To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

Classification

Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).^1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.^3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.^1,4-6

Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.⁷ It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.⁶ The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.^1,8

Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.⁴ Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.^4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.⁹

Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.¹⁰

Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).¹¹ In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).¹⁰

Dermatologic Presentation and Clinical Symptoms

The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported^4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.⁶ These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.

Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.⁸ In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.⁴

Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.¹² In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.^12,13

Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.² The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.¹¹

The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.^4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.⁸ In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.^1,6

Treatment and Prevention

Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.³ If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.¹⁴ Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.¹⁵

There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.⁸ The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.⁵

Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.⁸ Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.^8,14

Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.^4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.

Medical Complications

Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.¹² The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.⁵ When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.¹⁶

Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.⁵ The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.² Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.¹²

Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.²

Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.² However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.

Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.⁵

Classification

Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).^1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.^3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.^1,4-6

Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.⁷ It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.⁶ The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.^1,8

Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.⁴ Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.^4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.⁹

Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.¹⁰

Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).¹¹ In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).¹⁰

Dermatologic Presentation and Clinical Symptoms

The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported^4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.⁶ These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.

Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.⁸ In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.⁴

Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.¹² In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.^12,13

Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.² The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.¹¹

The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.^4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.⁸ In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.^1,6

Treatment and Prevention

Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.³ If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.¹⁴ Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.¹⁵

There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.⁸ The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.⁵

Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.⁸ Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.^8,14

Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.^4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.

Medical Complications

Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.¹² The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.⁵ When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.¹⁶

Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.⁵ The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.² Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.¹²

Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.²

Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.² However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.

Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.⁵

Classification

Triatomine bugs (Triatoma) and the wheel bug (Arilus cristatus) are part of the family Reduviidae (order Hemiptera, a name that describes the sucking proboscis on the front of the insect’s head).^1,2 Both arthropods are found in multiple countries and are especially common in warmer areas, including in the United States, where they can be seen from Texas to California.^3,4 Because blood-feeding triatomines need a blood meal to survive while laying eggs and then throughout their 5 developmental nymph stages to undergo molting, they feed on mammals, such as opossums, raccoons, pack rats, and armadillos, whereas wheel bugs mainly prey on soft-bodied insects.^1,4-6

Triatoma bugs seek cutaneous blood vessels using thermosensors in their antennae to locate blood flow under the skin for feeding. After inserting the proboscis, they release nitric oxide and an anticoagulant that allows for continuous blood flow while feeding.⁷ It has been reported that triatomine bugs are not able to bite through clothing, instead seeking exposed skin, particularly near mucous membranes, such as the hands, arms, feet, head, and trunk. The name kissing bug for triatomines was coined because bites near the mouth are common.⁶ The bite typically is painless and occurs mainly at night when the insect is most active. After obtaining a blood meal, triatomine bugs seek shelter and hide in mud and daub structures, cracks, crevices, and furniture.^1,8

Unlike Triatoma species, A cristatus does not require a blood meal for development and survival, leading it to prey on soft-bodied insects. Piercing prey with the proboscis, wheel bugs inject a toxin to digest the contents and suck the digested contents through this apparatus.⁴ Because the wheel bug does not require a blood meal, it typically bites a human only for defense if it feels threatened. Unlike the painless bite of a triatomine bug, the bite of A cristatus is extremely painful; it has been described as the worst arthropod bite—worse than a hornet’s sting. The pain from the bite is caused by the toxin being injected into the skin; possible retention of the proboscis makes the pain worse.^4,9 In addition, when A cristatus is disturbed, it exudes pungent material from a pair of bright orange subrectal glands while stridulating to repulse predators.⁹

Although Triatoma species and A cristatus have separate roles in nature and vastly different impacts on health, they often are mistaken for the same arthropod when seen in nature. Features that members of Reduviidae share include large bodies (relative to their overall length); long thin legs; a narrow head; wings; and a long sucking proboscis on the front of the head.¹⁰

Characteristics that differentiate Triatoma and A cristatus species include size, color, and distinctive markings. Most triatomine bugs are 12- to 36-mm long; are dark brown or black; and have what are called tiger-stripe orange markings on the peripheral two-thirds of the body (Figure 1).¹¹ In contrast, wheel bugs commonly are bigger—measuring longer than 1.25 inches—and gray, with a cogwheel-like structure on the thorax (Figure 2).¹⁰

Dermatologic Presentation and Clinical Symptoms

The area of involved skin on patients presenting with Triatoma or A cristatus bites may resemble other insect bites. Many bites from Triatoma bugs and A cristatus initially present as an erythematous, raised, pruritic papule with a central punctum that is visible because of the involvement of the proboscis. However, other presentations of bites from both arthropods have been reported^4,6,7: grouped vesicles on an erythematous base; indurated, giant, urticarial-type wheels measuring 10 to 15 mm in diameter; and hemorrhagic bullous nodules (Figure 3). Associated lymphangitis or lymphadenitis is typical of the latter 2 variations.⁶ These variations in presentation can be mistaken for other causes of similarly presenting lesions, such as shingles or spider bites, leading to delayed or missed diagnosis.

Patients may present with a single bite or multiple bites due to the feeding pattern of Triatoma bugs; if the host moves or disrupts its feeding, the arthropod takes multiple bites to finish feeding.⁸ In comparison, 4 common variations of wheel bug bites have been reported: (1) a painful bite without complications; (2) a cutaneous horn and papilloma at the site of toxin injection; (3) a necrotic ulcer around the central punctum caused by injected toxin; and (4) an abscess under the central punctum due to secondary infection.⁴

Anaphylaxis—Although the bites of Triatoma and A cristatus present differently, both can cause anaphylaxis. Triatoma is implicated more often than A cristatus as the cause of anaphylaxis.¹² In fact, Triatoma bites are among the more common causes of anaphylaxis from bug bites, with multiple cases of these reactions reported in the literature.^12,13

Symptoms of Triatoma anaphylaxis include acute-onset urticarial rash, flushing, dyspnea, wheezing, nausea, vomiting, and localized edema.² The cause of anaphylaxis is proteins in Triatoma saliva, including 20-kDa procalin, which incites the systemic reaction. Other potential causes of anaphylaxis include serine protease, which has similarities to salivary protein and desmoglein in humans.¹¹

The degree of reaction to a bite depends on the patient's sensitization to antigenic proteins in each insect’s saliva.^4,6 Patients who have a bite from a triatomine bug are at risk for subsequent bites, as household infestation is likely due to the pliability of the insect, allowing it to hide in small spaces unnoticed.⁸ In the case of a bite from Triatoma or A cristatus, sensitization may lead to severe and worsening reactions with subsequent bites, which ultimately can result in life-threatening anaphylaxis.^1,6

Treatment and Prevention

Treatment of Triatoma and A cristatus bites depends on the severity of the patient’s reaction to the bite. A local reaction to a bite from either insect can be treated supportively with local corticosteroids and antihistamines.³ If the patient is sensitized to proteins associated with a bite, standard anaphylaxis treatment such as epinephrine and intravenous antihistamines may be indicated.¹⁴ Secondary infection can be treated with antibiotics; a formed abscess might need to be drained or debrided.¹⁵

There’s No Place Like Home—Because Triatoma bugs have a pliable exoskeleton and can squeeze into small spaces, they commonly infest dwellings where they find multiple attractants: light, heat, carbon dioxide, and lactic acid.⁸ The more household occupants (including pets), the higher the levels of carbon dioxide and lactic acid, thus the greater the attraction. Infestation of a home can lead to the spread of diseases harbored by Triatoma, including Chagas disease, which is caused by the parasite Trypanosoma cruzi.⁵

Preventive measures can be taken to reduce the risk and extent of home infestation by Triatoma bugs, including insecticides, a solid foundation, window screens, air conditioning, sealing of cracks and crevices, outdoor light management, and removal of clutter throughout the house.⁸ Because Triatoma bugs cannot bite through clothing, protective clothing and bug repellent on exposed skin can be employed. Another degree of protection is offered by pest management, especially control of rodents by removing food, water, and nests in areas where triatomine bugs feed off of that population.^8,14

Unlike triatomine bugs, wheel bugs tend not to invade houses; therefore, these preventive measures are unnecessary. If a wheel bug is identified, do not engage the arthropod due to the defensive nature of its attack.^4,9 Such deliberate avoidance should ensure protection from the wheel bug’s painful bite.

Medical Complications

Although triatomine bugs and wheel bugs are in the same taxonomic family, subsequent infection is unique to Triatoma bugs because they need a blood meal to survive. Because Triatoma bugs feed on mammals, they present an increased opportunity for transmitting the causative agents of infection from hosts on which they have fed.¹² The principal parasite transmitted by triatomines is T cruzi, which causes Chagas disease and lives in the gastrointestinal (GI) tract of the insect.⁵ When a triatomine bug seeks out a mucosal surface to bite, including the mouth, it defecates and urinates during or shortly after feeding, leading to contamination of the initial wound or mucosal surfaces. In addition, Triatoma bugs are vectors for transmission of Serratia marcescans, Bartonella henselae, and Mycobacterium leprae.¹⁶

Chagas Disease—This infection has 3 stages: acute, intermediate, and chronic.⁵ The acute stage can present with symptoms of conjunctivitis, fever, lymphadenopathy, hepatosplenomegaly, and anemia. The intermediate stage typically is asymptomatic. The chronic stage usually involves the heart and GI tract and causes cardiac aneurysms, cardiomegaly, megacolon, and megaesophagus. Initial symptoms can be a localized nodule (chagoma) at the inoculation site, fever, fatigue, lymphadenopathy, and hepatosplenomegaly.² Unilateral palpebral edema with associated lymphadenopathy (Romaña sign) also can be seen—not to be confused with bilateral swelling in an acute reaction to an insect bite. Romaña sign is pathognomonic of T cruzi infection; bilateral palpebral swelling is typical of an allergic reaction.¹²

Identification of a triatomine bite is the first step in diagnosing Chagas disease, which can be life-threatening. Among chronic carriers of Chagas disease, 30% develop GI and cardiac symptoms, of which 20% to 30% develop cardiomyopathy, with serious symptoms that present 10 to 20 years after the asymptomatic intermediate phase.²

Chagas disease is endemic to Central and South America but is also seen in North America; 28,000 new cases are reported annually in South America and North America combined. Human migration from endemic areas and from rural to urban areas has promoted the spread of Chagas disease.² However, patients in the United States have a relatively low risk for Chagas disease, largely because of the quality of housing construction and use of insecticides.

Treatment options for Chagas disease include nifurtimox and benznidazole. Without treatment, the host immune response typically controls acute replication of the parasite but will lead to a chronic state, ultimately involving the heart and GI tract.⁵

When the Current Procedural Terminology (CPT) evaluation and management (E/M) reporting rules changed dramatically in January 2021, “bullet counting” became unnecessary and the coding level became based on either the new medical decision making (MDM) table or time spent on all activities relating to the care of the patient on the day of the encounter. ¹

To make your documentation more likely to pass audits, explicitly link parts of your documentation to CPT MDM descriptors. Part 1 of this series discussed how to approach the “spot check,” a commonly encountered chief concern (CC) within dermatology, with 2 scenarios presented.² The American Medical Association³ and American Academy of Dermatology⁴ have provided education that focuses on how to report a given vignette, but specific examples of documentation with commentary are uncommon. In part 2, we describe how to best code an encounter that includes a “spot check” with other concerns.

Scenario 3: By the Way, Doc

A 34-year-old presents with a new spot on the left cheek that seems to be growing and changing shape rapidly. You examine the patient and discuss treatment options. The documentation reads as follows:

• CC: New spot on left cheek that seems to be growing and changing shape rapidly.
• History: No family history of skin cancer; concerned about scarring, no blood thinner.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy.
• Impression: Rule out melanoma (undiagnosed new problem with uncertain prognosis).
• Plan: Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive gene expression profiling (GEP) melanoma rule-out test. (Based on the decision you and the patient make, you also would document which option was chosen, so a biopsy would include your standard documentation, and if the GEP is chosen, you would simply state that this was chosen and performed.)

As you turn to leave the room, the patient says:“By the way, Doc, can you do anything about these silvery spots on my elbows, knees, and buttocks?” You look at the areas of concern and diagnose the patient with psoriasis.

How would it be best to approach this scenario? It depends on which treatment option the patient chooses.

If you performed a noninvasive GEP melanoma rule-out test, the CPT reporting does not change with the addition of the new problem, and only the codes 99204 (new patient office or other outpatient visit) or 99214 (established patient office or other outpatient visit) would be reported. This would be because, with the original documentation, the number and complexity of problems would be an “undiagnosed new problem with uncertain prognosis,” which would be moderate complexity (column 1, level 4). There are no data that are reviewed or analyzed, which would be straightforward (column 2, level 2). For risk, the discussion of the biopsy as a diagnostic choice should include possible scarring, bleeding, pain, and infection, which would be best described as a decision regarding minor surgery with identified patient or procedure risk factors, given the identified patient concerns, making this of moderate complexity (column 3, level 4).¹

Importantly, even if the procedure is not chosen as the final treatment plan, the discussion regarding the surgery, including the risks, benefits, and alternatives, can still count toward this category in the MDM table. Therefore, in this scenario, documentation would best fit with CPT code 99204 for a new patient or 99214 for an established patient. The addition of the psoriasis diagnosis would not change the level of service but also should include documentation of the psoriasis as medically necessary.

However, if you perform the biopsy, then the documentation above would only allow reporting the biopsy, as the decision to perform a 0- or 10-day global procedure is “bundled” with the procedure if performed on the same date of service. Therefore, with the addition of the psoriasis diagnosis, you would now use a separate E/M code to report the psoriasis. You must append a modifier −25 to the E/M code to certify that you are dealing with a separate and discrete problem with no overlap in physician work.

Clearly you also have an E/M to report. But what level? Is this chronic? Yes, as CPT clearly defines chronic as “[a] problem with an expected duration of at least one year or until the death of the patient.”^1,5

But is this stable progressive or showing side effects of treatment? “‘Stable’ for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function,” according to the CPT descriptors. Therefore, in this scenario, the documentation would best fit a chronic illness with exacerbation, progression, or side effects of treatment (column 1, level 4), which is of moderate complexity.¹

But what about column 3, where we look at risks of testing and treatment? This would depend on the type of treatment given. If an over-the-counter product such as a tar gel is recommended, this is a low risk (column 3, level 3), which would mean this lower value determines the E/M code to be 99213 or 99203 depending on whether this is an established or new patient, respectively. If we treat with a prescription medication such as a topical corticosteroid, we are providing prescription drug management (column 3, level 4), which is moderate risk, and we would use codes 99204 or 99214, assuming we document appropriately. Again, including the CPT terminology of “not at treatment goal” in your impression and “prescription drug management” in your plan tells an auditor what you are thinking and doing.^1,5

The Takeaway—Clearly if a GEP is performed, there is a single CPT code used—99204 or 99214. If the biopsy is performed, there would be a biopsy code and an E/M code with a modifier −25 attached to the latter. For the documentation below, a 99204 or 99214 would be the chosen E/M code:

• CC: (1) New spot on left cheek that seems to be growing and changing shape rapidly; (2) Silvery spots on elbows, knees, and buttocks for which patient desires treatment.
• History: No family history of skin cancer; concerned about scarring, no blood thinner. Mom has psoriasis. Tried petroleum jelly on scaly areas but no better.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy. Silver scaly erythematous plaques on elbows, knees, sacrum.
• Impression: (1) Rule out melanoma (undiagnosed new problem with uncertain prognosis); (2) Psoriasis (chronic disease not at treatment goal).
• Plan: (1) Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive GEP melanoma rule-out test. Patient wants biopsy. Consent, biopsy via shave technique. Lidocaine hydrochloride 1% with epinephrine 1 cc, prepare and drape, aluminum chloride for hemostasis, ointment and bandage applied, care instructions provided; (2) Discuss options. Calcipotriene cream daily; triamcinolone ointment 0.1% twice a day (prescription drug management). Review bathing, avoiding trauma to site, no picking.

Scenario 4: Here for a Total-Body Screening Examination

Medicare does not cover skin cancer screenings as a primary CC. Being worried or knowing someone with melanoma are not CCs that are covered. However, “spot of concern,” “changing mole,” or ”new growth” would be. Conversely, if the patient has a history of skin cancer, actinic keratoses, or other premalignant lesions, and/or is immunosuppressed or has a high-risk genetic syndrome, the visit may be covered if these factors are documented in the note.⁶

For the diagnosis, the International Classification of Diseases, Tenth Revision, code Z12.83—“encounter for screening for malignant neoplasm of skin”—is not an appropriate primary billing code. However, D48.5—“neoplasm of behavior of skin”—can be, unless there is a specific diagnosis you are able to make (eg, melanocytic nevus, seborrheic keratosis).⁶

Let’s look at documentation examples:

• CC: 1-year follow-up on basal cell carcinoma (BCC) excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence.
• Plan: Reassure. Annual surveillance in 1 year.

Using what we have previously discussed, this would likely be considered CPT code 99212 (established patient office visit). However, it is important to ensure all concerns and treatment interventions are fully documented. Consider this fuller documentation with bolded additions:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence and heliodermatosis/chronic sun damage not at treat-ment goal.
• Plan: Reassure. Annual surveillance in 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

This is better but still possibly confusing to an auditor. Consider instead with bolded additions to the changes to the impression:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose (D22.39)⁷ and prior BCC treatment site with no sign of recurrence (Z85.828: “personal history of other malignant neoplasm of skin) and heliodermatosis/chronic sun damage not at treatment goal (L57.8: “other skin changes due to chronic exposure to nonionizing radiation”).
• Plan: Reassure. Annual surveillance 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

We now have chronic heliodermatitis not at treatment goal, which is moderate (column 1, level 4), and the over-the-counter broad-spectrum sun protection factor 30+ sunscreen (column 1, low) would be best coded as CPT code 99213.

Final Thoughts

“Spot check” encounters are common dermatologic visits, both on their own and in combination with other concerns. With the updated E/M guidelines, it is crucial to clarify and streamline your documentation. In particular, utilize language clearly defining the number and complexity of problems, data to be reviewed and/or analyzed, and appropriate risk stratification to ensure appropriate reimbursement and minimize your difficulties with audits.

When the Current Procedural Terminology (CPT) evaluation and management (E/M) reporting rules changed dramatically in January 2021, “bullet counting” became unnecessary and the coding level became based on either the new medical decision making (MDM) table or time spent on all activities relating to the care of the patient on the day of the encounter. ¹

To make your documentation more likely to pass audits, explicitly link parts of your documentation to CPT MDM descriptors. Part 1 of this series discussed how to approach the “spot check,” a commonly encountered chief concern (CC) within dermatology, with 2 scenarios presented.² The American Medical Association³ and American Academy of Dermatology⁴ have provided education that focuses on how to report a given vignette, but specific examples of documentation with commentary are uncommon. In part 2, we describe how to best code an encounter that includes a “spot check” with other concerns.

Scenario 3: By the Way, Doc

A 34-year-old presents with a new spot on the left cheek that seems to be growing and changing shape rapidly. You examine the patient and discuss treatment options. The documentation reads as follows:

• CC: New spot on left cheek that seems to be growing and changing shape rapidly.
• History: No family history of skin cancer; concerned about scarring, no blood thinner.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy.
• Impression: Rule out melanoma (undiagnosed new problem with uncertain prognosis).
• Plan: Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive gene expression profiling (GEP) melanoma rule-out test. (Based on the decision you and the patient make, you also would document which option was chosen, so a biopsy would include your standard documentation, and if the GEP is chosen, you would simply state that this was chosen and performed.)

As you turn to leave the room, the patient says:“By the way, Doc, can you do anything about these silvery spots on my elbows, knees, and buttocks?” You look at the areas of concern and diagnose the patient with psoriasis.

How would it be best to approach this scenario? It depends on which treatment option the patient chooses.

If you performed a noninvasive GEP melanoma rule-out test, the CPT reporting does not change with the addition of the new problem, and only the codes 99204 (new patient office or other outpatient visit) or 99214 (established patient office or other outpatient visit) would be reported. This would be because, with the original documentation, the number and complexity of problems would be an “undiagnosed new problem with uncertain prognosis,” which would be moderate complexity (column 1, level 4). There are no data that are reviewed or analyzed, which would be straightforward (column 2, level 2). For risk, the discussion of the biopsy as a diagnostic choice should include possible scarring, bleeding, pain, and infection, which would be best described as a decision regarding minor surgery with identified patient or procedure risk factors, given the identified patient concerns, making this of moderate complexity (column 3, level 4).¹

Importantly, even if the procedure is not chosen as the final treatment plan, the discussion regarding the surgery, including the risks, benefits, and alternatives, can still count toward this category in the MDM table. Therefore, in this scenario, documentation would best fit with CPT code 99204 for a new patient or 99214 for an established patient. The addition of the psoriasis diagnosis would not change the level of service but also should include documentation of the psoriasis as medically necessary.

However, if you perform the biopsy, then the documentation above would only allow reporting the biopsy, as the decision to perform a 0- or 10-day global procedure is “bundled” with the procedure if performed on the same date of service. Therefore, with the addition of the psoriasis diagnosis, you would now use a separate E/M code to report the psoriasis. You must append a modifier −25 to the E/M code to certify that you are dealing with a separate and discrete problem with no overlap in physician work.

Clearly you also have an E/M to report. But what level? Is this chronic? Yes, as CPT clearly defines chronic as “[a] problem with an expected duration of at least one year or until the death of the patient.”^1,5

But is this stable progressive or showing side effects of treatment? “‘Stable’ for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function,” according to the CPT descriptors. Therefore, in this scenario, the documentation would best fit a chronic illness with exacerbation, progression, or side effects of treatment (column 1, level 4), which is of moderate complexity.¹

But what about column 3, where we look at risks of testing and treatment? This would depend on the type of treatment given. If an over-the-counter product such as a tar gel is recommended, this is a low risk (column 3, level 3), which would mean this lower value determines the E/M code to be 99213 or 99203 depending on whether this is an established or new patient, respectively. If we treat with a prescription medication such as a topical corticosteroid, we are providing prescription drug management (column 3, level 4), which is moderate risk, and we would use codes 99204 or 99214, assuming we document appropriately. Again, including the CPT terminology of “not at treatment goal” in your impression and “prescription drug management” in your plan tells an auditor what you are thinking and doing.^1,5

The Takeaway—Clearly if a GEP is performed, there is a single CPT code used—99204 or 99214. If the biopsy is performed, there would be a biopsy code and an E/M code with a modifier −25 attached to the latter. For the documentation below, a 99204 or 99214 would be the chosen E/M code:

• CC: (1) New spot on left cheek that seems to be growing and changing shape rapidly; (2) Silvery spots on elbows, knees, and buttocks for which patient desires treatment.
• History: No family history of skin cancer; concerned about scarring, no blood thinner. Mom has psoriasis. Tried petroleum jelly on scaly areas but no better.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy. Silver scaly erythematous plaques on elbows, knees, sacrum.
• Impression: (1) Rule out melanoma (undiagnosed new problem with uncertain prognosis); (2) Psoriasis (chronic disease not at treatment goal).
• Plan: (1) Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive GEP melanoma rule-out test. Patient wants biopsy. Consent, biopsy via shave technique. Lidocaine hydrochloride 1% with epinephrine 1 cc, prepare and drape, aluminum chloride for hemostasis, ointment and bandage applied, care instructions provided; (2) Discuss options. Calcipotriene cream daily; triamcinolone ointment 0.1% twice a day (prescription drug management). Review bathing, avoiding trauma to site, no picking.

Scenario 4: Here for a Total-Body Screening Examination

Medicare does not cover skin cancer screenings as a primary CC. Being worried or knowing someone with melanoma are not CCs that are covered. However, “spot of concern,” “changing mole,” or ”new growth” would be. Conversely, if the patient has a history of skin cancer, actinic keratoses, or other premalignant lesions, and/or is immunosuppressed or has a high-risk genetic syndrome, the visit may be covered if these factors are documented in the note.⁶

For the diagnosis, the International Classification of Diseases, Tenth Revision, code Z12.83—“encounter for screening for malignant neoplasm of skin”—is not an appropriate primary billing code. However, D48.5—“neoplasm of behavior of skin”—can be, unless there is a specific diagnosis you are able to make (eg, melanocytic nevus, seborrheic keratosis).⁶

Let’s look at documentation examples:

• CC: 1-year follow-up on basal cell carcinoma (BCC) excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence.
• Plan: Reassure. Annual surveillance in 1 year.

Using what we have previously discussed, this would likely be considered CPT code 99212 (established patient office visit). However, it is important to ensure all concerns and treatment interventions are fully documented. Consider this fuller documentation with bolded additions:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence and heliodermatosis/chronic sun damage not at treat-ment goal.
• Plan: Reassure. Annual surveillance in 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

This is better but still possibly confusing to an auditor. Consider instead with bolded additions to the changes to the impression:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose (D22.39)⁷ and prior BCC treatment site with no sign of recurrence (Z85.828: “personal history of other malignant neoplasm of skin) and heliodermatosis/chronic sun damage not at treatment goal (L57.8: “other skin changes due to chronic exposure to nonionizing radiation”).
• Plan: Reassure. Annual surveillance 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

We now have chronic heliodermatitis not at treatment goal, which is moderate (column 1, level 4), and the over-the-counter broad-spectrum sun protection factor 30+ sunscreen (column 1, low) would be best coded as CPT code 99213.

Final Thoughts

“Spot check” encounters are common dermatologic visits, both on their own and in combination with other concerns. With the updated E/M guidelines, it is crucial to clarify and streamline your documentation. In particular, utilize language clearly defining the number and complexity of problems, data to be reviewed and/or analyzed, and appropriate risk stratification to ensure appropriate reimbursement and minimize your difficulties with audits.

When the Current Procedural Terminology (CPT) evaluation and management (E/M) reporting rules changed dramatically in January 2021, “bullet counting” became unnecessary and the coding level became based on either the new medical decision making (MDM) table or time spent on all activities relating to the care of the patient on the day of the encounter. ¹

To make your documentation more likely to pass audits, explicitly link parts of your documentation to CPT MDM descriptors. Part 1 of this series discussed how to approach the “spot check,” a commonly encountered chief concern (CC) within dermatology, with 2 scenarios presented.² The American Medical Association³ and American Academy of Dermatology⁴ have provided education that focuses on how to report a given vignette, but specific examples of documentation with commentary are uncommon. In part 2, we describe how to best code an encounter that includes a “spot check” with other concerns.

Scenario 3: By the Way, Doc

A 34-year-old presents with a new spot on the left cheek that seems to be growing and changing shape rapidly. You examine the patient and discuss treatment options. The documentation reads as follows:

• CC: New spot on left cheek that seems to be growing and changing shape rapidly.
• History: No family history of skin cancer; concerned about scarring, no blood thinner.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy.
• Impression: Rule out melanoma (undiagnosed new problem with uncertain prognosis).
• Plan: Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive gene expression profiling (GEP) melanoma rule-out test. (Based on the decision you and the patient make, you also would document which option was chosen, so a biopsy would include your standard documentation, and if the GEP is chosen, you would simply state that this was chosen and performed.)

As you turn to leave the room, the patient says:“By the way, Doc, can you do anything about these silvery spots on my elbows, knees, and buttocks?” You look at the areas of concern and diagnose the patient with psoriasis.

How would it be best to approach this scenario? It depends on which treatment option the patient chooses.

If you performed a noninvasive GEP melanoma rule-out test, the CPT reporting does not change with the addition of the new problem, and only the codes 99204 (new patient office or other outpatient visit) or 99214 (established patient office or other outpatient visit) would be reported. This would be because, with the original documentation, the number and complexity of problems would be an “undiagnosed new problem with uncertain prognosis,” which would be moderate complexity (column 1, level 4). There are no data that are reviewed or analyzed, which would be straightforward (column 2, level 2). For risk, the discussion of the biopsy as a diagnostic choice should include possible scarring, bleeding, pain, and infection, which would be best described as a decision regarding minor surgery with identified patient or procedure risk factors, given the identified patient concerns, making this of moderate complexity (column 3, level 4).¹

Importantly, even if the procedure is not chosen as the final treatment plan, the discussion regarding the surgery, including the risks, benefits, and alternatives, can still count toward this category in the MDM table. Therefore, in this scenario, documentation would best fit with CPT code 99204 for a new patient or 99214 for an established patient. The addition of the psoriasis diagnosis would not change the level of service but also should include documentation of the psoriasis as medically necessary.

However, if you perform the biopsy, then the documentation above would only allow reporting the biopsy, as the decision to perform a 0- or 10-day global procedure is “bundled” with the procedure if performed on the same date of service. Therefore, with the addition of the psoriasis diagnosis, you would now use a separate E/M code to report the psoriasis. You must append a modifier −25 to the E/M code to certify that you are dealing with a separate and discrete problem with no overlap in physician work.

Clearly you also have an E/M to report. But what level? Is this chronic? Yes, as CPT clearly defines chronic as “[a] problem with an expected duration of at least one year or until the death of the patient.”^1,5

But is this stable progressive or showing side effects of treatment? “‘Stable’ for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function,” according to the CPT descriptors. Therefore, in this scenario, the documentation would best fit a chronic illness with exacerbation, progression, or side effects of treatment (column 1, level 4), which is of moderate complexity.¹

But what about column 3, where we look at risks of testing and treatment? This would depend on the type of treatment given. If an over-the-counter product such as a tar gel is recommended, this is a low risk (column 3, level 3), which would mean this lower value determines the E/M code to be 99213 or 99203 depending on whether this is an established or new patient, respectively. If we treat with a prescription medication such as a topical corticosteroid, we are providing prescription drug management (column 3, level 4), which is moderate risk, and we would use codes 99204 or 99214, assuming we document appropriately. Again, including the CPT terminology of “not at treatment goal” in your impression and “prescription drug management” in your plan tells an auditor what you are thinking and doing.^1,5

The Takeaway—Clearly if a GEP is performed, there is a single CPT code used—99204 or 99214. If the biopsy is performed, there would be a biopsy code and an E/M code with a modifier −25 attached to the latter. For the documentation below, a 99204 or 99214 would be the chosen E/M code:

• CC: (1) New spot on left cheek that seems to be growing and changing shape rapidly; (2) Silvery spots on elbows, knees, and buttocks for which patient desires treatment.
• History: No family history of skin cancer; concerned about scarring, no blood thinner. Mom has psoriasis. Tried petroleum jelly on scaly areas but no better.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy. Silver scaly erythematous plaques on elbows, knees, sacrum.
• Impression: (1) Rule out melanoma (undiagnosed new problem with uncertain prognosis); (2) Psoriasis (chronic disease not at treatment goal).
• Plan: (1) Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive GEP melanoma rule-out test. Patient wants biopsy. Consent, biopsy via shave technique. Lidocaine hydrochloride 1% with epinephrine 1 cc, prepare and drape, aluminum chloride for hemostasis, ointment and bandage applied, care instructions provided; (2) Discuss options. Calcipotriene cream daily; triamcinolone ointment 0.1% twice a day (prescription drug management). Review bathing, avoiding trauma to site, no picking.

Scenario 4: Here for a Total-Body Screening Examination

Medicare does not cover skin cancer screenings as a primary CC. Being worried or knowing someone with melanoma are not CCs that are covered. However, “spot of concern,” “changing mole,” or ”new growth” would be. Conversely, if the patient has a history of skin cancer, actinic keratoses, or other premalignant lesions, and/or is immunosuppressed or has a high-risk genetic syndrome, the visit may be covered if these factors are documented in the note.⁶

For the diagnosis, the International Classification of Diseases, Tenth Revision, code Z12.83—“encounter for screening for malignant neoplasm of skin”—is not an appropriate primary billing code. However, D48.5—“neoplasm of behavior of skin”—can be, unless there is a specific diagnosis you are able to make (eg, melanocytic nevus, seborrheic keratosis).⁶

Let’s look at documentation examples:

• CC: 1-year follow-up on basal cell carcinoma (BCC) excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence.
• Plan: Reassure. Annual surveillance in 1 year.

Using what we have previously discussed, this would likely be considered CPT code 99212 (established patient office visit). However, it is important to ensure all concerns and treatment interventions are fully documented. Consider this fuller documentation with bolded additions:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose and prior BCC treatment site with no sign of recurrence and heliodermatosis/chronic sun damage not at treat-ment goal.
• Plan: Reassure. Annual surveillance in 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

This is better but still possibly confusing to an auditor. Consider instead with bolded additions to the changes to the impression:

• CC: 1-year follow-up on BCC excision and concern about a new spot on the nose.
• History: Notice new spot on the nose; due for annual follow-up and came early for nose lesion. Also unhappy with generally looking older.
• Examination: Left ala with flesh-colored papule dermoscopically banal. Prior left back BCC excision site soft and supple. Diffuse changes of chronic sun damage. Total-body examination performed, except perianal and external genitalia, and is unremarkable.
• Impression: Fibrous papule of nose (D22.39)⁷ and prior BCC treatment site with no sign of recurrence (Z85.828: “personal history of other malignant neoplasm of skin) and heliodermatosis/chronic sun damage not at treatment goal (L57.8: “other skin changes due to chronic exposure to nonionizing radiation”).
• Plan: Reassure. Annual surveillance 1 year. Over-the-counter broad-spectrum sun protection factor 30+ sunscreen daily.

We now have chronic heliodermatitis not at treatment goal, which is moderate (column 1, level 4), and the over-the-counter broad-spectrum sun protection factor 30+ sunscreen (column 1, low) would be best coded as CPT code 99213.

Final Thoughts

“Spot check” encounters are common dermatologic visits, both on their own and in combination with other concerns. With the updated E/M guidelines, it is crucial to clarify and streamline your documentation. In particular, utilize language clearly defining the number and complexity of problems, data to be reviewed and/or analyzed, and appropriate risk stratification to ensure appropriate reimbursement and minimize your difficulties with audits.

The Diagnosis: Dominant Dystrophic Epidermolysis Bullosa

Blisters in a neonate may be caused by infectious, traumatic, autoimmune, or congenital etiologies. Biopsy findings correlated with clinical findings usually can establish a prompt diagnosis when the clinical diagnosis is uncertain. Direct immunofluorescence (DIF) as well as indirect immunofluorescence studies are useful when autoimmune blistering disease or congenital or heritable disorders of skin fragility are in the differential diagnosis. Many genetic abnormalities of skin fragility are associated with marked morbidity and mortality, and prompt diagnosis is essential to provide proper care. Our patient’s parents had no history of skin disorders, and there was no known family history of blistering disease or traumatic birth. A heritable disorder of skin fragility was still a top consideration because of the extensive blistering in the absence of any other symptoms.

Although dystrophic epidermolysis bullosa (DEB) is an uncommon cause of skin fragility in neonates, our patient’s presentation was typical because of the extensive blistering and increased fragility of the skin at pressure points. Dystrophic epidermolysis bullosa has both dominant and recessive presentations that span a spectrum from mild and focal skin blistering to extensive blistering with esophageal involvement.¹ Early diagnosis and treatment can mitigate potential failure to thrive or premature death. Inherited mutations in the type VII collagen gene, COL7A1, are causative.² Dominant DEB may be associated with dental caries, swallowing problems secondary to esophageal scarring, and constipation, as well as dystrophic or absent nails. Immunomapping studies of the skin often reveal type VII collagen cytoplasmic granules in the epidermis and weaker reaction in the roof of the subepidermal separation (quiz image).³ Abnormalities in type VII collagen impact the production of anchoring fibrils. Blister cleavage occurs in the sublamina densa with type VII collagen staining evident on the blister roof (quiz image).⁴ Patients with severe generalized recessive DEB may have barely detectable type VII collagen. In our patient, the cytoplasmic staining and weak staining in the epidermal roof of the separation confirmed the clinical impression of dominant DEB.

Autoimmune blistering disease should be considered in the histologic differential diagnosis, but it usually is associated with obvious disease in the mother. Direct immunofluorescence of pemphigoid gestationis reveals linear deposition of C3 at the basement membrane zone, which also can be associated with IgG (Figure 1). Neonates receiving passive transfer of antibodies may develop annular erythema, vesicles, and even dyshidroticlike changes on the soles.⁵

Suction blisters are subepithelial.^6,7 When they occur in the neonatal period, they often are localized and are thought to be the result of vigorous sucking in utero.⁶ They quickly resolve without treatment and do not reveal abnormalities on DIF. If immunomapping is done for type VII collagen, it will be located at the floor of the suction blister (Figure 2).

Bullous pemphigoid is associated with deposition of linear IgG along the dermoepidermal junction—IgG4 is most common—and/or C3 (Figure 3). Direct immunofluorescence on split-skin biopsy reveals IgG on the epidermal side of the blister in bullous pemphigoid in contrast to epidermolysis bullosa acquisita, where the immune deposits are found on the dermal side of the split.^8,9 Linear IgA bullous disease is associated with IgA deposition (Figure 4).^10,11 Secretory IgA derived from breast milk can be causative.¹¹ Neonatal linear IgA bullous disease is a serious condition associated with marked mucosal involvement that can eventuate in respiratory compromise. Prompt recognition is important; breastfeeding must be stopped and supportive therapy must be provided.

Other types of vesicular or pustular eruptions in the newborn usually are easily diagnosed by their typical clinical presentation without biopsy. Erythema toxicum neonatorum usually presents within 1 to 2 days of birth. It is self-limited and often resembles acne, but it also occurs on the trunk and extremities. Transient neonatal pustular melanosis may be present at birth and predominantly is seen in newborns with skin of color. Lesions easily rupture and usually resolve within 1 to 2 days. Infectious causes of blistering often can be identified on clinical examination and confirmed by culture. Herpes simplex virus infection is associated with characteristic multinucleated giant cells as well as steel grey nuclei evident on routine histologic evaluation. Bullous impetigo reveals superficial acantholysis and will have negative findings on DIF.¹²

When a neonate presents with widespread blistering, both genetic disorders of skin fragility as well as passive transfer of antibodies from maternal autoimmune disease need to be considered. Direct immunofluorescence and indirect immunofluorescence immunomapping findings can be useful in clarifying the diagnosis when heritable disorders of skin fragility or autoimmune blistering diseases are a clinical consideration.

The Diagnosis: Dominant Dystrophic Epidermolysis Bullosa

Blisters in a neonate may be caused by infectious, traumatic, autoimmune, or congenital etiologies. Biopsy findings correlated with clinical findings usually can establish a prompt diagnosis when the clinical diagnosis is uncertain. Direct immunofluorescence (DIF) as well as indirect immunofluorescence studies are useful when autoimmune blistering disease or congenital or heritable disorders of skin fragility are in the differential diagnosis. Many genetic abnormalities of skin fragility are associated with marked morbidity and mortality, and prompt diagnosis is essential to provide proper care. Our patient’s parents had no history of skin disorders, and there was no known family history of blistering disease or traumatic birth. A heritable disorder of skin fragility was still a top consideration because of the extensive blistering in the absence of any other symptoms.

Although dystrophic epidermolysis bullosa (DEB) is an uncommon cause of skin fragility in neonates, our patient’s presentation was typical because of the extensive blistering and increased fragility of the skin at pressure points. Dystrophic epidermolysis bullosa has both dominant and recessive presentations that span a spectrum from mild and focal skin blistering to extensive blistering with esophageal involvement.¹ Early diagnosis and treatment can mitigate potential failure to thrive or premature death. Inherited mutations in the type VII collagen gene, COL7A1, are causative.² Dominant DEB may be associated with dental caries, swallowing problems secondary to esophageal scarring, and constipation, as well as dystrophic or absent nails. Immunomapping studies of the skin often reveal type VII collagen cytoplasmic granules in the epidermis and weaker reaction in the roof of the subepidermal separation (quiz image).³ Abnormalities in type VII collagen impact the production of anchoring fibrils. Blister cleavage occurs in the sublamina densa with type VII collagen staining evident on the blister roof (quiz image).⁴ Patients with severe generalized recessive DEB may have barely detectable type VII collagen. In our patient, the cytoplasmic staining and weak staining in the epidermal roof of the separation confirmed the clinical impression of dominant DEB.

Autoimmune blistering disease should be considered in the histologic differential diagnosis, but it usually is associated with obvious disease in the mother. Direct immunofluorescence of pemphigoid gestationis reveals linear deposition of C3 at the basement membrane zone, which also can be associated with IgG (Figure 1). Neonates receiving passive transfer of antibodies may develop annular erythema, vesicles, and even dyshidroticlike changes on the soles.⁵

Suction blisters are subepithelial.^6,7 When they occur in the neonatal period, they often are localized and are thought to be the result of vigorous sucking in utero.⁶ They quickly resolve without treatment and do not reveal abnormalities on DIF. If immunomapping is done for type VII collagen, it will be located at the floor of the suction blister (Figure 2).

Bullous pemphigoid is associated with deposition of linear IgG along the dermoepidermal junction—IgG4 is most common—and/or C3 (Figure 3). Direct immunofluorescence on split-skin biopsy reveals IgG on the epidermal side of the blister in bullous pemphigoid in contrast to epidermolysis bullosa acquisita, where the immune deposits are found on the dermal side of the split.^8,9 Linear IgA bullous disease is associated with IgA deposition (Figure 4).^10,11 Secretory IgA derived from breast milk can be causative.¹¹ Neonatal linear IgA bullous disease is a serious condition associated with marked mucosal involvement that can eventuate in respiratory compromise. Prompt recognition is important; breastfeeding must be stopped and supportive therapy must be provided.

Other types of vesicular or pustular eruptions in the newborn usually are easily diagnosed by their typical clinical presentation without biopsy. Erythema toxicum neonatorum usually presents within 1 to 2 days of birth. It is self-limited and often resembles acne, but it also occurs on the trunk and extremities. Transient neonatal pustular melanosis may be present at birth and predominantly is seen in newborns with skin of color. Lesions easily rupture and usually resolve within 1 to 2 days. Infectious causes of blistering often can be identified on clinical examination and confirmed by culture. Herpes simplex virus infection is associated with characteristic multinucleated giant cells as well as steel grey nuclei evident on routine histologic evaluation. Bullous impetigo reveals superficial acantholysis and will have negative findings on DIF.¹²

When a neonate presents with widespread blistering, both genetic disorders of skin fragility as well as passive transfer of antibodies from maternal autoimmune disease need to be considered. Direct immunofluorescence and indirect immunofluorescence immunomapping findings can be useful in clarifying the diagnosis when heritable disorders of skin fragility or autoimmune blistering diseases are a clinical consideration.

The Diagnosis: Dominant Dystrophic Epidermolysis Bullosa

Blisters in a neonate may be caused by infectious, traumatic, autoimmune, or congenital etiologies. Biopsy findings correlated with clinical findings usually can establish a prompt diagnosis when the clinical diagnosis is uncertain. Direct immunofluorescence (DIF) as well as indirect immunofluorescence studies are useful when autoimmune blistering disease or congenital or heritable disorders of skin fragility are in the differential diagnosis. Many genetic abnormalities of skin fragility are associated with marked morbidity and mortality, and prompt diagnosis is essential to provide proper care. Our patient’s parents had no history of skin disorders, and there was no known family history of blistering disease or traumatic birth. A heritable disorder of skin fragility was still a top consideration because of the extensive blistering in the absence of any other symptoms.

Although dystrophic epidermolysis bullosa (DEB) is an uncommon cause of skin fragility in neonates, our patient’s presentation was typical because of the extensive blistering and increased fragility of the skin at pressure points. Dystrophic epidermolysis bullosa has both dominant and recessive presentations that span a spectrum from mild and focal skin blistering to extensive blistering with esophageal involvement.¹ Early diagnosis and treatment can mitigate potential failure to thrive or premature death. Inherited mutations in the type VII collagen gene, COL7A1, are causative.² Dominant DEB may be associated with dental caries, swallowing problems secondary to esophageal scarring, and constipation, as well as dystrophic or absent nails. Immunomapping studies of the skin often reveal type VII collagen cytoplasmic granules in the epidermis and weaker reaction in the roof of the subepidermal separation (quiz image).³ Abnormalities in type VII collagen impact the production of anchoring fibrils. Blister cleavage occurs in the sublamina densa with type VII collagen staining evident on the blister roof (quiz image).⁴ Patients with severe generalized recessive DEB may have barely detectable type VII collagen. In our patient, the cytoplasmic staining and weak staining in the epidermal roof of the separation confirmed the clinical impression of dominant DEB.

Autoimmune blistering disease should be considered in the histologic differential diagnosis, but it usually is associated with obvious disease in the mother. Direct immunofluorescence of pemphigoid gestationis reveals linear deposition of C3 at the basement membrane zone, which also can be associated with IgG (Figure 1). Neonates receiving passive transfer of antibodies may develop annular erythema, vesicles, and even dyshidroticlike changes on the soles.⁵

Suction blisters are subepithelial.^6,7 When they occur in the neonatal period, they often are localized and are thought to be the result of vigorous sucking in utero.⁶ They quickly resolve without treatment and do not reveal abnormalities on DIF. If immunomapping is done for type VII collagen, it will be located at the floor of the suction blister (Figure 2).

Bullous pemphigoid is associated with deposition of linear IgG along the dermoepidermal junction—IgG4 is most common—and/or C3 (Figure 3). Direct immunofluorescence on split-skin biopsy reveals IgG on the epidermal side of the blister in bullous pemphigoid in contrast to epidermolysis bullosa acquisita, where the immune deposits are found on the dermal side of the split.^8,9 Linear IgA bullous disease is associated with IgA deposition (Figure 4).^10,11 Secretory IgA derived from breast milk can be causative.¹¹ Neonatal linear IgA bullous disease is a serious condition associated with marked mucosal involvement that can eventuate in respiratory compromise. Prompt recognition is important; breastfeeding must be stopped and supportive therapy must be provided.

Other types of vesicular or pustular eruptions in the newborn usually are easily diagnosed by their typical clinical presentation without biopsy. Erythema toxicum neonatorum usually presents within 1 to 2 days of birth. It is self-limited and often resembles acne, but it also occurs on the trunk and extremities. Transient neonatal pustular melanosis may be present at birth and predominantly is seen in newborns with skin of color. Lesions easily rupture and usually resolve within 1 to 2 days. Infectious causes of blistering often can be identified on clinical examination and confirmed by culture. Herpes simplex virus infection is associated with characteristic multinucleated giant cells as well as steel grey nuclei evident on routine histologic evaluation. Bullous impetigo reveals superficial acantholysis and will have negative findings on DIF.¹²

When a neonate presents with widespread blistering, both genetic disorders of skin fragility as well as passive transfer of antibodies from maternal autoimmune disease need to be considered. Direct immunofluorescence and indirect immunofluorescence immunomapping findings can be useful in clarifying the diagnosis when heritable disorders of skin fragility or autoimmune blistering diseases are a clinical consideration.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Nearly all dermatologists are aware that psoriatic arthritis (PsA) is one of the most prevalent comorbidities associated with psoriasis, yet we may lack the insight regarding how to utilize this information. After all, we specialize in the skin, not the joints, right?

When I graduated from residency in 2014, I began staffing our psoriasis clinic, where we care for the toughest, most complicated psoriasis patients, many of them struggling with both severe recalcitrant psoriasis as well as debilitating PsA. In 2016, we partnered with rheumatology to open a multidisciplinary psoriasis and PsA clinic, and I quickly began to appreciate how much PsA was being overlooked simply because patients with psoriasis were not being asked about their joints.

To start, let’s look at several facts:

1. One quarter of patients with psoriasis also have PsA.¹
2. Skin disease most commonly develops before PsA.¹
3. Fifteen percent of PsA cases go undiagnosed, which dramatically increases the risk for deformed joints, erosions, osteolysis, sacroiliitis, and arthritis mutilans² and also increases the cost of health care.³
4. Everyone is crazy busy—rheumatology wait lists often are months long.

Given that dermatologists are the ones who already are seeing the majority of patients who develop PsA, we play a key role in screening for this debilitating comorbidity and starting therapy for patients with both psoriasis and PsA. We, too, are crazy busy; therefore, we need to make this process quick and efficient but also reliable. Fortunately, the Psoriasis Epidemiology Screening Tool (PEST) is effective, fast, and very easy. With only 5 questions and a sensitivity and specificity of around 70%,⁴ this short and simple questionnaire can be incorporated into an intake form or rooming note or can just be asked during the visit. The questions include whether the patient currently has or has had a swollen joint, nail pits, heel pain, and/or dactylitis, as well as if they have been told by a physician that they have arthritis. A score of 3 or higher is considered positive and a referral to rheumatology should be considered. At the bare minimum, I highly encourage all dermatologists to incorporate the PEST screening tool into their practice.

During the physical examination itself, be sure to look at the patient’s nails and also look for joint swelling and redness, especially in the hands. When palpating a swollen joint, the presence of inflammatory arthritis will feel spongy or boggy, while the osteophytes associated with osteoarthritis will feel hard. Radiography of the affected joint may be helpful, but keep in mind that bone changes are latter sequelae of PsA, and negative radiographs do not rule out PsA.

If you highly suspect PsA after using the PEST screening tool and palpating any swollen joints, then a rheumatology referral certainly is warranted. Medication that covers both psoriasis and PsA also can be initiated. Although methotrexate often is used for joints, higher doses (ie, >15 mg/wk) usually are needed. A 2019 Cochrane review found that low-dose methotrexate (ie, ≤15 mg/wk) may be only slightly more effective then placebo⁵—certainly not a ringing endorsement for its use in PsA. Additionally, quality data demonstrating methotrexate’s efficacy for enthesitis or axial spondyloarthritis is lacking, and methotrexate has not demonstrated an ability to slow the radiographic progression of joints. In contrast, the anti–tumor necrosis factor agents, including adalimumab, infliximab, etanercept, and certolizumab, as well as ustekinumab and the anti–IL-17 biologics secukinumab and ixekizumab have demonstrated efficacy in American College of Rheumatology (ACR) scores, enthesitis, dactylitis, and prevention of radiographic progression of joints.^6,7 Although brodalumab, an anti–IL-17 receptor inhibitor, demonstrated improvement in ACR scores, enthesitis, and dactylitis, data on its effects on radiographic progression of joints were inconclusive given the phase III trial’s premature ending due to suicidal ideation and behavior in participants.⁸ Several of the anti–IL-23 agents also may help PsA, with trials demonstrating improvements in ACR scores, enthesitis, and dactylitis; however, only guselkumab 100 mg every 4 weeks decreased radiographic progression of joints.⁹ Additionally, with the age of the Janus kinase (JAK) inhibitor upon us, there are several JAK/TYK2 inhibitors that are approved by the US Food and Drug Administration for psoriasis (deucravacitinib) as well as for PsA (tofacitinib, upadacitinib), and there are more JAK inhibitors in the pipeline. These medications are effective; however, I do encourage caution and careful consideration in selecting the appropriate patient, as data demonstrated an increased risk for major adverse cardiovascular events and cancer in older (>50 years) rheumatoid arthritis patients who had at least 1 cardiovascular risk factor and were treated with tofacitinib.¹⁰ Although several other trials have not demonstrated this increased risk, further data are needed to determine risk for both pan-JAK inhibitors as well as selective JAK inhibitors and TYK2 inhibitors. Additionally, given psoriasis already is closely linked with many cardiovascular risk factors including heart disease, obesity, hypertension, hyperlipidemia, and diabetes mellitus,¹¹ it will be important to have long-term safety information for JAK inhibitors in the psoriasis and PsA population.

Dermatologists are in a pivotal position to identify patients affected by PsA and start an appropriate systemic medication. We can help make an enormous impact on our patients’ lives as well as help decrease the economic impact of untreated disease. Let’s join the effort to save the joints!

Nearly all dermatologists are aware that psoriatic arthritis (PsA) is one of the most prevalent comorbidities associated with psoriasis, yet we may lack the insight regarding how to utilize this information. After all, we specialize in the skin, not the joints, right?

When I graduated from residency in 2014, I began staffing our psoriasis clinic, where we care for the toughest, most complicated psoriasis patients, many of them struggling with both severe recalcitrant psoriasis as well as debilitating PsA. In 2016, we partnered with rheumatology to open a multidisciplinary psoriasis and PsA clinic, and I quickly began to appreciate how much PsA was being overlooked simply because patients with psoriasis were not being asked about their joints.

To start, let’s look at several facts:

1. One quarter of patients with psoriasis also have PsA.¹
2. Skin disease most commonly develops before PsA.¹
3. Fifteen percent of PsA cases go undiagnosed, which dramatically increases the risk for deformed joints, erosions, osteolysis, sacroiliitis, and arthritis mutilans² and also increases the cost of health care.³
4. Everyone is crazy busy—rheumatology wait lists often are months long.

Given that dermatologists are the ones who already are seeing the majority of patients who develop PsA, we play a key role in screening for this debilitating comorbidity and starting therapy for patients with both psoriasis and PsA. We, too, are crazy busy; therefore, we need to make this process quick and efficient but also reliable. Fortunately, the Psoriasis Epidemiology Screening Tool (PEST) is effective, fast, and very easy. With only 5 questions and a sensitivity and specificity of around 70%,⁴ this short and simple questionnaire can be incorporated into an intake form or rooming note or can just be asked during the visit. The questions include whether the patient currently has or has had a swollen joint, nail pits, heel pain, and/or dactylitis, as well as if they have been told by a physician that they have arthritis. A score of 3 or higher is considered positive and a referral to rheumatology should be considered. At the bare minimum, I highly encourage all dermatologists to incorporate the PEST screening tool into their practice.

During the physical examination itself, be sure to look at the patient’s nails and also look for joint swelling and redness, especially in the hands. When palpating a swollen joint, the presence of inflammatory arthritis will feel spongy or boggy, while the osteophytes associated with osteoarthritis will feel hard. Radiography of the affected joint may be helpful, but keep in mind that bone changes are latter sequelae of PsA, and negative radiographs do not rule out PsA.

If you highly suspect PsA after using the PEST screening tool and palpating any swollen joints, then a rheumatology referral certainly is warranted. Medication that covers both psoriasis and PsA also can be initiated. Although methotrexate often is used for joints, higher doses (ie, >15 mg/wk) usually are needed. A 2019 Cochrane review found that low-dose methotrexate (ie, ≤15 mg/wk) may be only slightly more effective then placebo⁵—certainly not a ringing endorsement for its use in PsA. Additionally, quality data demonstrating methotrexate’s efficacy for enthesitis or axial spondyloarthritis is lacking, and methotrexate has not demonstrated an ability to slow the radiographic progression of joints. In contrast, the anti–tumor necrosis factor agents, including adalimumab, infliximab, etanercept, and certolizumab, as well as ustekinumab and the anti–IL-17 biologics secukinumab and ixekizumab have demonstrated efficacy in American College of Rheumatology (ACR) scores, enthesitis, dactylitis, and prevention of radiographic progression of joints.^6,7 Although brodalumab, an anti–IL-17 receptor inhibitor, demonstrated improvement in ACR scores, enthesitis, and dactylitis, data on its effects on radiographic progression of joints were inconclusive given the phase III trial’s premature ending due to suicidal ideation and behavior in participants.⁸ Several of the anti–IL-23 agents also may help PsA, with trials demonstrating improvements in ACR scores, enthesitis, and dactylitis; however, only guselkumab 100 mg every 4 weeks decreased radiographic progression of joints.⁹ Additionally, with the age of the Janus kinase (JAK) inhibitor upon us, there are several JAK/TYK2 inhibitors that are approved by the US Food and Drug Administration for psoriasis (deucravacitinib) as well as for PsA (tofacitinib, upadacitinib), and there are more JAK inhibitors in the pipeline. These medications are effective; however, I do encourage caution and careful consideration in selecting the appropriate patient, as data demonstrated an increased risk for major adverse cardiovascular events and cancer in older (>50 years) rheumatoid arthritis patients who had at least 1 cardiovascular risk factor and were treated with tofacitinib.¹⁰ Although several other trials have not demonstrated this increased risk, further data are needed to determine risk for both pan-JAK inhibitors as well as selective JAK inhibitors and TYK2 inhibitors. Additionally, given psoriasis already is closely linked with many cardiovascular risk factors including heart disease, obesity, hypertension, hyperlipidemia, and diabetes mellitus,¹¹ it will be important to have long-term safety information for JAK inhibitors in the psoriasis and PsA population.

Dermatologists are in a pivotal position to identify patients affected by PsA and start an appropriate systemic medication. We can help make an enormous impact on our patients’ lives as well as help decrease the economic impact of untreated disease. Let’s join the effort to save the joints!

Nearly all dermatologists are aware that psoriatic arthritis (PsA) is one of the most prevalent comorbidities associated with psoriasis, yet we may lack the insight regarding how to utilize this information. After all, we specialize in the skin, not the joints, right?

When I graduated from residency in 2014, I began staffing our psoriasis clinic, where we care for the toughest, most complicated psoriasis patients, many of them struggling with both severe recalcitrant psoriasis as well as debilitating PsA. In 2016, we partnered with rheumatology to open a multidisciplinary psoriasis and PsA clinic, and I quickly began to appreciate how much PsA was being overlooked simply because patients with psoriasis were not being asked about their joints.

To start, let’s look at several facts:

1. One quarter of patients with psoriasis also have PsA.¹
2. Skin disease most commonly develops before PsA.¹
3. Fifteen percent of PsA cases go undiagnosed, which dramatically increases the risk for deformed joints, erosions, osteolysis, sacroiliitis, and arthritis mutilans² and also increases the cost of health care.³
4. Everyone is crazy busy—rheumatology wait lists often are months long.

Given that dermatologists are the ones who already are seeing the majority of patients who develop PsA, we play a key role in screening for this debilitating comorbidity and starting therapy for patients with both psoriasis and PsA. We, too, are crazy busy; therefore, we need to make this process quick and efficient but also reliable. Fortunately, the Psoriasis Epidemiology Screening Tool (PEST) is effective, fast, and very easy. With only 5 questions and a sensitivity and specificity of around 70%,⁴ this short and simple questionnaire can be incorporated into an intake form or rooming note or can just be asked during the visit. The questions include whether the patient currently has or has had a swollen joint, nail pits, heel pain, and/or dactylitis, as well as if they have been told by a physician that they have arthritis. A score of 3 or higher is considered positive and a referral to rheumatology should be considered. At the bare minimum, I highly encourage all dermatologists to incorporate the PEST screening tool into their practice.

During the physical examination itself, be sure to look at the patient’s nails and also look for joint swelling and redness, especially in the hands. When palpating a swollen joint, the presence of inflammatory arthritis will feel spongy or boggy, while the osteophytes associated with osteoarthritis will feel hard. Radiography of the affected joint may be helpful, but keep in mind that bone changes are latter sequelae of PsA, and negative radiographs do not rule out PsA.

If you highly suspect PsA after using the PEST screening tool and palpating any swollen joints, then a rheumatology referral certainly is warranted. Medication that covers both psoriasis and PsA also can be initiated. Although methotrexate often is used for joints, higher doses (ie, >15 mg/wk) usually are needed. A 2019 Cochrane review found that low-dose methotrexate (ie, ≤15 mg/wk) may be only slightly more effective then placebo⁵—certainly not a ringing endorsement for its use in PsA. Additionally, quality data demonstrating methotrexate’s efficacy for enthesitis or axial spondyloarthritis is lacking, and methotrexate has not demonstrated an ability to slow the radiographic progression of joints. In contrast, the anti–tumor necrosis factor agents, including adalimumab, infliximab, etanercept, and certolizumab, as well as ustekinumab and the anti–IL-17 biologics secukinumab and ixekizumab have demonstrated efficacy in American College of Rheumatology (ACR) scores, enthesitis, dactylitis, and prevention of radiographic progression of joints.^6,7 Although brodalumab, an anti–IL-17 receptor inhibitor, demonstrated improvement in ACR scores, enthesitis, and dactylitis, data on its effects on radiographic progression of joints were inconclusive given the phase III trial’s premature ending due to suicidal ideation and behavior in participants.⁸ Several of the anti–IL-23 agents also may help PsA, with trials demonstrating improvements in ACR scores, enthesitis, and dactylitis; however, only guselkumab 100 mg every 4 weeks decreased radiographic progression of joints.⁹ Additionally, with the age of the Janus kinase (JAK) inhibitor upon us, there are several JAK/TYK2 inhibitors that are approved by the US Food and Drug Administration for psoriasis (deucravacitinib) as well as for PsA (tofacitinib, upadacitinib), and there are more JAK inhibitors in the pipeline. These medications are effective; however, I do encourage caution and careful consideration in selecting the appropriate patient, as data demonstrated an increased risk for major adverse cardiovascular events and cancer in older (>50 years) rheumatoid arthritis patients who had at least 1 cardiovascular risk factor and were treated with tofacitinib.¹⁰ Although several other trials have not demonstrated this increased risk, further data are needed to determine risk for both pan-JAK inhibitors as well as selective JAK inhibitors and TYK2 inhibitors. Additionally, given psoriasis already is closely linked with many cardiovascular risk factors including heart disease, obesity, hypertension, hyperlipidemia, and diabetes mellitus,¹¹ it will be important to have long-term safety information for JAK inhibitors in the psoriasis and PsA population.

Dermatologists are in a pivotal position to identify patients affected by PsA and start an appropriate systemic medication. We can help make an enormous impact on our patients’ lives as well as help decrease the economic impact of untreated disease. Let’s join the effort to save the joints!

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Practice Gap

Nail art can skew the results of optical coherence tomography (OCT), a noninvasive imaging technology that is used to visualize nail morphology in diseases such as psoriatic arthritis and onychomycosis, with a penetration depth of 2 mm and high-resolution images.¹ Few studies have evaluated the effects of nail art on OCT. Saleah and colleagues¹ found that clear, semitransparent, and red nail polishes do not interfere with visualization of the nail plate, whereas nontransparent gel polish and art stones obscure the image. They did not comment on the effect of glitter nail art in their study, though they did test 1 nail that contained glitter.¹ Monpeurt et al² compared matte and glossy nail polishes. They found that matte polish was readily identifiable from the nail plate, whereas glossy polish presented a greater number of artifacts.²

The Solution

We looked at 3 glitter nail polishes—gold, pink, and silver—that were scanned by OCT to assess the effect of the polish on the resulting image. We determined that glitter particles completely obscured the nail bed and nail plate, regardless of color (Figure 1). Glossy clear polish imparted a distinct film on the top of the nail plate that did not obscure the nail plate or the nail bed (Figure 2).

We conclude that glitter nail polish contains numerous reflective solid particles that interfere with OCT imaging of the nail plate and nail bed. As a result, we recommend removal of nail art to properly assess nail pathology. Because removal may need to be conducted by a nail technician, the treating clinician should inform the patient ahead of time to come to the appointment with bare (ie, unpolished) nails.

Practice Implications

Bringing awareness to the necessity of removing nail art prior to OCT imaging is crucial because many patients partake in its application, and removal may require the involvement of a professional nail technician. If a patient can be made aware that they should remove all nail art in advance, they will be better prepared for an OCT imaging session. Such a protocol increases efficiency, decreases diagnostic delay, and reduces cost associated with multiple office visits.

Practice Gap

Nail art can skew the results of optical coherence tomography (OCT), a noninvasive imaging technology that is used to visualize nail morphology in diseases such as psoriatic arthritis and onychomycosis, with a penetration depth of 2 mm and high-resolution images.¹ Few studies have evaluated the effects of nail art on OCT. Saleah and colleagues¹ found that clear, semitransparent, and red nail polishes do not interfere with visualization of the nail plate, whereas nontransparent gel polish and art stones obscure the image. They did not comment on the effect of glitter nail art in their study, though they did test 1 nail that contained glitter.¹ Monpeurt et al² compared matte and glossy nail polishes. They found that matte polish was readily identifiable from the nail plate, whereas glossy polish presented a greater number of artifacts.²

The Solution

We looked at 3 glitter nail polishes—gold, pink, and silver—that were scanned by OCT to assess the effect of the polish on the resulting image. We determined that glitter particles completely obscured the nail bed and nail plate, regardless of color (Figure 1). Glossy clear polish imparted a distinct film on the top of the nail plate that did not obscure the nail plate or the nail bed (Figure 2).

We conclude that glitter nail polish contains numerous reflective solid particles that interfere with OCT imaging of the nail plate and nail bed. As a result, we recommend removal of nail art to properly assess nail pathology. Because removal may need to be conducted by a nail technician, the treating clinician should inform the patient ahead of time to come to the appointment with bare (ie, unpolished) nails.

Practice Implications

Bringing awareness to the necessity of removing nail art prior to OCT imaging is crucial because many patients partake in its application, and removal may require the involvement of a professional nail technician. If a patient can be made aware that they should remove all nail art in advance, they will be better prepared for an OCT imaging session. Such a protocol increases efficiency, decreases diagnostic delay, and reduces cost associated with multiple office visits.

Practice Gap

Nail art can skew the results of optical coherence tomography (OCT), a noninvasive imaging technology that is used to visualize nail morphology in diseases such as psoriatic arthritis and onychomycosis, with a penetration depth of 2 mm and high-resolution images.¹ Few studies have evaluated the effects of nail art on OCT. Saleah and colleagues¹ found that clear, semitransparent, and red nail polishes do not interfere with visualization of the nail plate, whereas nontransparent gel polish and art stones obscure the image. They did not comment on the effect of glitter nail art in their study, though they did test 1 nail that contained glitter.¹ Monpeurt et al² compared matte and glossy nail polishes. They found that matte polish was readily identifiable from the nail plate, whereas glossy polish presented a greater number of artifacts.²

The Solution

We looked at 3 glitter nail polishes—gold, pink, and silver—that were scanned by OCT to assess the effect of the polish on the resulting image. We determined that glitter particles completely obscured the nail bed and nail plate, regardless of color (Figure 1). Glossy clear polish imparted a distinct film on the top of the nail plate that did not obscure the nail plate or the nail bed (Figure 2).

We conclude that glitter nail polish contains numerous reflective solid particles that interfere with OCT imaging of the nail plate and nail bed. As a result, we recommend removal of nail art to properly assess nail pathology. Because removal may need to be conducted by a nail technician, the treating clinician should inform the patient ahead of time to come to the appointment with bare (ie, unpolished) nails.

Practice Implications

Bringing awareness to the necessity of removing nail art prior to OCT imaging is crucial because many patients partake in its application, and removal may require the involvement of a professional nail technician. If a patient can be made aware that they should remove all nail art in advance, they will be better prepared for an OCT imaging session. Such a protocol increases efficiency, decreases diagnostic delay, and reduces cost associated with multiple office visits.

Racial disparities in melanoma stage at diagnosis were less pronounced in a large cohort of Veterans Affairs patients, compared with a large cohort of U.S. men, a new analysis shows.

“The trend of a lower racial disparity in the VA in the proportion of melanomas with local disease and in the proportion of distant metastasis at presentation was observed across age groups,” wrote Martin A. Weinstock MD, PhD, and Rachel K. Lim, of the department of dermatology at Brown University, Providence, R.I., and the Center for Dermatoepidemiology at the VA Providence Healthcare System. The study was published online in the Journal of the American Academy of Dermatology.

“Melanoma was the fourth-most common cancer [diagnosed] in male VA patients in 2010,” wrote the authors, who also pointed out that “prior surveys found that 11%-13% of U.S. active-duty personnel routinely use sunscreen despite significant occupational sun exposure. Racial disparities are important concerns in the VA and elsewhere.”

To compare the stage of melanoma at presentation among White and non-Whites patients in the VA and in the general U.S. population, the researchers identified invasive cutaneous melanoma cases from 2000 to 2019 in the VA Corporate Data Warehouse and the Surveillance, Epidemiology and End Results Program (SEER).

They restricted the analysis to men because of the small proportion of women in the at-risk veteran population and excluded cases with an age younger than 20, those with unknown histology, and melanoma in situ. The researchers performed two-tailed z-tests to evaluate the difference in proportions of melanoma stages between the veteran population and the general population.

The analysis included 44,077 cases of invasive melanoma in the VA and 217,030 in SEER. Racial disparities in melanoma staging were substantially less pronounced in the VA than in SEER.

In the VA, localized disease represented 77.9% of melanomas among Whites versus 71.0% among non-Whites. But in SEER, localized disease represented 80.7% of melanomas among Whites versus 61.5% in non-Whites – over double the VA disparity (P < .0001).

Christoph Burgstedt/Science Photo Library/Getty Images

Likewise, the disparity between Whites and nonwhites observed for regional or distant metastatic disease at presentation in the VA was lower than the disparity observed in SEER. For example, in the VA, distant metastatic disease at presentation represented 6.1% of melanomas among Whites versus 8.6% among non-Whites, while in SEER it represented 4.8% of melanomas among Whites versus 11.3% in non-Whites – again, more than double the VA disparity (P < .0001).

“These differences between the VA and SEER were less marked” among those older than 65 years, the researchers wrote. “Notably, the differences between VA and SEER in racial disparities among those greater than 65 in age were still significant for localized disease and for distant metastasis.”

The findings suggest that the VA “may be more effective in reducing racial disparities in melanoma stage at diagnosis, potentially due to all patients in the VA dataset having insured access to health care, regardless of socioeconomic status,” the researchers concluded. Similarly, the decreased difference in racial disparities observed in patients older than 65 across systems “may be related to the availability of Medicare to the older general populations. The authors acknowledged several study limitations, such as the predominantly elderly and male VA population, potentially underreported utilization of non-VA dermatologic care, and variation in geographic regions covered by each database.

Travis W. Blalock, MD, director of dermatologic surgery, Mohs micrographic surgery, and cutaneous oncology at Emory University, Atlanta, who was asked to comment on the work, said in an interview he would have liked to see a more detailed breakdown of the younger patients, “for those in their 30s and 40s, to see if this trend held up.”

He would have also liked to see how the data trended over time, adding, “while this, broadly, may be good news for our veterans, attributing this finding to a reduction in access disparity or some other organizational intervention seems a little premature. Regardless, Dr. Weinstock has given us, once again, information from our veterans to probe for the betterment of all patients.”

The researchers reported having no relevant disclosures and the study had no funding. Dr. Blalock disclosed that he has served as a principal investigator for Castle Biosciences.

Racial disparities in melanoma stage at diagnosis were less pronounced in a large cohort of Veterans Affairs patients, compared with a large cohort of U.S. men, a new analysis shows.

“The trend of a lower racial disparity in the VA in the proportion of melanomas with local disease and in the proportion of distant metastasis at presentation was observed across age groups,” wrote Martin A. Weinstock MD, PhD, and Rachel K. Lim, of the department of dermatology at Brown University, Providence, R.I., and the Center for Dermatoepidemiology at the VA Providence Healthcare System. The study was published online in the Journal of the American Academy of Dermatology.

“Melanoma was the fourth-most common cancer [diagnosed] in male VA patients in 2010,” wrote the authors, who also pointed out that “prior surveys found that 11%-13% of U.S. active-duty personnel routinely use sunscreen despite significant occupational sun exposure. Racial disparities are important concerns in the VA and elsewhere.”

To compare the stage of melanoma at presentation among White and non-Whites patients in the VA and in the general U.S. population, the researchers identified invasive cutaneous melanoma cases from 2000 to 2019 in the VA Corporate Data Warehouse and the Surveillance, Epidemiology and End Results Program (SEER).

They restricted the analysis to men because of the small proportion of women in the at-risk veteran population and excluded cases with an age younger than 20, those with unknown histology, and melanoma in situ. The researchers performed two-tailed z-tests to evaluate the difference in proportions of melanoma stages between the veteran population and the general population.

The analysis included 44,077 cases of invasive melanoma in the VA and 217,030 in SEER. Racial disparities in melanoma staging were substantially less pronounced in the VA than in SEER.

In the VA, localized disease represented 77.9% of melanomas among Whites versus 71.0% among non-Whites. But in SEER, localized disease represented 80.7% of melanomas among Whites versus 61.5% in non-Whites – over double the VA disparity (P < .0001).

Christoph Burgstedt/Science Photo Library/Getty Images

Likewise, the disparity between Whites and nonwhites observed for regional or distant metastatic disease at presentation in the VA was lower than the disparity observed in SEER. For example, in the VA, distant metastatic disease at presentation represented 6.1% of melanomas among Whites versus 8.6% among non-Whites, while in SEER it represented 4.8% of melanomas among Whites versus 11.3% in non-Whites – again, more than double the VA disparity (P < .0001).

“These differences between the VA and SEER were less marked” among those older than 65 years, the researchers wrote. “Notably, the differences between VA and SEER in racial disparities among those greater than 65 in age were still significant for localized disease and for distant metastasis.”

The findings suggest that the VA “may be more effective in reducing racial disparities in melanoma stage at diagnosis, potentially due to all patients in the VA dataset having insured access to health care, regardless of socioeconomic status,” the researchers concluded. Similarly, the decreased difference in racial disparities observed in patients older than 65 across systems “may be related to the availability of Medicare to the older general populations. The authors acknowledged several study limitations, such as the predominantly elderly and male VA population, potentially underreported utilization of non-VA dermatologic care, and variation in geographic regions covered by each database.

Travis W. Blalock, MD, director of dermatologic surgery, Mohs micrographic surgery, and cutaneous oncology at Emory University, Atlanta, who was asked to comment on the work, said in an interview he would have liked to see a more detailed breakdown of the younger patients, “for those in their 30s and 40s, to see if this trend held up.”

He would have also liked to see how the data trended over time, adding, “while this, broadly, may be good news for our veterans, attributing this finding to a reduction in access disparity or some other organizational intervention seems a little premature. Regardless, Dr. Weinstock has given us, once again, information from our veterans to probe for the betterment of all patients.”

The researchers reported having no relevant disclosures and the study had no funding. Dr. Blalock disclosed that he has served as a principal investigator for Castle Biosciences.

Racial disparities in melanoma stage at diagnosis were less pronounced in a large cohort of Veterans Affairs patients, compared with a large cohort of U.S. men, a new analysis shows.

“The trend of a lower racial disparity in the VA in the proportion of melanomas with local disease and in the proportion of distant metastasis at presentation was observed across age groups,” wrote Martin A. Weinstock MD, PhD, and Rachel K. Lim, of the department of dermatology at Brown University, Providence, R.I., and the Center for Dermatoepidemiology at the VA Providence Healthcare System. The study was published online in the Journal of the American Academy of Dermatology.

“Melanoma was the fourth-most common cancer [diagnosed] in male VA patients in 2010,” wrote the authors, who also pointed out that “prior surveys found that 11%-13% of U.S. active-duty personnel routinely use sunscreen despite significant occupational sun exposure. Racial disparities are important concerns in the VA and elsewhere.”

To compare the stage of melanoma at presentation among White and non-Whites patients in the VA and in the general U.S. population, the researchers identified invasive cutaneous melanoma cases from 2000 to 2019 in the VA Corporate Data Warehouse and the Surveillance, Epidemiology and End Results Program (SEER).

They restricted the analysis to men because of the small proportion of women in the at-risk veteran population and excluded cases with an age younger than 20, those with unknown histology, and melanoma in situ. The researchers performed two-tailed z-tests to evaluate the difference in proportions of melanoma stages between the veteran population and the general population.

The analysis included 44,077 cases of invasive melanoma in the VA and 217,030 in SEER. Racial disparities in melanoma staging were substantially less pronounced in the VA than in SEER.

In the VA, localized disease represented 77.9% of melanomas among Whites versus 71.0% among non-Whites. But in SEER, localized disease represented 80.7% of melanomas among Whites versus 61.5% in non-Whites – over double the VA disparity (P < .0001).

Christoph Burgstedt/Science Photo Library/Getty Images

Likewise, the disparity between Whites and nonwhites observed for regional or distant metastatic disease at presentation in the VA was lower than the disparity observed in SEER. For example, in the VA, distant metastatic disease at presentation represented 6.1% of melanomas among Whites versus 8.6% among non-Whites, while in SEER it represented 4.8% of melanomas among Whites versus 11.3% in non-Whites – again, more than double the VA disparity (P < .0001).

“These differences between the VA and SEER were less marked” among those older than 65 years, the researchers wrote. “Notably, the differences between VA and SEER in racial disparities among those greater than 65 in age were still significant for localized disease and for distant metastasis.”

The findings suggest that the VA “may be more effective in reducing racial disparities in melanoma stage at diagnosis, potentially due to all patients in the VA dataset having insured access to health care, regardless of socioeconomic status,” the researchers concluded. Similarly, the decreased difference in racial disparities observed in patients older than 65 across systems “may be related to the availability of Medicare to the older general populations. The authors acknowledged several study limitations, such as the predominantly elderly and male VA population, potentially underreported utilization of non-VA dermatologic care, and variation in geographic regions covered by each database.

Travis W. Blalock, MD, director of dermatologic surgery, Mohs micrographic surgery, and cutaneous oncology at Emory University, Atlanta, who was asked to comment on the work, said in an interview he would have liked to see a more detailed breakdown of the younger patients, “for those in their 30s and 40s, to see if this trend held up.”

He would have also liked to see how the data trended over time, adding, “while this, broadly, may be good news for our veterans, attributing this finding to a reduction in access disparity or some other organizational intervention seems a little premature. Regardless, Dr. Weinstock has given us, once again, information from our veterans to probe for the betterment of all patients.”

The researchers reported having no relevant disclosures and the study had no funding. Dr. Blalock disclosed that he has served as a principal investigator for Castle Biosciences.

Continuous glucose monitors (CGMs) could enhance care of hospitalized people with diabetes, supplementing or possibly even replacing the use of finger sticks to draw blood to measure a patient’s glucose level. But that technological future will require ensuring that the monitoring devices are as accurate as the conventional method, experts told this news organization.

In 2020, the U.S. Food and Drug Administration enabled in-hospital use of CGMs to reduce contact between patients and health care providers during the COVID-19 pandemic. Diabetes is a risk factor for more severe COVID, meaning that many patients with the infection also required ongoing care for their blood sugar problems. 

Prior to the pandemic, in-person finger-stick tests were the primary means of measuring glucose for hospitalized patients with diabetes.

The trouble is that finger-stick measurements quickly become inaccurate.

“Glucose is a measurement that changes pretty rapidly,” said Eileen Faulds, RN, PhD, an endocrinology nurse and health services researcher at the Ohio State University, Columbus. Finger sticks might occur only four or five times per day, Dr. Faulds noted, or as often as every hour for people who receive insulin intravenously. But even that more frequent pace is far from continuous.

“With CGM we can get the glucose level in real time,” Dr. Faulds said. 

Dr. Faulds is lead author of a new study in the Journal of Diabetes Science and Technology, which shows that nurses in the ICU believe that using continuous monitors, subcutaneous filaments connected to sensors that regularly report glucose levels, enables better patient care than does relying on periodic glucose tests alone. Nurses still used traditional finger sticks, which Dr. Faulds notes are highly accurate at the time of the reading.

In a 2022 study, glucose levels generated by CGM and those measured by finger sticks varied by up to 14%. A hybrid care model combining CGMs and finger stick tests may emerge, Dr. Faulds said.
 

A gusher of glucose data

People with diabetes have long been able to use CGMs in their daily lives, which typically report the glucose value to a smartphone or watch. The devices are now part of hospital care as well. In 2022, the Food and Drug Administration granted a breakthrough therapy designation to the company Dexcom for use of its CGMs to manage care of people with diabetes in hospitals.

One open question is how often CGMs should report glucose readings for optimum patient health. Dexcom’s G6 CGM reports glucose levels every five minutes, for example, whereas Abbott’s FreeStyle Libre 2 delivers glucose values every minute. 

“We wouldn’t look at each value, we would look at the big picture,” to determine if a patient is at risk of becoming hyper- or hypoglycemic, said Lizda Guerrero-Arroyo, MD, a postdoctoral fellow in endocrinology at the Emory University School of Medicine, Atlanta. Dr. Guerrero-Arroyo recently reported that clinicians in multiple ICUs began to use CGMs in conjunction with finger sticks during the pandemic and felt the devices could reduce patient discomfort. 

“A finger stick is very painful,” Dr. Guerrero-Arroyo said, and a bottleneck for nursing staff who administer these tests. In contrast, Dr. Faulds said, CGM placement is essentially painless and requires less labor on the ward to manage.

Beyond use in the ICU, clinicians are also experimenting with use of CGMs to monitor blood sugar levels in people with diabetes who are undergoing general surgery. And other researchers are describing how to integrate data from CGMs into patient care tools such as the electronic health record, although a standard way to do this does not yet exist.

Assuming CGMs remain part of the mix for in-hospital care of people with diabetes, clinicians may mainly need trend summaries of how glucose levels rise and fall over time, said data scientist Samantha Spierling Bagsic, PhD, of the Scripps Whittier Diabetes Institute, San Diego. Dr. Guerrero-Arroyo said that she shares that vision. But a minute-by-minute analysis of glucose levels also may be necessary to get a granular sense of how changing a patient’s insulin level affects their blood sugar, Dr. Spierling Bagsic said.

“We need to figure out what data different audiences need, how often we need to measure glucose, and how to present that information to different audiences in different ways,” said Dr. Spierling Bagsic, a co-author of the study about integrating CGM data into patient care tools.

The wider use of CGMs in hospitals may be one silver lining of the COVID-19 pandemic. As an inpatient endocrinology nurse, Dr. Faulds said that she wanted to use CGMs prior to the outbreak, but at that point, a critical mass of studies about their benefits was missing.

“We all know the terrible things that happened during the pandemic,” Dr. Faulds said. “But it gave us the allowance to use CGMs, and we saw that nurses loved them.”

Dr. Faulds reports relationships with Dexcom and Insulet and has received an honorarium from Medscape. Dr. Guerrero-Arroyo and Dr. Spierling Bagsic reported no financial conflicts of interest.

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

Continuous glucose monitors (CGMs) could enhance care of hospitalized people with diabetes, supplementing or possibly even replacing the use of finger sticks to draw blood to measure a patient’s glucose level. But that technological future will require ensuring that the monitoring devices are as accurate as the conventional method, experts told this news organization.

In 2020, the U.S. Food and Drug Administration enabled in-hospital use of CGMs to reduce contact between patients and health care providers during the COVID-19 pandemic. Diabetes is a risk factor for more severe COVID, meaning that many patients with the infection also required ongoing care for their blood sugar problems. 

Prior to the pandemic, in-person finger-stick tests were the primary means of measuring glucose for hospitalized patients with diabetes.

The trouble is that finger-stick measurements quickly become inaccurate.

“Glucose is a measurement that changes pretty rapidly,” said Eileen Faulds, RN, PhD, an endocrinology nurse and health services researcher at the Ohio State University, Columbus. Finger sticks might occur only four or five times per day, Dr. Faulds noted, or as often as every hour for people who receive insulin intravenously. But even that more frequent pace is far from continuous.

“With CGM we can get the glucose level in real time,” Dr. Faulds said. 

Dr. Faulds is lead author of a new study in the Journal of Diabetes Science and Technology, which shows that nurses in the ICU believe that using continuous monitors, subcutaneous filaments connected to sensors that regularly report glucose levels, enables better patient care than does relying on periodic glucose tests alone. Nurses still used traditional finger sticks, which Dr. Faulds notes are highly accurate at the time of the reading.

In a 2022 study, glucose levels generated by CGM and those measured by finger sticks varied by up to 14%. A hybrid care model combining CGMs and finger stick tests may emerge, Dr. Faulds said.
 

A gusher of glucose data

People with diabetes have long been able to use CGMs in their daily lives, which typically report the glucose value to a smartphone or watch. The devices are now part of hospital care as well. In 2022, the Food and Drug Administration granted a breakthrough therapy designation to the company Dexcom for use of its CGMs to manage care of people with diabetes in hospitals.

One open question is how often CGMs should report glucose readings for optimum patient health. Dexcom’s G6 CGM reports glucose levels every five minutes, for example, whereas Abbott’s FreeStyle Libre 2 delivers glucose values every minute. 

“We wouldn’t look at each value, we would look at the big picture,” to determine if a patient is at risk of becoming hyper- or hypoglycemic, said Lizda Guerrero-Arroyo, MD, a postdoctoral fellow in endocrinology at the Emory University School of Medicine, Atlanta. Dr. Guerrero-Arroyo recently reported that clinicians in multiple ICUs began to use CGMs in conjunction with finger sticks during the pandemic and felt the devices could reduce patient discomfort. 

“A finger stick is very painful,” Dr. Guerrero-Arroyo said, and a bottleneck for nursing staff who administer these tests. In contrast, Dr. Faulds said, CGM placement is essentially painless and requires less labor on the ward to manage.

Beyond use in the ICU, clinicians are also experimenting with use of CGMs to monitor blood sugar levels in people with diabetes who are undergoing general surgery. And other researchers are describing how to integrate data from CGMs into patient care tools such as the electronic health record, although a standard way to do this does not yet exist.

Assuming CGMs remain part of the mix for in-hospital care of people with diabetes, clinicians may mainly need trend summaries of how glucose levels rise and fall over time, said data scientist Samantha Spierling Bagsic, PhD, of the Scripps Whittier Diabetes Institute, San Diego. Dr. Guerrero-Arroyo said that she shares that vision. But a minute-by-minute analysis of glucose levels also may be necessary to get a granular sense of how changing a patient’s insulin level affects their blood sugar, Dr. Spierling Bagsic said.

“We need to figure out what data different audiences need, how often we need to measure glucose, and how to present that information to different audiences in different ways,” said Dr. Spierling Bagsic, a co-author of the study about integrating CGM data into patient care tools.

The wider use of CGMs in hospitals may be one silver lining of the COVID-19 pandemic. As an inpatient endocrinology nurse, Dr. Faulds said that she wanted to use CGMs prior to the outbreak, but at that point, a critical mass of studies about their benefits was missing.

“We all know the terrible things that happened during the pandemic,” Dr. Faulds said. “But it gave us the allowance to use CGMs, and we saw that nurses loved them.”

Dr. Faulds reports relationships with Dexcom and Insulet and has received an honorarium from Medscape. Dr. Guerrero-Arroyo and Dr. Spierling Bagsic reported no financial conflicts of interest.

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

Continuous glucose monitors (CGMs) could enhance care of hospitalized people with diabetes, supplementing or possibly even replacing the use of finger sticks to draw blood to measure a patient’s glucose level. But that technological future will require ensuring that the monitoring devices are as accurate as the conventional method, experts told this news organization.

In 2020, the U.S. Food and Drug Administration enabled in-hospital use of CGMs to reduce contact between patients and health care providers during the COVID-19 pandemic. Diabetes is a risk factor for more severe COVID, meaning that many patients with the infection also required ongoing care for their blood sugar problems. 

Prior to the pandemic, in-person finger-stick tests were the primary means of measuring glucose for hospitalized patients with diabetes.

The trouble is that finger-stick measurements quickly become inaccurate.

“Glucose is a measurement that changes pretty rapidly,” said Eileen Faulds, RN, PhD, an endocrinology nurse and health services researcher at the Ohio State University, Columbus. Finger sticks might occur only four or five times per day, Dr. Faulds noted, or as often as every hour for people who receive insulin intravenously. But even that more frequent pace is far from continuous.

“With CGM we can get the glucose level in real time,” Dr. Faulds said. 

Dr. Faulds is lead author of a new study in the Journal of Diabetes Science and Technology, which shows that nurses in the ICU believe that using continuous monitors, subcutaneous filaments connected to sensors that regularly report glucose levels, enables better patient care than does relying on periodic glucose tests alone. Nurses still used traditional finger sticks, which Dr. Faulds notes are highly accurate at the time of the reading.

In a 2022 study, glucose levels generated by CGM and those measured by finger sticks varied by up to 14%. A hybrid care model combining CGMs and finger stick tests may emerge, Dr. Faulds said.
 

A gusher of glucose data

People with diabetes have long been able to use CGMs in their daily lives, which typically report the glucose value to a smartphone or watch. The devices are now part of hospital care as well. In 2022, the Food and Drug Administration granted a breakthrough therapy designation to the company Dexcom for use of its CGMs to manage care of people with diabetes in hospitals.

One open question is how often CGMs should report glucose readings for optimum patient health. Dexcom’s G6 CGM reports glucose levels every five minutes, for example, whereas Abbott’s FreeStyle Libre 2 delivers glucose values every minute. 

“We wouldn’t look at each value, we would look at the big picture,” to determine if a patient is at risk of becoming hyper- or hypoglycemic, said Lizda Guerrero-Arroyo, MD, a postdoctoral fellow in endocrinology at the Emory University School of Medicine, Atlanta. Dr. Guerrero-Arroyo recently reported that clinicians in multiple ICUs began to use CGMs in conjunction with finger sticks during the pandemic and felt the devices could reduce patient discomfort. 

“A finger stick is very painful,” Dr. Guerrero-Arroyo said, and a bottleneck for nursing staff who administer these tests. In contrast, Dr. Faulds said, CGM placement is essentially painless and requires less labor on the ward to manage.

Beyond use in the ICU, clinicians are also experimenting with use of CGMs to monitor blood sugar levels in people with diabetes who are undergoing general surgery. And other researchers are describing how to integrate data from CGMs into patient care tools such as the electronic health record, although a standard way to do this does not yet exist.

Assuming CGMs remain part of the mix for in-hospital care of people with diabetes, clinicians may mainly need trend summaries of how glucose levels rise and fall over time, said data scientist Samantha Spierling Bagsic, PhD, of the Scripps Whittier Diabetes Institute, San Diego. Dr. Guerrero-Arroyo said that she shares that vision. But a minute-by-minute analysis of glucose levels also may be necessary to get a granular sense of how changing a patient’s insulin level affects their blood sugar, Dr. Spierling Bagsic said.

“We need to figure out what data different audiences need, how often we need to measure glucose, and how to present that information to different audiences in different ways,” said Dr. Spierling Bagsic, a co-author of the study about integrating CGM data into patient care tools.

The wider use of CGMs in hospitals may be one silver lining of the COVID-19 pandemic. As an inpatient endocrinology nurse, Dr. Faulds said that she wanted to use CGMs prior to the outbreak, but at that point, a critical mass of studies about their benefits was missing.

“We all know the terrible things that happened during the pandemic,” Dr. Faulds said. “But it gave us the allowance to use CGMs, and we saw that nurses loved them.”

Dr. Faulds reports relationships with Dexcom and Insulet and has received an honorarium from Medscape. Dr. Guerrero-Arroyo and Dr. Spierling Bagsic reported no financial conflicts of interest.

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