of Delusional Parasitosis

It is important to distinguish DI phenomenology into primary and secondary causes. Primary DI refers to cases where the delusion and formication occur spontaneously. In contrast, in secondary DI the delusion and other manifestations (eg, formication) happen secondarily to underlying broader diagnoses such as illicit substance abuse, primary psychiatric conditions including schizophrenia, organic brain syndrome, and vitamin B₁₂ deficiency.

It is well known that primary DI overwhelmingly occurs in older women, whereas secondary DI does not show this same predilection. It has been a big unanswered question as to why primary DI so often occurs not only in women but specifically in older women. The latest theory that has been advancing in Europe and is supported by some data, including magnetic resonance imaging of the brain, involves the dopamine transporter (DAT) system, which is important in making sure the dopamine level in the intersynaptic space is not excessive.¹ The DAT system is much more prominent in woman vs men and deteriorates with age due to declining estrogen levels. This age-related loss of striatal DAT is thought to be one possible etiology of DI. It has been hypothesized that decreased DAT functioning may cause an increase in extracellular striatal dopamine levels in the synapse that can lead to tactile hallucinations and delusions, which are hallmark symptoms seen in DI. Given that women experience a greater age-related DAT decline in striatal subregions than men, it is thought that primary DI mainly affects older women due to the decline of neuroprotective effects of estrogen on DAT activity with age.² Further studies should evaluate the possibility of estrogen replacement therapy for treatment of DI.

Improving Care of Psychodermatology Patients in Clinic

There are several medications that are known to be effective for the treatment of DI, including pimozide, risperidone, aripiprazole, and olanzapine, among others. Pimozide is uniquely accepted by DI patients because it has no official psychiatric indication from the US Food and Drug Administration (FDA); it is only indicated in the United States for Tourette syndrome, which is a neurologic disorder. Therefore, pimozide arguably can be disregarded as a true antipsychotic agent. The fact that its chemical structure is similar to those of bona fide antipsychotic medications does not necessarily put it in this same category, as there also are antiemetic and antitussive medications (eg, prochlorperazine, promethazine) with chemical structures similar to antipsychotics, but clinicians generally do not think of these drugs as antipsychotics despite the similarities. This nuanced and admittedly somewhat arbitrary categorization is critical to patient care; in our clinic, we have found that patients who categorically refuse to consider all psychiatric medications are much more willing to try pimozide for this very reason, that this medication can uniquely be presented to the DI patient as an agent not used in psychiatry. We have found great success in treatment with pimozide, even with relatively low doses.^3,4

One of the main reasons dermatologists are reluctant to prescribe antipsychotic medications or even pimozide is the concern for side effects, especially tardive dyskinesia (TD), which is thought to be irreversible and untreatable. However, after a half century of worldwide use of pimozide in dermatology, a PubMed search of English-language articles indexed for MEDLINE using the terms pimozide and tardive dyskinesia, tardive dyskinesia and delusions of parasitosis, tardive dyskinesia and dermatology, and tardive dyskinesia and delusional infestation/Morgellons disease yielded only 1 known case of TD reported in dermatologic use for DI.⁵ In this particular case, TD-like symptoms did not appear until after pimozide had been discontinued for 1 month. Therefore, it is not clear if this case was true TD or a condition known as withdrawal dyskinesia, which mimics TD and usually is self-limiting.⁵

The senior author (J.K.) has been using pimozide for treatment of DI for more than 30 years and has not encountered TD or any other notable side effects. The reason for this extremely low incidence of side effects may be due to its high efficacy in treating DI; hence, only a low dose of pimozide usually is needed. At the University of California, San Francisco, Psychodermatology Clinic, pimozide typically is used to treat DI at a low dose of 3 mg or less daily, starting with 0.5 or 1 mg and slowly titrating upward until a clinically effective dose is reached. Pimozide rarely is used long-term; after the resolution of symptoms, the dose usually is continued at the clinically effective dose for a few months and then is slowly tapered off. In contrast, for a condition such as schizophrenia, an antipsychotic medication often is needed at high doses for life, resulting in higher TD occurrences being reported. Therefore, even though the newer antipsychotic agents are preferable to pimozide because of their somewhat lower risk for TD, in actual clinical practice many, if not most, DI patients detest any suggestion of taking a medication for “crazy people.” Thus, we find that pimozide’s inherent superior acceptability among DI patients often is critical to enabling any effective treatment to occur at all due to the fact that the provider can honestly say that pimozide has no FDA psychiatric indication.

Still, one of the biggest apprehensions with initiating and continuing these medications in dermatology is fear of TD. Now, dermatologists can be made aware that if this very rare side effect occurs, there are medications approved to treat TD, even if the anti-TD therapy is administered by a neurologist. For the first time, 2 medications were approved by the FDA for treatment of TD in 2017, namely valbenazine and deutetrabenazine. These medications represent a class known as vesicular monoamine transporter type 2 inhibitors and function by ultimately reducing the amount of dopamine released from the presynaptic dopaminergic neurons. In phase 3 trials for valbenazine and deutetrabenazine, 40% (N=234) and 34% (N=222) of patients, respectively, achieved a response, which was defined as at least a 50% decrease from baseline on the abnormal involuntary movement scale dyskinesia score in 6 to 12 weeks compared to 9% and 12%, respectively, with placebo.Discontinuation because of an adverse event was seldom encountered with both medications.⁶

Conclusion

The recent developments in psychodermatology with regard to DI are encouraging. The advent of new evidence and theories suggestive of an organic basis for DI could help this condition become more respected in the eyes of the dermatologist as a bona fide disorder. Moreover, the new developments and availability of medications that can treat TD can further make it easier for dermatologists to consider offering DI patients truly meaningful treatment that they desperately need. Therefore, both of these developments are welcomed for our specialty.

The management of delusional infestation (DI), also known as Morgellons disease or delusional parasitosis, can lead to some of the most difficult and stressful patient encounters in dermatology. As a specialty, dermatology providers are trained to respect scientific objectivity and pride themselves on their visual diagnostic acumen. Therefore, having to accommodate a patient’s erroneous ideations and potentially treat a psychiatric pathology poses a challenge for many dermatology providers because it requires shifting their mindset to where the subjective reality becomes the primary issue during the visit. This disconnect may lead to strife between the patient and the provider. All of these issues may make it difficult for dermatologists to connect with DI patients with the usual courtesy and consideration given to other patients. Moreover, some dermatologists find it difficult to respect the chief concern, which often is seen as purely psychological because there may be some lingering bias where psychological concerns perhaps are not seen as bona fide or legitimate disorders.

Is There a Biologic Basis for DI? A New Theory on the Etiology of Delusional Parasitosis

It is important to distinguish DI phenomenology into primary and secondary causes. Primary DI refers to cases where the delusion and formication occur spontaneously. In contrast, in secondary DI the delusion and other manifestations (eg, formication) happen secondarily to underlying broader diagnoses such as illicit substance abuse, primary psychiatric conditions including schizophrenia, organic brain syndrome, and vitamin B₁₂ deficiency.

It is well known that primary DI overwhelmingly occurs in older women, whereas secondary DI does not show this same predilection. It has been a big unanswered question as to why primary DI so often occurs not only in women but specifically in older women. The latest theory that has been advancing in Europe and is supported by some data, including magnetic resonance imaging of the brain, involves the dopamine transporter (DAT) system, which is important in making sure the dopamine level in the intersynaptic space is not excessive.¹ The DAT system is much more prominent in woman vs men and deteriorates with age due to declining estrogen levels. This age-related loss of striatal DAT is thought to be one possible etiology of DI. It has been hypothesized that decreased DAT functioning may cause an increase in extracellular striatal dopamine levels in the synapse that can lead to tactile hallucinations and delusions, which are hallmark symptoms seen in DI. Given that women experience a greater age-related DAT decline in striatal subregions than men, it is thought that primary DI mainly affects older women due to the decline of neuroprotective effects of estrogen on DAT activity with age.² Further studies should evaluate the possibility of estrogen replacement therapy for treatment of DI.

Improving Care of Psychodermatology Patients in Clinic

There are several medications that are known to be effective for the treatment of DI, including pimozide, risperidone, aripiprazole, and olanzapine, among others. Pimozide is uniquely accepted by DI patients because it has no official psychiatric indication from the US Food and Drug Administration (FDA); it is only indicated in the United States for Tourette syndrome, which is a neurologic disorder. Therefore, pimozide arguably can be disregarded as a true antipsychotic agent. The fact that its chemical structure is similar to those of bona fide antipsychotic medications does not necessarily put it in this same category, as there also are antiemetic and antitussive medications (eg, prochlorperazine, promethazine) with chemical structures similar to antipsychotics, but clinicians generally do not think of these drugs as antipsychotics despite the similarities. This nuanced and admittedly somewhat arbitrary categorization is critical to patient care; in our clinic, we have found that patients who categorically refuse to consider all psychiatric medications are much more willing to try pimozide for this very reason, that this medication can uniquely be presented to the DI patient as an agent not used in psychiatry. We have found great success in treatment with pimozide, even with relatively low doses.^3,4

One of the main reasons dermatologists are reluctant to prescribe antipsychotic medications or even pimozide is the concern for side effects, especially tardive dyskinesia (TD), which is thought to be irreversible and untreatable. However, after a half century of worldwide use of pimozide in dermatology, a PubMed search of English-language articles indexed for MEDLINE using the terms pimozide and tardive dyskinesia, tardive dyskinesia and delusions of parasitosis, tardive dyskinesia and dermatology, and tardive dyskinesia and delusional infestation/Morgellons disease yielded only 1 known case of TD reported in dermatologic use for DI.⁵ In this particular case, TD-like symptoms did not appear until after pimozide had been discontinued for 1 month. Therefore, it is not clear if this case was true TD or a condition known as withdrawal dyskinesia, which mimics TD and usually is self-limiting.⁵

The senior author (J.K.) has been using pimozide for treatment of DI for more than 30 years and has not encountered TD or any other notable side effects. The reason for this extremely low incidence of side effects may be due to its high efficacy in treating DI; hence, only a low dose of pimozide usually is needed. At the University of California, San Francisco, Psychodermatology Clinic, pimozide typically is used to treat DI at a low dose of 3 mg or less daily, starting with 0.5 or 1 mg and slowly titrating upward until a clinically effective dose is reached. Pimozide rarely is used long-term; after the resolution of symptoms, the dose usually is continued at the clinically effective dose for a few months and then is slowly tapered off. In contrast, for a condition such as schizophrenia, an antipsychotic medication often is needed at high doses for life, resulting in higher TD occurrences being reported. Therefore, even though the newer antipsychotic agents are preferable to pimozide because of their somewhat lower risk for TD, in actual clinical practice many, if not most, DI patients detest any suggestion of taking a medication for “crazy people.” Thus, we find that pimozide’s inherent superior acceptability among DI patients often is critical to enabling any effective treatment to occur at all due to the fact that the provider can honestly say that pimozide has no FDA psychiatric indication.

Still, one of the biggest apprehensions with initiating and continuing these medications in dermatology is fear of TD. Now, dermatologists can be made aware that if this very rare side effect occurs, there are medications approved to treat TD, even if the anti-TD therapy is administered by a neurologist. For the first time, 2 medications were approved by the FDA for treatment of TD in 2017, namely valbenazine and deutetrabenazine. These medications represent a class known as vesicular monoamine transporter type 2 inhibitors and function by ultimately reducing the amount of dopamine released from the presynaptic dopaminergic neurons. In phase 3 trials for valbenazine and deutetrabenazine, 40% (N=234) and 34% (N=222) of patients, respectively, achieved a response, which was defined as at least a 50% decrease from baseline on the abnormal involuntary movement scale dyskinesia score in 6 to 12 weeks compared to 9% and 12%, respectively, with placebo.Discontinuation because of an adverse event was seldom encountered with both medications.⁶

Conclusion

The recent developments in psychodermatology with regard to DI are encouraging. The advent of new evidence and theories suggestive of an organic basis for DI could help this condition become more respected in the eyes of the dermatologist as a bona fide disorder. Moreover, the new developments and availability of medications that can treat TD can further make it easier for dermatologists to consider offering DI patients truly meaningful treatment that they desperately need. Therefore, both of these developments are welcomed for our specialty.

Case Report

A 67-year-old Black woman presented with a long-standing history of pruritus and “scaly thick bumps” on the lower extremities. Upon further questioning, she reported a 30-year history of placing her feet by an electric space heater and daily baths in “very hot” water. A review of systems and medical history were unremarkable, and the patient was not on any medications. Initial physical examination of the lower extremities demonstrated lichenified plaques and scattered, firm, ulcerated nodules surrounded by mottled postinflammatory hyperpigmentation with sharp demarcation at the midcalf bilaterally (Figure 1).

Subsequently, the patient was shown to have multiple actinic keratoses and SCCs, both in situ and invasive, within the areas of EAI (Figure 2). The patient had no actinic keratoses or other cutaneous malignant neoplasms elsewhere on the skin. Management of actinic keratoses, SCC in situ, and invasive SCC on the lower extremities included numerous excisions, treatment with liquid nitrogen, and topical 5-fluorouracil under occlusion. The patient continues to be monitored frequently.

Comment

Presentation of EAI
Erythema ab igne is a cutaneous reaction resulting from prolonged exposure to an infrared heat source at temperatures insufficient to cause a burn (37 °F to 113 °F [2.78 °C to 45 °C]). Initially presenting as transient blanchable erythema, chronic heat exposure induces persistent areas of reticular erythema, often accompanied by hyperpigmentation, epidermal atrophy, and telangiectases.¹ Erythema ab igne is most commonly reported on the anterior shins, inner thighs, and back, and it is historically associated with open fires and coal stoves. More recently, other implicated causes include heating pads, laptop computers, heated furniture, and electric space heaters.^2,3 Erythema ab igne often is asymptomatic but can present with pruritus and a burning sensation. Treatment involves removal of the inciting heat source, which might allow resolution of early-stage lesions. Long-term exposure leads to permanent skin discoloration and on occasion predisposes patients to malignant transformation.³

Histopathology of EAI
Histologically, later stages of EAI can demonstrate focal hyperkeratosis with dyskeratosis and increased dermal elastosis, similar to actinic damage, with a predisposition to develop SCC.² Notably, early reports document various heat-induced carcinomas, including kangri-burn cancers among Kashmiris, kang thermal cancers in China, and kairo cancers in Japan.^2,4,5 More recent reports identify cutaneous carcinomas arising specifically in the setting of EAI, most commonly SCC³; Merkel cell carcinoma and cutaneous marginal zone lymphoma are less commonly reported malignancies.^6,7 Given the frequency of malignant transformation within sites of thermal exposure, chronic heat exposure may share a common pathophysiology with SCC and other neoplasms, including Merkel cell carcinoma and cutaneous marginal zone lymphoma.

SCC in Black Individuals
Squamous cell carcinoma is the most common skin cancer in Black individuals, with a notably higher incidence in high-risk subpopulations (immunosuppressed patients). Unlike White individuals, SCCs frequently occur in non–sun-exposed areas in Black individuals and are associated with unique risk factors, such as human papillomavirus, as demonstrated in Black transplant patients.⁸ A retrospective study examining the characteristics of SCC on the legs of Black individuals documented atypical hyperkeratotic neoplasms surrounded by abnormal pigmentation and mottling of surrounding skin.⁹ Morphologic skin changes could be the result of chronic thermal damage: Numerous patients reported a history of leg warming from an open heat source. Other patients had an actual diagnosis of EAI. The predilection for less-exposed skin suggests UV radiation (UVR) might be a less important predisposing risk factor for this racial group, and the increased mortality associated with SCC in Black individuals might represent a more aggressive nature to this subset of SCCs.⁹ Furthermore, infrared radiation (IRR), such as fires and coal stoves, might have the potential to stimulate skin changes similar to those associated with UVR and ultimately malignant changes.

Infrared Radiation
Compared to UVR, little is known about the biological effects of IRR (wavelength, 760 nm to 1 mm), to which human skin is constantly exposed from natural and artificial light sources. Early studies have demonstrated the carcinogenic potential of IRR, observing an augmentation of UVR-induced tumorigenesis in the presence of heat. More recently, IRR was observed to stimulate increased collagenase production from dermal fibroblasts and influence pathways (extracellular signal-related kinases 1/2 and p38 mitogen-activated protein kinases) in a similar fashion to UVB and UVA.^10,11 Therefore, IRR might be capable of eliciting molecular responses comparable to those caused by UVR.

Conclusion

Although SCC in association with EAI is uncommon, historical reports of thermal cancers and scientific observations of IRR-induced biological and molecular effects support EAI as a predisposing risk factor for SCC and the important need for close monitoring by physicians. Studies are needed to further elucidate the pathologic effects of IRR, with more promotion of caution relating to thermal exposure.

Case Report

A 67-year-old Black woman presented with a long-standing history of pruritus and “scaly thick bumps” on the lower extremities. Upon further questioning, she reported a 30-year history of placing her feet by an electric space heater and daily baths in “very hot” water. A review of systems and medical history were unremarkable, and the patient was not on any medications. Initial physical examination of the lower extremities demonstrated lichenified plaques and scattered, firm, ulcerated nodules surrounded by mottled postinflammatory hyperpigmentation with sharp demarcation at the midcalf bilaterally (Figure 1).

Subsequently, the patient was shown to have multiple actinic keratoses and SCCs, both in situ and invasive, within the areas of EAI (Figure 2). The patient had no actinic keratoses or other cutaneous malignant neoplasms elsewhere on the skin. Management of actinic keratoses, SCC in situ, and invasive SCC on the lower extremities included numerous excisions, treatment with liquid nitrogen, and topical 5-fluorouracil under occlusion. The patient continues to be monitored frequently.

Comment

Presentation of EAI
Erythema ab igne is a cutaneous reaction resulting from prolonged exposure to an infrared heat source at temperatures insufficient to cause a burn (37 °F to 113 °F [2.78 °C to 45 °C]). Initially presenting as transient blanchable erythema, chronic heat exposure induces persistent areas of reticular erythema, often accompanied by hyperpigmentation, epidermal atrophy, and telangiectases.¹ Erythema ab igne is most commonly reported on the anterior shins, inner thighs, and back, and it is historically associated with open fires and coal stoves. More recently, other implicated causes include heating pads, laptop computers, heated furniture, and electric space heaters.^2,3 Erythema ab igne often is asymptomatic but can present with pruritus and a burning sensation. Treatment involves removal of the inciting heat source, which might allow resolution of early-stage lesions. Long-term exposure leads to permanent skin discoloration and on occasion predisposes patients to malignant transformation.³

Histopathology of EAI
Histologically, later stages of EAI can demonstrate focal hyperkeratosis with dyskeratosis and increased dermal elastosis, similar to actinic damage, with a predisposition to develop SCC.² Notably, early reports document various heat-induced carcinomas, including kangri-burn cancers among Kashmiris, kang thermal cancers in China, and kairo cancers in Japan.^2,4,5 More recent reports identify cutaneous carcinomas arising specifically in the setting of EAI, most commonly SCC³; Merkel cell carcinoma and cutaneous marginal zone lymphoma are less commonly reported malignancies.^6,7 Given the frequency of malignant transformation within sites of thermal exposure, chronic heat exposure may share a common pathophysiology with SCC and other neoplasms, including Merkel cell carcinoma and cutaneous marginal zone lymphoma.

SCC in Black Individuals
Squamous cell carcinoma is the most common skin cancer in Black individuals, with a notably higher incidence in high-risk subpopulations (immunosuppressed patients). Unlike White individuals, SCCs frequently occur in non–sun-exposed areas in Black individuals and are associated with unique risk factors, such as human papillomavirus, as demonstrated in Black transplant patients.⁸ A retrospective study examining the characteristics of SCC on the legs of Black individuals documented atypical hyperkeratotic neoplasms surrounded by abnormal pigmentation and mottling of surrounding skin.⁹ Morphologic skin changes could be the result of chronic thermal damage: Numerous patients reported a history of leg warming from an open heat source. Other patients had an actual diagnosis of EAI. The predilection for less-exposed skin suggests UV radiation (UVR) might be a less important predisposing risk factor for this racial group, and the increased mortality associated with SCC in Black individuals might represent a more aggressive nature to this subset of SCCs.⁹ Furthermore, infrared radiation (IRR), such as fires and coal stoves, might have the potential to stimulate skin changes similar to those associated with UVR and ultimately malignant changes.

Infrared Radiation
Compared to UVR, little is known about the biological effects of IRR (wavelength, 760 nm to 1 mm), to which human skin is constantly exposed from natural and artificial light sources. Early studies have demonstrated the carcinogenic potential of IRR, observing an augmentation of UVR-induced tumorigenesis in the presence of heat. More recently, IRR was observed to stimulate increased collagenase production from dermal fibroblasts and influence pathways (extracellular signal-related kinases 1/2 and p38 mitogen-activated protein kinases) in a similar fashion to UVB and UVA.^10,11 Therefore, IRR might be capable of eliciting molecular responses comparable to those caused by UVR.

Conclusion

Although SCC in association with EAI is uncommon, historical reports of thermal cancers and scientific observations of IRR-induced biological and molecular effects support EAI as a predisposing risk factor for SCC and the important need for close monitoring by physicians. Studies are needed to further elucidate the pathologic effects of IRR, with more promotion of caution relating to thermal exposure.

Case Report

A 67-year-old Black woman presented with a long-standing history of pruritus and “scaly thick bumps” on the lower extremities. Upon further questioning, she reported a 30-year history of placing her feet by an electric space heater and daily baths in “very hot” water. A review of systems and medical history were unremarkable, and the patient was not on any medications. Initial physical examination of the lower extremities demonstrated lichenified plaques and scattered, firm, ulcerated nodules surrounded by mottled postinflammatory hyperpigmentation with sharp demarcation at the midcalf bilaterally (Figure 1).

Subsequently, the patient was shown to have multiple actinic keratoses and SCCs, both in situ and invasive, within the areas of EAI (Figure 2). The patient had no actinic keratoses or other cutaneous malignant neoplasms elsewhere on the skin. Management of actinic keratoses, SCC in situ, and invasive SCC on the lower extremities included numerous excisions, treatment with liquid nitrogen, and topical 5-fluorouracil under occlusion. The patient continues to be monitored frequently.

Comment

Presentation of EAI
Erythema ab igne is a cutaneous reaction resulting from prolonged exposure to an infrared heat source at temperatures insufficient to cause a burn (37 °F to 113 °F [2.78 °C to 45 °C]). Initially presenting as transient blanchable erythema, chronic heat exposure induces persistent areas of reticular erythema, often accompanied by hyperpigmentation, epidermal atrophy, and telangiectases.¹ Erythema ab igne is most commonly reported on the anterior shins, inner thighs, and back, and it is historically associated with open fires and coal stoves. More recently, other implicated causes include heating pads, laptop computers, heated furniture, and electric space heaters.^2,3 Erythema ab igne often is asymptomatic but can present with pruritus and a burning sensation. Treatment involves removal of the inciting heat source, which might allow resolution of early-stage lesions. Long-term exposure leads to permanent skin discoloration and on occasion predisposes patients to malignant transformation.³

Histopathology of EAI
Histologically, later stages of EAI can demonstrate focal hyperkeratosis with dyskeratosis and increased dermal elastosis, similar to actinic damage, with a predisposition to develop SCC.² Notably, early reports document various heat-induced carcinomas, including kangri-burn cancers among Kashmiris, kang thermal cancers in China, and kairo cancers in Japan.^2,4,5 More recent reports identify cutaneous carcinomas arising specifically in the setting of EAI, most commonly SCC³; Merkel cell carcinoma and cutaneous marginal zone lymphoma are less commonly reported malignancies.^6,7 Given the frequency of malignant transformation within sites of thermal exposure, chronic heat exposure may share a common pathophysiology with SCC and other neoplasms, including Merkel cell carcinoma and cutaneous marginal zone lymphoma.

SCC in Black Individuals
Squamous cell carcinoma is the most common skin cancer in Black individuals, with a notably higher incidence in high-risk subpopulations (immunosuppressed patients). Unlike White individuals, SCCs frequently occur in non–sun-exposed areas in Black individuals and are associated with unique risk factors, such as human papillomavirus, as demonstrated in Black transplant patients.⁸ A retrospective study examining the characteristics of SCC on the legs of Black individuals documented atypical hyperkeratotic neoplasms surrounded by abnormal pigmentation and mottling of surrounding skin.⁹ Morphologic skin changes could be the result of chronic thermal damage: Numerous patients reported a history of leg warming from an open heat source. Other patients had an actual diagnosis of EAI. The predilection for less-exposed skin suggests UV radiation (UVR) might be a less important predisposing risk factor for this racial group, and the increased mortality associated with SCC in Black individuals might represent a more aggressive nature to this subset of SCCs.⁹ Furthermore, infrared radiation (IRR), such as fires and coal stoves, might have the potential to stimulate skin changes similar to those associated with UVR and ultimately malignant changes.

Infrared Radiation
Compared to UVR, little is known about the biological effects of IRR (wavelength, 760 nm to 1 mm), to which human skin is constantly exposed from natural and artificial light sources. Early studies have demonstrated the carcinogenic potential of IRR, observing an augmentation of UVR-induced tumorigenesis in the presence of heat. More recently, IRR was observed to stimulate increased collagenase production from dermal fibroblasts and influence pathways (extracellular signal-related kinases 1/2 and p38 mitogen-activated protein kinases) in a similar fashion to UVB and UVA.^10,11 Therefore, IRR might be capable of eliciting molecular responses comparable to those caused by UVR.

Conclusion

Although SCC in association with EAI is uncommon, historical reports of thermal cancers and scientific observations of IRR-induced biological and molecular effects support EAI as a predisposing risk factor for SCC and the important need for close monitoring by physicians. Studies are needed to further elucidate the pathologic effects of IRR, with more promotion of caution relating to thermal exposure.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

The ability of advanced practice providers (APPs) to practice independently has been a recent topic of discussion among both the medical community and legislatures. Advanced practice provider is an umbrella term that includes physician assistants (PAs) and advanced practice registered nurses, including nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists. Since Congress passed the Balanced Budget Act of 1997, APPs can bill and be paid independently if they are not practicing incident to a physician or in a facility.¹ Currently, NPs can practice independently in 27 states and Washington, DC. Physician assistants are required to practice under the supervision of a physician; however, the extent of supervision varies by state.² Advocates for broadening the scope of practice for APPs argue that NPs and PAs will help to fill the physician deficit, particularly in primary care and rural regions. It has been projected that by 2025, the United States will require an additional 46,000 primary care providers to meet growing medical needs.³

On October 3, 2019, President Donald Trump issued the Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, in which he proposed an alternative to “Medicare for all.”⁴ This order instructed the Secretary of Health and Human Services to prepare a regulation that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions and all other licensure requirements . . . that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their field.” Furthermore, President Trump proposed that “services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.”⁴

In response to the executive order, members of the medical community utilized Reddit, an online public forum, and Medscape, a medical news website, to vocalize opinions on the executive order.^5,6 Our goal was to analyze the characteristics of those who participated in the discussion and their points of view on the plan to broaden the scope of practice and change the Medicare reimbursement plans for APPs.

Methods

All comments on the October 3, 2019, Medscape article, “Trump Executive Order Seeks Proposals on Medicare Pay for NPs, PAs,”⁵ and the corresponding Reddit discussion on this article⁶ were reviewed and characterized by the type of commenter—doctor of medicine (MD)/doctor of osteopathic medicine (DO), NP/RN/certified registered nurse anesthetist, PA, medical student, PA student, NP student, pharmacist, dietician, emergency medical technician, scribe, or unknown—as identified in their username, title, or in the text of the comment. Gender of the commenter was recorded when provided. Commenters were further grouped by their support or lack of support for the executive order based on their comments. Patients’ comments underwent further qualitative analysis to identify general themes.

All analyses were conducted with RStudio statistical software. Analyses were reported as proportions. Variables were compared by χ² and Fisher exact tests. Odds ratios with 95% CIs were calculated. P<.05 was considered statistically significant.

Results

A total of 352 comments (130 on Medscape and 222 on Reddit) posted by 155 unique users (57 on Medscape and 98 on Reddit) were included in the analysis (Table 1). Of the 51 Medscape commenters who identified a gender, 60.7% were male and 39.2% were female. Reddit commenters did not identify a gender. Commenters included MD and DO physicians (43.2%), NPs/RNs/certified registered nurse anesthetists (13.5%), medical students (11.0%), PAs (9.7%), pharmacists (3.2%), NP students (1.9%), PA students (1.3%), emergency medical technicians (1.3%), dieticians (0.6%), and scribes (0.6%). Physicians (54.5% vs 36.73%; P=.032) and NPs (22.8% vs 8.2%; P=.009) made up a larger percentage of all comments on Medscape compared to Reddit, where medical students were more prevalent (16.3% vs 1.8%; P=.005). Nursing students and PA students more commonly posted on Reddit (4.08% of Reddit commenters vs 1.75% of Medscape commenters), though this difference did not achieve statistical significance.

A majority of commenters did not support the executive order, with only 20.6% approving of the plan, 54.8% disapproving, and 24.5% remaining neutral (Figure). Advanced practice providers—NPs, PAs, NP/PA students, and APPs not otherwise specified—were more likely to support the executive order, with 52.3% voicing their support compared to only 4.8% of physicians and medical students expressing support (P<.0001). Similarly, physicians and medical students were more likely to disapprove of the order, with 75.0% voicing concerns compared to only 27.3% of APPs dissenting (P<.0001). A similar percentage of both physicians/medical students and APPs remained neutral (20.2% vs 18.2%). Commenters on Medscape were more likely to voice support for the executive order than those on Reddit (36.8% vs 11.2%; P=.0002), likely due to the higher percentage of NP and PA comments on the former.

Comment

President Trump’s executive order follows a trend of decreasing required oversight of APPs; however, this study indicates that these policies would face pushback from many physicians. These results are consistent with a prior study that analyzed 309 comments on an article in The New York Times made by physicians, APPs, patients, and laypeople, in which 24.7% had mistrust of APPs and 14.9% had concerns over APP supervision compared to 9% who supported APP independent practice.⁷ It is clear that there is a serious divide in opinion that threatens to harm the existing collaborations between physicians and APPs.

Primary Care Coverage With APPs
In the comments analyzed in our study, supporters of the executive order argued that an increase in APPs practicing independently would provide much-needed primary care coverage to patients in underserved regions. However, APPs are instead well represented across most specialties, with a majority in dermatology. Of the 4 million procedures billed independently by APPs in 2012, 54.8% were in the field of dermatology.⁸ The employment of APPs by dermatologists has grown from 28% of practices in 2005 to 46% in 2014, making this issue of particular importance to our field.^9,10

Education and Training of APPs
In our analysis, many physicians cited concerns about the education and training of APPs. Dermatologists receive approximately 10,000 hours of training over the course of residency. Per the American Academy of Physician Assistants, PAs spend more than 2000 hours over a 26-month period on various clinical rotations, “with an emphasis on primary care.”¹¹ There are multiple routes to become an advanced practice RN with varying classroom and clinical requirements, with one pathway requiring a bachelor of science in nursing, followed by a master’s degree requiring 500 to 700 hours of supervised clinical work. Although the Dermatology Nurses’ Association and Society of Dermatology Physician Assistants (http://www.dermpa.org) provide online modules, annual conventions with training workshops, and short fellowship programs, neither have formal guidelines on minimum requirements to diagnose and treat dermatologic conditions.² Despite the lack of formalized dermatologic training, APPs billed for 13.4% of all dermatology procedures submitted to Medicare in 2015.¹²

Quality of Patient Care
In our study, physicians also voiced concern over reduced quality of patient care. In a review of 33,647 skin cancer screening examinations, PAs biopsied an average of 39.4 skin lesions, while dermatologists biopsied an average of 25.4 skin lesions to diagnose 1 case of melanoma.¹³ In addition, nonphysician providers accounted for 37.9% of defendants in 174 legal cases related to injury from cutaneous laser surgery.¹⁴ Before further laws are enacted regarding the independent practice and billing by NPs and PAs in the field of dermatology, further research is needed to address patient outcomes and safety.

Limitations
This study was subject to several limitations. Because of a lack of other sources offering discussions on the topic, our sample size was limited. Self-identification of users presents a challenge, as an individual can pose as a physician or APP without validation of credentials. Although great care was taken to minimize bias, grouping comments into broad categories may misinterpret a poster’s intentions. Furthermore, the data collected represent only a small proportion of the medical community—readers of Medscape and Reddit who have the motivation to create a user profile and post a comment rather than put their efforts into lobbying or contacting legislators. Those posting may have stronger political opinions or more poignant experiences than the general public. Although selection bias impacts the generalizability of our findings, this analysis allows for deeper insight into the beliefs of a vocal subset of the medical community who may not have the opportunity to present their opinions elsewhere.

Conclusion

Our analysis of the response to President Trump’s executive order reveals that a rollout of these regulations would be met with strong opposition. On October 29, 2019, more than 100 professional organizations, including the American Medical Association and the American Academy of Dermatology, wrote a letter to the Secretary of Health and Human Services that eloquently echoed the sentiments of the physician commenters in this study: “Scope of practice of health care professionals should be based on standardized, adequate training and demonstrated competence in patient care, not politics. While all health care professionals share an important role in providing care to patients, their skillset is not interchangeable with that of a fully trained physician.”¹⁵ The executive order would lead to a major shift in the current medical landscape, and as such, it is prudent that these concerns are addressed.

Practice Gap

Practical patient positioning is a commonly overlooked method of tension control during excision and repair that allows for easier closure.¹ Although positioning is a basic step in dermatologic surgery, it often is difficult and awkward for both the patient and physician. Here, we describe basic principles in patient positioning that increase tension across the surgical site during excision and reduce tension during closure. By reducing the amount of work required for excision and closure, procedures are completed more quickly, which increases efficiency. These techniques should be considered during dermatologic surgery at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities.

Technique: Upper Back Procedures

When removing lesions on the upper back, lying completely prone is uncomfortable for the patient and leaves the shoulders hyperextended.² Instead, position the patient with the arms extended anteriorly, hugging a pillow, while lying prone or on one side (Figure 1). In this position, excision of the lesion is facilitated by increased tension across the upper back. In addition, this position is notably more comfortable for the patient. During closure, the patient should lie on the side contralateral to the surgical site, with the elbow resting at the hip and the ipsilateral arm lying parallel to the torso (Figure 2).

Following procedures on the upper back and shoulders, we typically recommend that the patient wear an arm sling on the ipsilateral side for 1 week. Doing so reliably limits mobility postoperatively and does not require the patient to constantly monitor their movement.

Technique: Lower Extremity Procedures

Anterior Lower Extremity
During excision of a lesion on the anterior lower extremity, we recommend that the patient be positioned with their knee bent and heel resting on the examination table. Ideally, the knee is flexed at approximately a 45° angle (Figure 3).³ In this position, excision of the lesion is facilitated by increased tension across the anterior lower extremity. During closure of these lesions, the patient should lie supine with the knee fully extended and the leg resting on the surgical bed or a pillow.

Posterior Lower Extremity
During excision of lesions on the posterior lower extremity, the patient should be positioned lying prone, with the knee fully extended, resting on the surgical bed or a pillow, which facilitates excision of the lesion by increasing tension across the site. During closure of these lesions, the patient should lie on the side contralateral to the surgical site, with the leg fully extended for support. The surgical leg should be flexed at the knee at approximately a 45° angle (Figure 4).

Practice Implications

Despite being an important step, patient positioning is an often-overlooked component of dermatologic surgery. Positioning becomes even more important in areas of high tension and repetitive motion, such as the upper back and lower extremities, where the risk of wound dehiscence and poor scar cosmesis is increased.¹ Experienced dermatologic surgeons should utilize patient positioning, taking advantage of tension instead of working against it.

We have found that these 2 simple principles can aid in simplifying the excision and repair processes. Increasing tension across the surgical site during excision reduces the work required by the surgeon to reach the appropriate depth. Conversely, decreased tension across the surgical site decreases the work required for closure. These principles should be considered prior to the procedure; the patient should then be positioned in a way that maximizes tension across the surgical site during excision and minimizes tension across the surgical site during closure.

Incorporating these techniques, especially at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities, not only increases efficiency but may also reduce the risk for wound dehiscence once the patient returns home and maintains their normal level of physical activity.

Practice Gap

Practical patient positioning is a commonly overlooked method of tension control during excision and repair that allows for easier closure.¹ Although positioning is a basic step in dermatologic surgery, it often is difficult and awkward for both the patient and physician. Here, we describe basic principles in patient positioning that increase tension across the surgical site during excision and reduce tension during closure. By reducing the amount of work required for excision and closure, procedures are completed more quickly, which increases efficiency. These techniques should be considered during dermatologic surgery at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities.

Technique: Upper Back Procedures

When removing lesions on the upper back, lying completely prone is uncomfortable for the patient and leaves the shoulders hyperextended.² Instead, position the patient with the arms extended anteriorly, hugging a pillow, while lying prone or on one side (Figure 1). In this position, excision of the lesion is facilitated by increased tension across the upper back. In addition, this position is notably more comfortable for the patient. During closure, the patient should lie on the side contralateral to the surgical site, with the elbow resting at the hip and the ipsilateral arm lying parallel to the torso (Figure 2).

Following procedures on the upper back and shoulders, we typically recommend that the patient wear an arm sling on the ipsilateral side for 1 week. Doing so reliably limits mobility postoperatively and does not require the patient to constantly monitor their movement.

Technique: Lower Extremity Procedures

Anterior Lower Extremity
During excision of a lesion on the anterior lower extremity, we recommend that the patient be positioned with their knee bent and heel resting on the examination table. Ideally, the knee is flexed at approximately a 45° angle (Figure 3).³ In this position, excision of the lesion is facilitated by increased tension across the anterior lower extremity. During closure of these lesions, the patient should lie supine with the knee fully extended and the leg resting on the surgical bed or a pillow.

Posterior Lower Extremity
During excision of lesions on the posterior lower extremity, the patient should be positioned lying prone, with the knee fully extended, resting on the surgical bed or a pillow, which facilitates excision of the lesion by increasing tension across the site. During closure of these lesions, the patient should lie on the side contralateral to the surgical site, with the leg fully extended for support. The surgical leg should be flexed at the knee at approximately a 45° angle (Figure 4).

Practice Implications

Despite being an important step, patient positioning is an often-overlooked component of dermatologic surgery. Positioning becomes even more important in areas of high tension and repetitive motion, such as the upper back and lower extremities, where the risk of wound dehiscence and poor scar cosmesis is increased.¹ Experienced dermatologic surgeons should utilize patient positioning, taking advantage of tension instead of working against it.

We have found that these 2 simple principles can aid in simplifying the excision and repair processes. Increasing tension across the surgical site during excision reduces the work required by the surgeon to reach the appropriate depth. Conversely, decreased tension across the surgical site decreases the work required for closure. These principles should be considered prior to the procedure; the patient should then be positioned in a way that maximizes tension across the surgical site during excision and minimizes tension across the surgical site during closure.

Incorporating these techniques, especially at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities, not only increases efficiency but may also reduce the risk for wound dehiscence once the patient returns home and maintains their normal level of physical activity.

Practice Gap

Practical patient positioning is a commonly overlooked method of tension control during excision and repair that allows for easier closure.¹ Although positioning is a basic step in dermatologic surgery, it often is difficult and awkward for both the patient and physician. Here, we describe basic principles in patient positioning that increase tension across the surgical site during excision and reduce tension during closure. By reducing the amount of work required for excision and closure, procedures are completed more quickly, which increases efficiency. These techniques should be considered during dermatologic surgery at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities.

Technique: Upper Back Procedures

When removing lesions on the upper back, lying completely prone is uncomfortable for the patient and leaves the shoulders hyperextended.² Instead, position the patient with the arms extended anteriorly, hugging a pillow, while lying prone or on one side (Figure 1). In this position, excision of the lesion is facilitated by increased tension across the upper back. In addition, this position is notably more comfortable for the patient. During closure, the patient should lie on the side contralateral to the surgical site, with the elbow resting at the hip and the ipsilateral arm lying parallel to the torso (Figure 2).

Following procedures on the upper back and shoulders, we typically recommend that the patient wear an arm sling on the ipsilateral side for 1 week. Doing so reliably limits mobility postoperatively and does not require the patient to constantly monitor their movement.

Technique: Lower Extremity Procedures

Anterior Lower Extremity
During excision of a lesion on the anterior lower extremity, we recommend that the patient be positioned with their knee bent and heel resting on the examination table. Ideally, the knee is flexed at approximately a 45° angle (Figure 3).³ In this position, excision of the lesion is facilitated by increased tension across the anterior lower extremity. During closure of these lesions, the patient should lie supine with the knee fully extended and the leg resting on the surgical bed or a pillow.

Posterior Lower Extremity
During excision of lesions on the posterior lower extremity, the patient should be positioned lying prone, with the knee fully extended, resting on the surgical bed or a pillow, which facilitates excision of the lesion by increasing tension across the site. During closure of these lesions, the patient should lie on the side contralateral to the surgical site, with the leg fully extended for support. The surgical leg should be flexed at the knee at approximately a 45° angle (Figure 4).

Practice Implications

Despite being an important step, patient positioning is an often-overlooked component of dermatologic surgery. Positioning becomes even more important in areas of high tension and repetitive motion, such as the upper back and lower extremities, where the risk of wound dehiscence and poor scar cosmesis is increased.¹ Experienced dermatologic surgeons should utilize patient positioning, taking advantage of tension instead of working against it.

We have found that these 2 simple principles can aid in simplifying the excision and repair processes. Increasing tension across the surgical site during excision reduces the work required by the surgeon to reach the appropriate depth. Conversely, decreased tension across the surgical site decreases the work required for closure. These principles should be considered prior to the procedure; the patient should then be positioned in a way that maximizes tension across the surgical site during excision and minimizes tension across the surgical site during closure.

Incorporating these techniques, especially at sites that are subject to both high tension and repetitive motion, such as the upper back and lower extremities, not only increases efficiency but may also reduce the risk for wound dehiscence once the patient returns home and maintains their normal level of physical activity.

Multifocal microvascular injury in the brain and olfactory bulbs is another possible adverse outcome from COVID-19, new research suggests.

Postmortem MRI brain scans of 13 patients who died from COVID-19 showed abnormalities in 10 of the participants. Of these, nine showed punctate hyperintensities, “which represented areas of microvascular injury and fibrinogen leakage,” the investigators reported. Immunostaining also showed a thinning of the basal lamina in five of these patients.

Further analyses showed punctate hypointensities linked to congested blood vessels in 10 patients. These areas were “interpreted as microhemorrhages,” the researchers noted.

There was no evidence of viral infection, including SARS-CoV-2.

“These findings may inform the interpretation of changes observed on [MRI] of punctate hyperintensities and linear hypointensities in patients with COVID-19,” wrote Myoung-Hwa Lee, PhD, a research fellow at the National Institute of Neurological Disorders and Stroke, and colleagues. The findings were published online Dec. 30 in a “correspondence” piece in the New England Journal of Medicine.
 

Interpret with caution

The investigators examined brains from a convenience sample of 19 patients (mean age, 50 years), all of whom died from COVID-19 between March and July 2020.

An 11.7-tesla scanner was used to obtain magnetic resonance microscopy images for 13 of the patients. In order to scan the olfactory bulb, the scanner was set at a resolution of 25 mcm; for the brain, it was set at 100 mcm.

Chromogenic immunostaining was used to assess brain abnormalities found in 10 of the patients. Multiplex fluorescence imaging was also used for some of the patients.

For 18 study participants, a histopathological brain examination was performed. In the patients who also had medical histories available to the researchers, five had mild respiratory syndrome, four had acute respiratory distress syndrome, two had pulmonary embolism, one had delirium, and three had unknown symptoms.

The punctate hyperintensities found on magnetic resonance microscopy were also found on histopathological exam. Collagen IV immunostaining showed a thinning in the basal lamina of endothelial cells in these areas.

In addition to congested blood vessels, punctate hypointensities were linked to areas of fibrinogen leakage – but also to “relatively intact vasculature,” the investigators reported.

“There was minimal perivascular inflammation in the specimens examined, but there was no vascular occlusion,” they added.

SARS-CoV-2 was also not found in any of the participants. “It is possible that the virus was cleared by the time of death or that viral copy numbers were below the level of detection by our assays,” the researchers noted.

In 13 of the patients, hypertrophic astrocytes, macrophage infiltrates, and perivascular-activated microglia were found. Eight patients showed CD3+ and CD8+ T cells in spaces and lumens next to endothelial cells.

Finally, five patients showed activated microglia next to neurons. This is “suggestive of neuronophagia in the olfactory bulb, substantial nigra, dorsal motor nucleus of the vagal nerve, and the pre-Bötzinger complex in the medulla, which is involved in the generation of spontaneous rhythmic breathing,” wrote the investigators.

In summary, vascular pathology was found in 10 cases, perivascular infiltrates were present in 13 cases, acute ischemic hypoxic neurons were present in 6 cases, and changes suggestive of neuronophagia were present in 5 cases.

The researchers noted that, although the study findings may be helpful when interpreting brain changes on MRI scan in this patient population, availability of clinical information for the participants was limited.

Therefore, “no conclusions can be drawn in relation to neurologic features of COVID-19,” they wrote.

The study was funded by NINDS. Dr. Lee and all but one of the other investigators reported no relevant financial relationships; the remaining investigator reported having received grants from NINDS during the conduct of this study.

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

Multifocal microvascular injury in the brain and olfactory bulbs is another possible adverse outcome from COVID-19, new research suggests.

Postmortem MRI brain scans of 13 patients who died from COVID-19 showed abnormalities in 10 of the participants. Of these, nine showed punctate hyperintensities, “which represented areas of microvascular injury and fibrinogen leakage,” the investigators reported. Immunostaining also showed a thinning of the basal lamina in five of these patients.

Further analyses showed punctate hypointensities linked to congested blood vessels in 10 patients. These areas were “interpreted as microhemorrhages,” the researchers noted.

There was no evidence of viral infection, including SARS-CoV-2.

“These findings may inform the interpretation of changes observed on [MRI] of punctate hyperintensities and linear hypointensities in patients with COVID-19,” wrote Myoung-Hwa Lee, PhD, a research fellow at the National Institute of Neurological Disorders and Stroke, and colleagues. The findings were published online Dec. 30 in a “correspondence” piece in the New England Journal of Medicine.
 

Interpret with caution

The investigators examined brains from a convenience sample of 19 patients (mean age, 50 years), all of whom died from COVID-19 between March and July 2020.

An 11.7-tesla scanner was used to obtain magnetic resonance microscopy images for 13 of the patients. In order to scan the olfactory bulb, the scanner was set at a resolution of 25 mcm; for the brain, it was set at 100 mcm.

Chromogenic immunostaining was used to assess brain abnormalities found in 10 of the patients. Multiplex fluorescence imaging was also used for some of the patients.

For 18 study participants, a histopathological brain examination was performed. In the patients who also had medical histories available to the researchers, five had mild respiratory syndrome, four had acute respiratory distress syndrome, two had pulmonary embolism, one had delirium, and three had unknown symptoms.

The punctate hyperintensities found on magnetic resonance microscopy were also found on histopathological exam. Collagen IV immunostaining showed a thinning in the basal lamina of endothelial cells in these areas.

In addition to congested blood vessels, punctate hypointensities were linked to areas of fibrinogen leakage – but also to “relatively intact vasculature,” the investigators reported.

“There was minimal perivascular inflammation in the specimens examined, but there was no vascular occlusion,” they added.

SARS-CoV-2 was also not found in any of the participants. “It is possible that the virus was cleared by the time of death or that viral copy numbers were below the level of detection by our assays,” the researchers noted.

In 13 of the patients, hypertrophic astrocytes, macrophage infiltrates, and perivascular-activated microglia were found. Eight patients showed CD3+ and CD8+ T cells in spaces and lumens next to endothelial cells.

Finally, five patients showed activated microglia next to neurons. This is “suggestive of neuronophagia in the olfactory bulb, substantial nigra, dorsal motor nucleus of the vagal nerve, and the pre-Bötzinger complex in the medulla, which is involved in the generation of spontaneous rhythmic breathing,” wrote the investigators.

In summary, vascular pathology was found in 10 cases, perivascular infiltrates were present in 13 cases, acute ischemic hypoxic neurons were present in 6 cases, and changes suggestive of neuronophagia were present in 5 cases.

The researchers noted that, although the study findings may be helpful when interpreting brain changes on MRI scan in this patient population, availability of clinical information for the participants was limited.

Therefore, “no conclusions can be drawn in relation to neurologic features of COVID-19,” they wrote.

The study was funded by NINDS. Dr. Lee and all but one of the other investigators reported no relevant financial relationships; the remaining investigator reported having received grants from NINDS during the conduct of this study.

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

Multifocal microvascular injury in the brain and olfactory bulbs is another possible adverse outcome from COVID-19, new research suggests.

Postmortem MRI brain scans of 13 patients who died from COVID-19 showed abnormalities in 10 of the participants. Of these, nine showed punctate hyperintensities, “which represented areas of microvascular injury and fibrinogen leakage,” the investigators reported. Immunostaining also showed a thinning of the basal lamina in five of these patients.

Further analyses showed punctate hypointensities linked to congested blood vessels in 10 patients. These areas were “interpreted as microhemorrhages,” the researchers noted.

There was no evidence of viral infection, including SARS-CoV-2.

“These findings may inform the interpretation of changes observed on [MRI] of punctate hyperintensities and linear hypointensities in patients with COVID-19,” wrote Myoung-Hwa Lee, PhD, a research fellow at the National Institute of Neurological Disorders and Stroke, and colleagues. The findings were published online Dec. 30 in a “correspondence” piece in the New England Journal of Medicine.
 

Interpret with caution

The investigators examined brains from a convenience sample of 19 patients (mean age, 50 years), all of whom died from COVID-19 between March and July 2020.

An 11.7-tesla scanner was used to obtain magnetic resonance microscopy images for 13 of the patients. In order to scan the olfactory bulb, the scanner was set at a resolution of 25 mcm; for the brain, it was set at 100 mcm.

Chromogenic immunostaining was used to assess brain abnormalities found in 10 of the patients. Multiplex fluorescence imaging was also used for some of the patients.

For 18 study participants, a histopathological brain examination was performed. In the patients who also had medical histories available to the researchers, five had mild respiratory syndrome, four had acute respiratory distress syndrome, two had pulmonary embolism, one had delirium, and three had unknown symptoms.

The punctate hyperintensities found on magnetic resonance microscopy were also found on histopathological exam. Collagen IV immunostaining showed a thinning in the basal lamina of endothelial cells in these areas.

In addition to congested blood vessels, punctate hypointensities were linked to areas of fibrinogen leakage – but also to “relatively intact vasculature,” the investigators reported.

“There was minimal perivascular inflammation in the specimens examined, but there was no vascular occlusion,” they added.

SARS-CoV-2 was also not found in any of the participants. “It is possible that the virus was cleared by the time of death or that viral copy numbers were below the level of detection by our assays,” the researchers noted.

In 13 of the patients, hypertrophic astrocytes, macrophage infiltrates, and perivascular-activated microglia were found. Eight patients showed CD3+ and CD8+ T cells in spaces and lumens next to endothelial cells.

Finally, five patients showed activated microglia next to neurons. This is “suggestive of neuronophagia in the olfactory bulb, substantial nigra, dorsal motor nucleus of the vagal nerve, and the pre-Bötzinger complex in the medulla, which is involved in the generation of spontaneous rhythmic breathing,” wrote the investigators.

In summary, vascular pathology was found in 10 cases, perivascular infiltrates were present in 13 cases, acute ischemic hypoxic neurons were present in 6 cases, and changes suggestive of neuronophagia were present in 5 cases.

The researchers noted that, although the study findings may be helpful when interpreting brain changes on MRI scan in this patient population, availability of clinical information for the participants was limited.

Therefore, “no conclusions can be drawn in relation to neurologic features of COVID-19,” they wrote.

The study was funded by NINDS. Dr. Lee and all but one of the other investigators reported no relevant financial relationships; the remaining investigator reported having received grants from NINDS during the conduct of this study.

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

To the Editor:

There is an irrefutable trend toward urban dermatology practice in the United States, leading to growing problems with rural access to care. The provision of rural clinical experiences and telehealth in dermatology residency training might increase the likelihood of trainees establishing a rural practice.

In 2017, the American Academy of Dermatology released an updated statement supporting direct patient access to board-certified dermatologists in an effort to reduce morbidity and mortality associated with skin disease.¹ Twenty percent of the US population lives in a rural and medically underserved location, yet these areas remain largely underserved, in part because of an irrefutable trend toward urban dermatology practice.^2-4 Successful approaches to improving rural access to dermatology care are poorly defined in the literature.

Several variables have been shown to influence a young physician’s decision to establish a clinical practice in geographically isolated areas, including rural upbringing, longitudinal rural clinical experiences during medical training, and family influences.⁵ Location of residency training is an additional variable that impacts practice location, though migration following dermatology residency is a complex phenomenon. However, training location does not guarantee retention of dermatology graduates in any particular geographic area.⁶ Practice incentives and stipends might encourage rural dermatology practice, yet these programs are underfunded. Last, telemedicine in dermatology (including teledermatology and teledermoscopy), though not always an ideal substitute for a live visit, can improve access to care in geographically isolated or underserved areas in general.^7-9

Focused recruitment of medical students interested in rural dermatology practice to accredited dermatology residency programs aligned with this goal represents another approach to improve geographic diversity in the field of dermatology. Online access to this information would be useful for both applicants and their mentors.

We assessed viewable online curricula related to rural dermatology and telemedicine experiences at all Accreditation Council for Graduate Medical Education (ACGME)–accredited residency programs. Telemedicine experiences at Veterans Health Administration (VHA) health systems also were assessed.

Methods

This study was exempt from review by the institutional review board at the University of Minnesota (Minneapolis, Minnesota)(IRB #STUDY00004915) because no human subjects were involved. Online curricula of all ACGME-accredited dermatology residency programs in the United States and Puerto Rico were reviewed from November to December 2018. The following information was recorded: specialized “rural-track” training; optional elective time in rural settings; teledermatology training; and teledermoscopy training.

Additionally, population density at each program’s primary location was determined using US Census Bureau data and with consideration to communities contained within particular Metropolitan Statistical Areas (MSAs)(eTable). Data were obtained from the VHA system to assess teledermatology services at VHA locations affiliated with residency programs.

Results

Of 154 dermatology residency programs identified in the United States and Puerto Rico, 142 were accredited at the time of data collection. Fifteen (10%) were based in communities of 50,000 individuals or fewer that were not near a large metropolitan area. One program (<1%) offered a specific rural track. Fifty-six programs (39%) cited optional rotations or clinical electives, or both, that could be utilized for a rural experience. Eighteen (12%) offered teledermatology experiences and 1 (<1%) offered teledermoscopy during training. Fifty-three programs (37%) offered a rotation at a VHA hospital that had an active teledermatology service.

Comment

Program websites are a free and easily accessible means of acquiring relevant information. The paucity of readily available data on rural dermatology and teledermatology opportunities is unfortunate and a detriment to dermatology residency applicants interested in rural practice, which may result in a missed opportunity to foster a true passion for rural medicine. A brief comment on a website can be impactful, leading to a postgraduate year 4 dermatology elective rotation at a prospective fellowship training site or a rural dermatology experience.

The paucity of dermatologists working directly in rural areas has led to development of teledermatology initiatives to reach deeply into underserved regions. One of the largest providers of teledermatology is the VHA, which standardized its teledermatology efforts in 2012 and provides remarkable educational opportunities for dermatology residents. However, many residency program and VHA websites provide no information about the participation of dermatology residents in the provision of teledermatology services.

A limitation of this study is that it is based on online published curricula. Dermatology residency programs with excellent rural curricula that are not published online might exist.

Residency program directors with an interest in geographic diversity are encouraged to provide rural and teledermatology opportunities and to update these offerings on their websites, which is a simple modifiable strategy that can impact the rural dermatology care gap by recruiting students interested in filling this role. These efforts should be studied to determine whether this strategy impacts resident selection as well as whether focused rural and telemedicine exposure during training increases the likelihood of establishing a rural dermatology practice in the future.

To the Editor:

There is an irrefutable trend toward urban dermatology practice in the United States, leading to growing problems with rural access to care. The provision of rural clinical experiences and telehealth in dermatology residency training might increase the likelihood of trainees establishing a rural practice.

In 2017, the American Academy of Dermatology released an updated statement supporting direct patient access to board-certified dermatologists in an effort to reduce morbidity and mortality associated with skin disease.¹ Twenty percent of the US population lives in a rural and medically underserved location, yet these areas remain largely underserved, in part because of an irrefutable trend toward urban dermatology practice.^2-4 Successful approaches to improving rural access to dermatology care are poorly defined in the literature.

Several variables have been shown to influence a young physician’s decision to establish a clinical practice in geographically isolated areas, including rural upbringing, longitudinal rural clinical experiences during medical training, and family influences.⁵ Location of residency training is an additional variable that impacts practice location, though migration following dermatology residency is a complex phenomenon. However, training location does not guarantee retention of dermatology graduates in any particular geographic area.⁶ Practice incentives and stipends might encourage rural dermatology practice, yet these programs are underfunded. Last, telemedicine in dermatology (including teledermatology and teledermoscopy), though not always an ideal substitute for a live visit, can improve access to care in geographically isolated or underserved areas in general.^7-9

Focused recruitment of medical students interested in rural dermatology practice to accredited dermatology residency programs aligned with this goal represents another approach to improve geographic diversity in the field of dermatology. Online access to this information would be useful for both applicants and their mentors.

We assessed viewable online curricula related to rural dermatology and telemedicine experiences at all Accreditation Council for Graduate Medical Education (ACGME)–accredited residency programs. Telemedicine experiences at Veterans Health Administration (VHA) health systems also were assessed.

Methods

This study was exempt from review by the institutional review board at the University of Minnesota (Minneapolis, Minnesota)(IRB #STUDY00004915) because no human subjects were involved. Online curricula of all ACGME-accredited dermatology residency programs in the United States and Puerto Rico were reviewed from November to December 2018. The following information was recorded: specialized “rural-track” training; optional elective time in rural settings; teledermatology training; and teledermoscopy training.

Additionally, population density at each program’s primary location was determined using US Census Bureau data and with consideration to communities contained within particular Metropolitan Statistical Areas (MSAs)(eTable). Data were obtained from the VHA system to assess teledermatology services at VHA locations affiliated with residency programs.

Results

Of 154 dermatology residency programs identified in the United States and Puerto Rico, 142 were accredited at the time of data collection. Fifteen (10%) were based in communities of 50,000 individuals or fewer that were not near a large metropolitan area. One program (<1%) offered a specific rural track. Fifty-six programs (39%) cited optional rotations or clinical electives, or both, that could be utilized for a rural experience. Eighteen (12%) offered teledermatology experiences and 1 (<1%) offered teledermoscopy during training. Fifty-three programs (37%) offered a rotation at a VHA hospital that had an active teledermatology service.

Comment

Program websites are a free and easily accessible means of acquiring relevant information. The paucity of readily available data on rural dermatology and teledermatology opportunities is unfortunate and a detriment to dermatology residency applicants interested in rural practice, which may result in a missed opportunity to foster a true passion for rural medicine. A brief comment on a website can be impactful, leading to a postgraduate year 4 dermatology elective rotation at a prospective fellowship training site or a rural dermatology experience.

The paucity of dermatologists working directly in rural areas has led to development of teledermatology initiatives to reach deeply into underserved regions. One of the largest providers of teledermatology is the VHA, which standardized its teledermatology efforts in 2012 and provides remarkable educational opportunities for dermatology residents. However, many residency program and VHA websites provide no information about the participation of dermatology residents in the provision of teledermatology services.

A limitation of this study is that it is based on online published curricula. Dermatology residency programs with excellent rural curricula that are not published online might exist.

Residency program directors with an interest in geographic diversity are encouraged to provide rural and teledermatology opportunities and to update these offerings on their websites, which is a simple modifiable strategy that can impact the rural dermatology care gap by recruiting students interested in filling this role. These efforts should be studied to determine whether this strategy impacts resident selection as well as whether focused rural and telemedicine exposure during training increases the likelihood of establishing a rural dermatology practice in the future.

To the Editor:

There is an irrefutable trend toward urban dermatology practice in the United States, leading to growing problems with rural access to care. The provision of rural clinical experiences and telehealth in dermatology residency training might increase the likelihood of trainees establishing a rural practice.

In 2017, the American Academy of Dermatology released an updated statement supporting direct patient access to board-certified dermatologists in an effort to reduce morbidity and mortality associated with skin disease.¹ Twenty percent of the US population lives in a rural and medically underserved location, yet these areas remain largely underserved, in part because of an irrefutable trend toward urban dermatology practice.^2-4 Successful approaches to improving rural access to dermatology care are poorly defined in the literature.

Several variables have been shown to influence a young physician’s decision to establish a clinical practice in geographically isolated areas, including rural upbringing, longitudinal rural clinical experiences during medical training, and family influences.⁵ Location of residency training is an additional variable that impacts practice location, though migration following dermatology residency is a complex phenomenon. However, training location does not guarantee retention of dermatology graduates in any particular geographic area.⁶ Practice incentives and stipends might encourage rural dermatology practice, yet these programs are underfunded. Last, telemedicine in dermatology (including teledermatology and teledermoscopy), though not always an ideal substitute for a live visit, can improve access to care in geographically isolated or underserved areas in general.^7-9

Focused recruitment of medical students interested in rural dermatology practice to accredited dermatology residency programs aligned with this goal represents another approach to improve geographic diversity in the field of dermatology. Online access to this information would be useful for both applicants and their mentors.

We assessed viewable online curricula related to rural dermatology and telemedicine experiences at all Accreditation Council for Graduate Medical Education (ACGME)–accredited residency programs. Telemedicine experiences at Veterans Health Administration (VHA) health systems also were assessed.

Methods

This study was exempt from review by the institutional review board at the University of Minnesota (Minneapolis, Minnesota)(IRB #STUDY00004915) because no human subjects were involved. Online curricula of all ACGME-accredited dermatology residency programs in the United States and Puerto Rico were reviewed from November to December 2018. The following information was recorded: specialized “rural-track” training; optional elective time in rural settings; teledermatology training; and teledermoscopy training.

Additionally, population density at each program’s primary location was determined using US Census Bureau data and with consideration to communities contained within particular Metropolitan Statistical Areas (MSAs)(eTable). Data were obtained from the VHA system to assess teledermatology services at VHA locations affiliated with residency programs.

Results

Of 154 dermatology residency programs identified in the United States and Puerto Rico, 142 were accredited at the time of data collection. Fifteen (10%) were based in communities of 50,000 individuals or fewer that were not near a large metropolitan area. One program (<1%) offered a specific rural track. Fifty-six programs (39%) cited optional rotations or clinical electives, or both, that could be utilized for a rural experience. Eighteen (12%) offered teledermatology experiences and 1 (<1%) offered teledermoscopy during training. Fifty-three programs (37%) offered a rotation at a VHA hospital that had an active teledermatology service.

Comment

Program websites are a free and easily accessible means of acquiring relevant information. The paucity of readily available data on rural dermatology and teledermatology opportunities is unfortunate and a detriment to dermatology residency applicants interested in rural practice, which may result in a missed opportunity to foster a true passion for rural medicine. A brief comment on a website can be impactful, leading to a postgraduate year 4 dermatology elective rotation at a prospective fellowship training site or a rural dermatology experience.

The paucity of dermatologists working directly in rural areas has led to development of teledermatology initiatives to reach deeply into underserved regions. One of the largest providers of teledermatology is the VHA, which standardized its teledermatology efforts in 2012 and provides remarkable educational opportunities for dermatology residents. However, many residency program and VHA websites provide no information about the participation of dermatology residents in the provision of teledermatology services.

A limitation of this study is that it is based on online published curricula. Dermatology residency programs with excellent rural curricula that are not published online might exist.

Residency program directors with an interest in geographic diversity are encouraged to provide rural and teledermatology opportunities and to update these offerings on their websites, which is a simple modifiable strategy that can impact the rural dermatology care gap by recruiting students interested in filling this role. These efforts should be studied to determine whether this strategy impacts resident selection as well as whether focused rural and telemedicine exposure during training increases the likelihood of establishing a rural dermatology practice in the future.

On March 11, 2020, the World Health Organization declared the outbreak of coronavirus disease 2019 (COVID-19) a pandemic, leading to an abrupt widespread shift to teledermatology, with postponement of nonessential in-office medical and surgical services, according to American Academy of Dermatology (AAD) recommendations.¹ Perspectives have been offered regarding skin cancer management during the pandemic²; however, the current literature is lacking guidance on skin cancer screening and prevention during the COVID-19 era.

Preliminary data show a 34.3% reduction in skin cancer referrals from February to April 2020 compared to the same period in 2019. The authors also presented a subsequent reduction in the number of skin cancer diagnoses in March 2020 compared to March 2019.³ Although the COVID-19 public health emergency should be prioritized by all health care workers, the duty to maintain disease prevention remains.

We aim to provide recommendations for this urgent topic. Our goal is finding balance in preventing an increase in the incidence of and mortality from skin cancer that results from delayed detection, while conserving personalprotective equipment and minimizing exposure, by patients and clinical personnel, to the severe acute respiratory syndrome coronavirus 2. A primary benefit of skin cancer screening lies in the ability to detect melanoma, which is associated with higher mortality than the more common nonmelanoma skin cancers, basal and cutaneous squamous cell carcinomas. We place preeminence on screening directed toward detecting melanoma. The main screening method that dermatologists employ is the total-body skin examination (TBSE). Another widely encouraged and utilized component in skin cancer prevention is patient education, emphasizing avoidance of risk factors, undertaking protective factors, and providing clear instructions for performing the patient-led skin self-examination (SSE).

Teledermatology Essentials for Skin Cancer Screening

Arguably, dermatology possesses the most potential for successfully utilizing telemedicine. Teledermatology has become widely implemented across the United States, secondary to the implications of the current pandemic. A report by Perkins and colleagues⁴ provided a positive outlook in the preliminary transition to teledermatology beginning in March 2020, though reported time of use was relatively short (3 weeks). A May 2020 article in Dermatology News provided tips for implementing telemedicine for practices.⁵

We agree with the comprehensive screening algorithm for teledermatology presented by Perkins and colleagues⁴ (Figure 1A in their report) and recommend the following for the screening and prevention of skin cancer:

• Patients with any characteristics of increased risk, including a personal or family history of melanoma, large congenital nevi, many melanotic nevi, dysplastic nevi, and Fitzpatrick skin types I and II,⁶ should be prioritized for an in-person visit for TBSE.

• Immunosuppressed patients, particularly organ transplant recipients and those with a history of skin cancer, should be prioritized for an in-person visit for TBSE.

• Established patients evaluated and determined to be at average risk for skin cancer should be offered a teledermatology visit. Suspicious findings during these visits should be prioritized for an in-person visit, with subsequent biopsy and follow-up.

• New patients should be offered a teledermatology visit.

These recommendations must be reviewed alongside each patient’s risk for travel and being present in person as well as other factors that might place the patient at increased risk for COVID-19.

Total-body skin examination, a widely used tool in the dermatologist’s tool kit, presents minimal risk to patients while providing important data for each dermatology patient’s profile, ultimately directing patient care. The role of TBSE in skin cancer screening and prevention has been in discussion even prior to the current pandemic. The US Preventive Services Task Force (USPSTF) has not declared a role for TBSE in recent years; however, USPSTF recommendations are formulated using data from all forms of screening, not only dermatologist-led interventions. Accordingly, USPSTF recommendations target primary care. The AAD has released statements addressing the role of TBSE and skin cancer prevention in the past, when necessary, to provide clarity.⁷

There is no clear definition of SSE or guidelines on how to educate a patient to perform regular SSE; however, the AAD provides patients with resources on how to perform an SSE.⁸ Just as dermatologists would provide education, advice, and guidance by directing patients to the AAD website for the SSE during an in-person visit, we encourage dermatologists to continue this practice during all teledermatology visits.

The role of teledermatology in skin cancer screening and prevention is limited; dermatologists will not be able to adequately perform TBSE as it would be done at in-person visits. Furthermore, the true implications of teledermatology compared to in-person visits during the COVID-19 pandemic have yet to be realized and analyzed. It is nonetheless important to appreciate that teledermatology holds great promise of benefit in skin cancer prevention, especially in the form of patient education by dermatologists. Practices in the realm of screening and prevention by health care professionals should be continually addressed during the pandemic; it is important to consider the implications associated with delays in diagnosis and treatment.

Teledermatology Limitations and Recommendations for High-Quality Visits

A benefit of video consultation (VC) vs telephone visits is visual interaction—the crux of dermatology. A 2019 study investigated VC experiences among providers and patients in the primary care setting. Benefits of VC were reported to include convenience for working patients and patients with mobility or mental health problems, visual cues, building rapport, and improving communication.⁹

Despite these benefits, VC is not without limitations. Many technical factors create variability in the quality of teledermatology VCs for a melanocytic lesion, including patient environment and lighting, color distortion, video resolution, and Internet connection. We make the following recommendations:

• Environment: Locate or create a dedicated space for teledermatology visits that is well lit, private, and has minimal background noise. Place the device on a level surface, center yourself in the frame, and keep the camera at eye level.

• Lighting: Use neutral lighting, placing the light source in front of you but behind the camera of the device. Avoid placing light sources, such as a window, behind you.

• Video resolution: Regardless of the type of camera (eg, integrated webcam, external camera), close out all other running software programs to optimize bandwidth during the visit.

• Internet connection: Use a wired connection (via an Ethernet cable) instead of a Wi-Fi connection to greatly decrease the chance of losing the connection during the visit. It also is faster than Wi-Fi.

• Addressing specific lesions: Patients should keep the device in place, repositioning themselves to show the lesions rather than moving the device by hand.

• Video capacity: Test your device’s video capacity beforehand, which can be as simple as video-calling a family member or friend from your designated space. Feedback regarding video and audio quality will help fine-tune your setup.

• Instructions to the patient: Provide clear instructions to the patient when photographs of specific lesions are needed for further review. Specify what view(s) you need and whether size or bilateral comparison is needed. A web post by VisualDx¹⁰ provides advice to patients on taking high-quality photographs.

Final Thoughts

Teledermatology indubitably presents a learning curve for dermatologists and patients. As with other technological advances in society, we are optimistic that, first, the confidence level in teledermatology use will increase, and, second, evidence-based data will pave the way to enhance this experience. We realize the inherent limitation of accessibility to certain technologies, which is regrettably far from equitable. Patients need a personal device equipped with audio and video; access to a high-quality Internet connection; some degree of technological literacy; and a quiet private location.

We hope to learn from all experiences during the current pandemic. Future innovation in teledermatology and in telemedicine generally should aim to address technological inequities to allow for the delivery of quality care to as many patients as possible.

On March 11, 2020, the World Health Organization declared the outbreak of coronavirus disease 2019 (COVID-19) a pandemic, leading to an abrupt widespread shift to teledermatology, with postponement of nonessential in-office medical and surgical services, according to American Academy of Dermatology (AAD) recommendations.¹ Perspectives have been offered regarding skin cancer management during the pandemic²; however, the current literature is lacking guidance on skin cancer screening and prevention during the COVID-19 era.

Preliminary data show a 34.3% reduction in skin cancer referrals from February to April 2020 compared to the same period in 2019. The authors also presented a subsequent reduction in the number of skin cancer diagnoses in March 2020 compared to March 2019.³ Although the COVID-19 public health emergency should be prioritized by all health care workers, the duty to maintain disease prevention remains.

We aim to provide recommendations for this urgent topic. Our goal is finding balance in preventing an increase in the incidence of and mortality from skin cancer that results from delayed detection, while conserving personalprotective equipment and minimizing exposure, by patients and clinical personnel, to the severe acute respiratory syndrome coronavirus 2. A primary benefit of skin cancer screening lies in the ability to detect melanoma, which is associated with higher mortality than the more common nonmelanoma skin cancers, basal and cutaneous squamous cell carcinomas. We place preeminence on screening directed toward detecting melanoma. The main screening method that dermatologists employ is the total-body skin examination (TBSE). Another widely encouraged and utilized component in skin cancer prevention is patient education, emphasizing avoidance of risk factors, undertaking protective factors, and providing clear instructions for performing the patient-led skin self-examination (SSE).

Teledermatology Essentials for Skin Cancer Screening

Arguably, dermatology possesses the most potential for successfully utilizing telemedicine. Teledermatology has become widely implemented across the United States, secondary to the implications of the current pandemic. A report by Perkins and colleagues⁴ provided a positive outlook in the preliminary transition to teledermatology beginning in March 2020, though reported time of use was relatively short (3 weeks). A May 2020 article in Dermatology News provided tips for implementing telemedicine for practices.⁵

We agree with the comprehensive screening algorithm for teledermatology presented by Perkins and colleagues⁴ (Figure 1A in their report) and recommend the following for the screening and prevention of skin cancer:

• Patients with any characteristics of increased risk, including a personal or family history of melanoma, large congenital nevi, many melanotic nevi, dysplastic nevi, and Fitzpatrick skin types I and II,⁶ should be prioritized for an in-person visit for TBSE.

• Immunosuppressed patients, particularly organ transplant recipients and those with a history of skin cancer, should be prioritized for an in-person visit for TBSE.

• Established patients evaluated and determined to be at average risk for skin cancer should be offered a teledermatology visit. Suspicious findings during these visits should be prioritized for an in-person visit, with subsequent biopsy and follow-up.

• New patients should be offered a teledermatology visit.

These recommendations must be reviewed alongside each patient’s risk for travel and being present in person as well as other factors that might place the patient at increased risk for COVID-19.

Total-body skin examination, a widely used tool in the dermatologist’s tool kit, presents minimal risk to patients while providing important data for each dermatology patient’s profile, ultimately directing patient care. The role of TBSE in skin cancer screening and prevention has been in discussion even prior to the current pandemic. The US Preventive Services Task Force (USPSTF) has not declared a role for TBSE in recent years; however, USPSTF recommendations are formulated using data from all forms of screening, not only dermatologist-led interventions. Accordingly, USPSTF recommendations target primary care. The AAD has released statements addressing the role of TBSE and skin cancer prevention in the past, when necessary, to provide clarity.⁷

There is no clear definition of SSE or guidelines on how to educate a patient to perform regular SSE; however, the AAD provides patients with resources on how to perform an SSE.⁸ Just as dermatologists would provide education, advice, and guidance by directing patients to the AAD website for the SSE during an in-person visit, we encourage dermatologists to continue this practice during all teledermatology visits.

The role of teledermatology in skin cancer screening and prevention is limited; dermatologists will not be able to adequately perform TBSE as it would be done at in-person visits. Furthermore, the true implications of teledermatology compared to in-person visits during the COVID-19 pandemic have yet to be realized and analyzed. It is nonetheless important to appreciate that teledermatology holds great promise of benefit in skin cancer prevention, especially in the form of patient education by dermatologists. Practices in the realm of screening and prevention by health care professionals should be continually addressed during the pandemic; it is important to consider the implications associated with delays in diagnosis and treatment.

Teledermatology Limitations and Recommendations for High-Quality Visits

A benefit of video consultation (VC) vs telephone visits is visual interaction—the crux of dermatology. A 2019 study investigated VC experiences among providers and patients in the primary care setting. Benefits of VC were reported to include convenience for working patients and patients with mobility or mental health problems, visual cues, building rapport, and improving communication.⁹

Despite these benefits, VC is not without limitations. Many technical factors create variability in the quality of teledermatology VCs for a melanocytic lesion, including patient environment and lighting, color distortion, video resolution, and Internet connection. We make the following recommendations:

• Environment: Locate or create a dedicated space for teledermatology visits that is well lit, private, and has minimal background noise. Place the device on a level surface, center yourself in the frame, and keep the camera at eye level.

• Lighting: Use neutral lighting, placing the light source in front of you but behind the camera of the device. Avoid placing light sources, such as a window, behind you.

• Video resolution: Regardless of the type of camera (eg, integrated webcam, external camera), close out all other running software programs to optimize bandwidth during the visit.

• Internet connection: Use a wired connection (via an Ethernet cable) instead of a Wi-Fi connection to greatly decrease the chance of losing the connection during the visit. It also is faster than Wi-Fi.

• Addressing specific lesions: Patients should keep the device in place, repositioning themselves to show the lesions rather than moving the device by hand.

• Video capacity: Test your device’s video capacity beforehand, which can be as simple as video-calling a family member or friend from your designated space. Feedback regarding video and audio quality will help fine-tune your setup.

• Instructions to the patient: Provide clear instructions to the patient when photographs of specific lesions are needed for further review. Specify what view(s) you need and whether size or bilateral comparison is needed. A web post by VisualDx¹⁰ provides advice to patients on taking high-quality photographs.

Final Thoughts

Teledermatology indubitably presents a learning curve for dermatologists and patients. As with other technological advances in society, we are optimistic that, first, the confidence level in teledermatology use will increase, and, second, evidence-based data will pave the way to enhance this experience. We realize the inherent limitation of accessibility to certain technologies, which is regrettably far from equitable. Patients need a personal device equipped with audio and video; access to a high-quality Internet connection; some degree of technological literacy; and a quiet private location.

We hope to learn from all experiences during the current pandemic. Future innovation in teledermatology and in telemedicine generally should aim to address technological inequities to allow for the delivery of quality care to as many patients as possible.

On March 11, 2020, the World Health Organization declared the outbreak of coronavirus disease 2019 (COVID-19) a pandemic, leading to an abrupt widespread shift to teledermatology, with postponement of nonessential in-office medical and surgical services, according to American Academy of Dermatology (AAD) recommendations.¹ Perspectives have been offered regarding skin cancer management during the pandemic²; however, the current literature is lacking guidance on skin cancer screening and prevention during the COVID-19 era.

Preliminary data show a 34.3% reduction in skin cancer referrals from February to April 2020 compared to the same period in 2019. The authors also presented a subsequent reduction in the number of skin cancer diagnoses in March 2020 compared to March 2019.³ Although the COVID-19 public health emergency should be prioritized by all health care workers, the duty to maintain disease prevention remains.

We aim to provide recommendations for this urgent topic. Our goal is finding balance in preventing an increase in the incidence of and mortality from skin cancer that results from delayed detection, while conserving personalprotective equipment and minimizing exposure, by patients and clinical personnel, to the severe acute respiratory syndrome coronavirus 2. A primary benefit of skin cancer screening lies in the ability to detect melanoma, which is associated with higher mortality than the more common nonmelanoma skin cancers, basal and cutaneous squamous cell carcinomas. We place preeminence on screening directed toward detecting melanoma. The main screening method that dermatologists employ is the total-body skin examination (TBSE). Another widely encouraged and utilized component in skin cancer prevention is patient education, emphasizing avoidance of risk factors, undertaking protective factors, and providing clear instructions for performing the patient-led skin self-examination (SSE).

Teledermatology Essentials for Skin Cancer Screening

Arguably, dermatology possesses the most potential for successfully utilizing telemedicine. Teledermatology has become widely implemented across the United States, secondary to the implications of the current pandemic. A report by Perkins and colleagues⁴ provided a positive outlook in the preliminary transition to teledermatology beginning in March 2020, though reported time of use was relatively short (3 weeks). A May 2020 article in Dermatology News provided tips for implementing telemedicine for practices.⁵

We agree with the comprehensive screening algorithm for teledermatology presented by Perkins and colleagues⁴ (Figure 1A in their report) and recommend the following for the screening and prevention of skin cancer:

• Patients with any characteristics of increased risk, including a personal or family history of melanoma, large congenital nevi, many melanotic nevi, dysplastic nevi, and Fitzpatrick skin types I and II,⁶ should be prioritized for an in-person visit for TBSE.

• Immunosuppressed patients, particularly organ transplant recipients and those with a history of skin cancer, should be prioritized for an in-person visit for TBSE.

• Established patients evaluated and determined to be at average risk for skin cancer should be offered a teledermatology visit. Suspicious findings during these visits should be prioritized for an in-person visit, with subsequent biopsy and follow-up.

• New patients should be offered a teledermatology visit.

These recommendations must be reviewed alongside each patient’s risk for travel and being present in person as well as other factors that might place the patient at increased risk for COVID-19.

Total-body skin examination, a widely used tool in the dermatologist’s tool kit, presents minimal risk to patients while providing important data for each dermatology patient’s profile, ultimately directing patient care. The role of TBSE in skin cancer screening and prevention has been in discussion even prior to the current pandemic. The US Preventive Services Task Force (USPSTF) has not declared a role for TBSE in recent years; however, USPSTF recommendations are formulated using data from all forms of screening, not only dermatologist-led interventions. Accordingly, USPSTF recommendations target primary care. The AAD has released statements addressing the role of TBSE and skin cancer prevention in the past, when necessary, to provide clarity.⁷

There is no clear definition of SSE or guidelines on how to educate a patient to perform regular SSE; however, the AAD provides patients with resources on how to perform an SSE.⁸ Just as dermatologists would provide education, advice, and guidance by directing patients to the AAD website for the SSE during an in-person visit, we encourage dermatologists to continue this practice during all teledermatology visits.

The role of teledermatology in skin cancer screening and prevention is limited; dermatologists will not be able to adequately perform TBSE as it would be done at in-person visits. Furthermore, the true implications of teledermatology compared to in-person visits during the COVID-19 pandemic have yet to be realized and analyzed. It is nonetheless important to appreciate that teledermatology holds great promise of benefit in skin cancer prevention, especially in the form of patient education by dermatologists. Practices in the realm of screening and prevention by health care professionals should be continually addressed during the pandemic; it is important to consider the implications associated with delays in diagnosis and treatment.

Teledermatology Limitations and Recommendations for High-Quality Visits

A benefit of video consultation (VC) vs telephone visits is visual interaction—the crux of dermatology. A 2019 study investigated VC experiences among providers and patients in the primary care setting. Benefits of VC were reported to include convenience for working patients and patients with mobility or mental health problems, visual cues, building rapport, and improving communication.⁹

Despite these benefits, VC is not without limitations. Many technical factors create variability in the quality of teledermatology VCs for a melanocytic lesion, including patient environment and lighting, color distortion, video resolution, and Internet connection. We make the following recommendations:

• Environment: Locate or create a dedicated space for teledermatology visits that is well lit, private, and has minimal background noise. Place the device on a level surface, center yourself in the frame, and keep the camera at eye level.

• Lighting: Use neutral lighting, placing the light source in front of you but behind the camera of the device. Avoid placing light sources, such as a window, behind you.

• Video resolution: Regardless of the type of camera (eg, integrated webcam, external camera), close out all other running software programs to optimize bandwidth during the visit.

• Internet connection: Use a wired connection (via an Ethernet cable) instead of a Wi-Fi connection to greatly decrease the chance of losing the connection during the visit. It also is faster than Wi-Fi.

• Addressing specific lesions: Patients should keep the device in place, repositioning themselves to show the lesions rather than moving the device by hand.

• Video capacity: Test your device’s video capacity beforehand, which can be as simple as video-calling a family member or friend from your designated space. Feedback regarding video and audio quality will help fine-tune your setup.

• Instructions to the patient: Provide clear instructions to the patient when photographs of specific lesions are needed for further review. Specify what view(s) you need and whether size or bilateral comparison is needed. A web post by VisualDx¹⁰ provides advice to patients on taking high-quality photographs.

Final Thoughts

Teledermatology indubitably presents a learning curve for dermatologists and patients. As with other technological advances in society, we are optimistic that, first, the confidence level in teledermatology use will increase, and, second, evidence-based data will pave the way to enhance this experience. We realize the inherent limitation of accessibility to certain technologies, which is regrettably far from equitable. Patients need a personal device equipped with audio and video; access to a high-quality Internet connection; some degree of technological literacy; and a quiet private location.

We hope to learn from all experiences during the current pandemic. Future innovation in teledermatology and in telemedicine generally should aim to address technological inequities to allow for the delivery of quality care to as many patients as possible.

Adults with inflammatory bowel disease were more likely to continue using vedolizumab, compared with anti–tumor necrosis factor (TNF) drugs over 3 years, based on data from a retrospective study of nearly 16,000 patients.

Patient persistence with prescribed therapy is essential to managing chronic inflammatory bowel disease (IBD), but data on the persistence of patients with treatments are limited, wrote Ulf Helwig, MD, of the Practice for Internal Medicine, Oldenburg, Germany, and colleagues. “With the advent of vedolizumab, physicians for the first time had the choice between biologicals with different modes of action,” they wrote.

In a study published in the Journal of Clinical Gastroenterology, the researchers used a national prescription database to identify 15,984 adults aged 18 years and older who were treatment-naive to biologics and received prescriptions between July 2014 and March 2017. Treatment persistence was defined as continuous treatment time of at least 90 days without prescription.

A total of 2,076 vedolizumab patients were matched with 2,076 adalimumab patients; 716 vedolizumab patients were matched with 716 golimumab patients; and 2,055 vedolizumab patients were matched with 2,055 infliximab patients.

Within 3 years after the first prescription, the overall persistence rates were 35.9% for vedolizumab, 27.8% for adalimumab, 20.7% for golimumab, and 29.8% for infliximab.

In matched-pair analysis, 35.2% of vedolizumab patients were persistent, compared with 28.9% of adalimumab patients over a 3-year period; the difference was statistically significant. In addition, 30.5% of vedolizumab patients persisted, compared with 25.4% of golimumab patients, also statistically significant. A matched-pair comparison between vedolizumab and infliximab (35.7% vs. 30.2%) was not statistically significant (P = 0.119).

In addition, vedolizumab patients were significantly less likely to discontinue therapy, compared with both adalimumab and golimumab patients, with hazard ratios of 0.86 and 0.60, respectively, in the matched pair analysis; discontinuation, compared with infliximab, was not statistically significant.

“Several reasons may account for significant rates of discontinuation reported for all biological treatments in IBD,” the researchers noted. “These comprise differences in health care systems in the concerned countries, including differences in availability of biologicals, access to reimbursed drugs, or different patient care settings,” they wrote.

The study findings were limited by several factors including the lack of data on specific IBD diagnoses, IBD severity, disease course, and dose escalation, they noted.

However, the study was strengthened by the large sample size and use of a real-world setting, they said.

“Further studies are needed to identify the reasons for persistence differences between vedolizumab and anti-TNF drugs,” they concluded.
 

Comparisons inform choices

“There are multiple biologic options for therapy of inflammatory bowel disease, and response to therapy tends to drop off over time in many patients for a variety of reasons including development of antibodies and escape from the mechanism of the action of the drug,” said Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, in an interview.

“Intolerance or side effects of medication also may lead to discontinuation of therapy,” said Dr. Isaacs. “This trial looks at therapy discontinuation among four biologics used for inflammatory bowel disease over a 3-year period after initiation of therapy in patients who were previous biologically naive. Reasons for discontinuation cannot be assessed with this data set,” she noted. “There are very few comparative trials with the different biologic therapies in IBD. This trial is important because it compares the two distinct biologic mechanisms of action and continuation of therapy in biologically naive patients,” she said.

Dr. Isaacs said she was not surprised by the study findings. “Discontinuation of anti-TNF therapy was more common, compared to vedolizumab and golimumab. There was no statistical difference in terms of therapy discontinuation with infliximab,” she said. “In general, vedolizumab is felt to be less systemically immunosuppressant with targeting of white blood cell trafficking to the gut, whereas anti-TNF therapy is more systemically immunosuppressant and may be associated with more systemic side effects,” she explained.

The study design does not allow for comment on comparative efficacy, “although the findings are intriguing,” said Dr. Isaacs. “If the discontinuations were caused by lack of efficacy, the findings in this study may help in positioning biologic therapy in the biologic-naive patients,” she said.

The study is “a ‘real-world’ experiment that suggests there is a difference between different biologic therapies for inflammatory bowel disease,” said Dr. Isaacs. “More controlled comparative efficacy trials are needed that can look at reasons for drug discontinuation between different populations. To date, the VARSITY trial comparing vedolizumab to adalimumab in ulcerative colitis is the only published trial to do this,” she added.  

The study received no outside funding. Lead author Dr. Helwig disclosed lecture and consulting fees from AbbVie, Amgen, Biogen, Celltrion, Hexal, MSD, Ferring, Falk Foundation, Takeda, Mundipharma, Pfizer, Hospira, and Vifor Pharma. Dr. Isaacs disclosed serving on the Data and Safety Monitoring Board (DSMB) for Janssen.

SOURCE: Helwig U et al. J Clin Gastroenterol. 2021 Jan. doi: 10.1097/MCG.0000000000001323

Story updated Jan. 6, 2021.

Adults with inflammatory bowel disease were more likely to continue using vedolizumab, compared with anti–tumor necrosis factor (TNF) drugs over 3 years, based on data from a retrospective study of nearly 16,000 patients.

Patient persistence with prescribed therapy is essential to managing chronic inflammatory bowel disease (IBD), but data on the persistence of patients with treatments are limited, wrote Ulf Helwig, MD, of the Practice for Internal Medicine, Oldenburg, Germany, and colleagues. “With the advent of vedolizumab, physicians for the first time had the choice between biologicals with different modes of action,” they wrote.

In a study published in the Journal of Clinical Gastroenterology, the researchers used a national prescription database to identify 15,984 adults aged 18 years and older who were treatment-naive to biologics and received prescriptions between July 2014 and March 2017. Treatment persistence was defined as continuous treatment time of at least 90 days without prescription.

A total of 2,076 vedolizumab patients were matched with 2,076 adalimumab patients; 716 vedolizumab patients were matched with 716 golimumab patients; and 2,055 vedolizumab patients were matched with 2,055 infliximab patients.

Within 3 years after the first prescription, the overall persistence rates were 35.9% for vedolizumab, 27.8% for adalimumab, 20.7% for golimumab, and 29.8% for infliximab.

In matched-pair analysis, 35.2% of vedolizumab patients were persistent, compared with 28.9% of adalimumab patients over a 3-year period; the difference was statistically significant. In addition, 30.5% of vedolizumab patients persisted, compared with 25.4% of golimumab patients, also statistically significant. A matched-pair comparison between vedolizumab and infliximab (35.7% vs. 30.2%) was not statistically significant (P = 0.119).

In addition, vedolizumab patients were significantly less likely to discontinue therapy, compared with both adalimumab and golimumab patients, with hazard ratios of 0.86 and 0.60, respectively, in the matched pair analysis; discontinuation, compared with infliximab, was not statistically significant.

“Several reasons may account for significant rates of discontinuation reported for all biological treatments in IBD,” the researchers noted. “These comprise differences in health care systems in the concerned countries, including differences in availability of biologicals, access to reimbursed drugs, or different patient care settings,” they wrote.

The study findings were limited by several factors including the lack of data on specific IBD diagnoses, IBD severity, disease course, and dose escalation, they noted.

However, the study was strengthened by the large sample size and use of a real-world setting, they said.

“Further studies are needed to identify the reasons for persistence differences between vedolizumab and anti-TNF drugs,” they concluded.
 

Comparisons inform choices

“There are multiple biologic options for therapy of inflammatory bowel disease, and response to therapy tends to drop off over time in many patients for a variety of reasons including development of antibodies and escape from the mechanism of the action of the drug,” said Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, in an interview.

“Intolerance or side effects of medication also may lead to discontinuation of therapy,” said Dr. Isaacs. “This trial looks at therapy discontinuation among four biologics used for inflammatory bowel disease over a 3-year period after initiation of therapy in patients who were previous biologically naive. Reasons for discontinuation cannot be assessed with this data set,” she noted. “There are very few comparative trials with the different biologic therapies in IBD. This trial is important because it compares the two distinct biologic mechanisms of action and continuation of therapy in biologically naive patients,” she said.

Dr. Isaacs said she was not surprised by the study findings. “Discontinuation of anti-TNF therapy was more common, compared to vedolizumab and golimumab. There was no statistical difference in terms of therapy discontinuation with infliximab,” she said. “In general, vedolizumab is felt to be less systemically immunosuppressant with targeting of white blood cell trafficking to the gut, whereas anti-TNF therapy is more systemically immunosuppressant and may be associated with more systemic side effects,” she explained.

The study design does not allow for comment on comparative efficacy, “although the findings are intriguing,” said Dr. Isaacs. “If the discontinuations were caused by lack of efficacy, the findings in this study may help in positioning biologic therapy in the biologic-naive patients,” she said.

The study is “a ‘real-world’ experiment that suggests there is a difference between different biologic therapies for inflammatory bowel disease,” said Dr. Isaacs. “More controlled comparative efficacy trials are needed that can look at reasons for drug discontinuation between different populations. To date, the VARSITY trial comparing vedolizumab to adalimumab in ulcerative colitis is the only published trial to do this,” she added.  

The study received no outside funding. Lead author Dr. Helwig disclosed lecture and consulting fees from AbbVie, Amgen, Biogen, Celltrion, Hexal, MSD, Ferring, Falk Foundation, Takeda, Mundipharma, Pfizer, Hospira, and Vifor Pharma. Dr. Isaacs disclosed serving on the Data and Safety Monitoring Board (DSMB) for Janssen.

SOURCE: Helwig U et al. J Clin Gastroenterol. 2021 Jan. doi: 10.1097/MCG.0000000000001323

Story updated Jan. 6, 2021.

Adults with inflammatory bowel disease were more likely to continue using vedolizumab, compared with anti–tumor necrosis factor (TNF) drugs over 3 years, based on data from a retrospective study of nearly 16,000 patients.

Patient persistence with prescribed therapy is essential to managing chronic inflammatory bowel disease (IBD), but data on the persistence of patients with treatments are limited, wrote Ulf Helwig, MD, of the Practice for Internal Medicine, Oldenburg, Germany, and colleagues. “With the advent of vedolizumab, physicians for the first time had the choice between biologicals with different modes of action,” they wrote.

In a study published in the Journal of Clinical Gastroenterology, the researchers used a national prescription database to identify 15,984 adults aged 18 years and older who were treatment-naive to biologics and received prescriptions between July 2014 and March 2017. Treatment persistence was defined as continuous treatment time of at least 90 days without prescription.

A total of 2,076 vedolizumab patients were matched with 2,076 adalimumab patients; 716 vedolizumab patients were matched with 716 golimumab patients; and 2,055 vedolizumab patients were matched with 2,055 infliximab patients.

Within 3 years after the first prescription, the overall persistence rates were 35.9% for vedolizumab, 27.8% for adalimumab, 20.7% for golimumab, and 29.8% for infliximab.

In matched-pair analysis, 35.2% of vedolizumab patients were persistent, compared with 28.9% of adalimumab patients over a 3-year period; the difference was statistically significant. In addition, 30.5% of vedolizumab patients persisted, compared with 25.4% of golimumab patients, also statistically significant. A matched-pair comparison between vedolizumab and infliximab (35.7% vs. 30.2%) was not statistically significant (P = 0.119).

In addition, vedolizumab patients were significantly less likely to discontinue therapy, compared with both adalimumab and golimumab patients, with hazard ratios of 0.86 and 0.60, respectively, in the matched pair analysis; discontinuation, compared with infliximab, was not statistically significant.

“Several reasons may account for significant rates of discontinuation reported for all biological treatments in IBD,” the researchers noted. “These comprise differences in health care systems in the concerned countries, including differences in availability of biologicals, access to reimbursed drugs, or different patient care settings,” they wrote.

The study findings were limited by several factors including the lack of data on specific IBD diagnoses, IBD severity, disease course, and dose escalation, they noted.

However, the study was strengthened by the large sample size and use of a real-world setting, they said.

“Further studies are needed to identify the reasons for persistence differences between vedolizumab and anti-TNF drugs,” they concluded.
 

Comparisons inform choices

“There are multiple biologic options for therapy of inflammatory bowel disease, and response to therapy tends to drop off over time in many patients for a variety of reasons including development of antibodies and escape from the mechanism of the action of the drug,” said Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, in an interview.

“Intolerance or side effects of medication also may lead to discontinuation of therapy,” said Dr. Isaacs. “This trial looks at therapy discontinuation among four biologics used for inflammatory bowel disease over a 3-year period after initiation of therapy in patients who were previous biologically naive. Reasons for discontinuation cannot be assessed with this data set,” she noted. “There are very few comparative trials with the different biologic therapies in IBD. This trial is important because it compares the two distinct biologic mechanisms of action and continuation of therapy in biologically naive patients,” she said.

Dr. Isaacs said she was not surprised by the study findings. “Discontinuation of anti-TNF therapy was more common, compared to vedolizumab and golimumab. There was no statistical difference in terms of therapy discontinuation with infliximab,” she said. “In general, vedolizumab is felt to be less systemically immunosuppressant with targeting of white blood cell trafficking to the gut, whereas anti-TNF therapy is more systemically immunosuppressant and may be associated with more systemic side effects,” she explained.

The study design does not allow for comment on comparative efficacy, “although the findings are intriguing,” said Dr. Isaacs. “If the discontinuations were caused by lack of efficacy, the findings in this study may help in positioning biologic therapy in the biologic-naive patients,” she said.

The study is “a ‘real-world’ experiment that suggests there is a difference between different biologic therapies for inflammatory bowel disease,” said Dr. Isaacs. “More controlled comparative efficacy trials are needed that can look at reasons for drug discontinuation between different populations. To date, the VARSITY trial comparing vedolizumab to adalimumab in ulcerative colitis is the only published trial to do this,” she added.  

The study received no outside funding. Lead author Dr. Helwig disclosed lecture and consulting fees from AbbVie, Amgen, Biogen, Celltrion, Hexal, MSD, Ferring, Falk Foundation, Takeda, Mundipharma, Pfizer, Hospira, and Vifor Pharma. Dr. Isaacs disclosed serving on the Data and Safety Monitoring Board (DSMB) for Janssen.

SOURCE: Helwig U et al. J Clin Gastroenterol. 2021 Jan. doi: 10.1097/MCG.0000000000001323

Story updated Jan. 6, 2021.