For Residents

Primary extramammary Paget disease (EMPD) is an adnexal carcinoma of the apocrine gland ducts that presents as an erythematous patch on cutaneous sites rich with apocrine glands.¹ Primary EMPD can be in situ or invasive with the potential to become metastatic.² Treatment of primary EMPD is challenging due to the difficulty of achieving clear surgical margins, as the tumor has microscopic spread throughout the epidermis in a skipping fashion.³ Mohs micrographic surgery is the treatment of choice; however, there is a clinical need to identify additional treatment modalities, especially for patients with unresectable, invasive, or metastatic primary EMPD,⁴ which partly is due to lack of data to understand the pathogenesis of primary EMPD. Recently, there have been studies investigating the genetic characteristics of EMPD tumors. The interaction between the programmed cell death receptor 1 (PD-1) and its ligand (PD-L1) is one of the pathways recently studied and has been reported to be a potential target in EMPD.^5-7 Programmed cell death receptor 1 signaling constitutes an immune checkpoint pathway that regulates the activation of tumor-specific T cells.⁸ In several malignancies, cancer cells express PD-L1 on their surface to activate PD-1 signaling in T cells as a mechanism to dampen the tumor-specific immune response and evade antitumor immunity.⁹ Thus, blocking PD-1 signaling widely is used to activate tumor-specific T cells and decrease tumor burden.¹⁰ Given the advances of immunotherapy in many neoplasms and the paucity of effective agents to treat EMPD, this article serves to shed light on recent data studying PD-1 signaling in EMPD and highlights the potential clinical use of immunotherapy for EMPD.

EMPD and Its Subtypes

Extramammary Paget disease is a rare adenocarcinoma typically affecting older patients (age >60 years) in cutaneous sites with abundant apocrine glands such as the genital and perianal skin.³ Extramammary Paget disease presents as an erythematous patch and frequently is treated initially as a skin dermatosis, resulting in a delay in diagnosis. Histologically, EMPD is characterized by the presence of single cells or a nest of cells having abundant pale cytoplasm and large vesicular nuclei distributed in the epidermis in a pagetoid fashion.¹¹

Extramammary Paget disease can be primary or secondary; the 2 subtypes behave differently both clinically and prognostically. Although primary EMPD is considered to be an adnexal carcinoma of the apocrine gland ducts, secondary EMPD is considered to be an intraepithelial extension of malignant cells from an underlying internal neoplasm.¹² The underlying malignancies usually are located within dermal adnexal glands or organs in the vicinity of the cutaneous lesion, such as the colon in the case of perianal EMPD. Histologically, primary and secondary EMPD can be differentiated based on their immunophenotypic staining profiles. Although all cases of EMPD show positive immunohistochemistry staining for cytokeratin 7, carcinoembryonic antigen, and epithelial membrane antigen, only primary EMPD will additionally stain for GCDFP-15 (gross cystic disease fluid protein 15) and GATA.¹¹ Regardless of the immunohistochemistry stains, every patient newly diagnosed with EMPD deserves a full workup for malignancy screening, including a colonoscopy, cystoscopy, mammography and Papanicolaou test in women, pelvic ultrasound, and computed tomography of the abdomen and pelvis.¹³

The first-line treatment of EMPD is surgery; however, obtaining clear surgical margins can be a challenge, with high recurrence rates due to the microscopic spread of the disease throughout the epidermis.⁴ In addition, anatomic location affects the surgical approach and patient survival. Recent studies on EMPD mortality outcomes in women show that mortality is higher in patients with vaginal EMPD than in those with vulvar/labial EMPD, partly due to the sensitive location that makes it difficult to perform wide local excisions.^13,14 Assessing the entire margins with tissue preservation using Mohs micrographic surgery has been shown to be successful in decreasing the recurrence rate, especially when coupled with the use of cytokeratin 7 immunohistochemistry.⁴ Other treatment modalities include radiation, topical imiquimod, and photodynamic therapy.^15,16 Regardless of treatment modality, EMPD requires long‐term follow-up to monitor for disease recurrence, regional lymphadenopathy, distant metastasis, or development of an internal malignancy.

The pathogenesis of primary EMPD remains unclear. The tumor is thought to be derived from Toker cells, which are pluripotent adnexal stem cells located in the epidermis that normally give rise to apocrine glands.¹⁷ There have been few studies investigating the genetic characteristics of EMPD lesions in an attempt to understand pathogenesis as well as to find druggable targets. Current data for targeted therapy have focused on HER2 (human epidermal growth factor receptor 2) hormone receptor expression,¹⁸ ERBB (erythroblastic oncogene B) amplification,¹⁹ CDK4 (cyclin-dependent kinase 4)–cyclin D1 signaling,²⁰ and most recently PD-1/PD-L1 pathway.^5-7

PD-1 Expression in EMPD: Implication for Immunotherapy

Most tumors display novel antigens that are recognized by the host immune system and thus stimulate cell-mediated and humoral pathways. The immune system naturally provides regulatory immune checkpoints to T cell–mediated immune responses. One of these checkpoints involves the interaction between PD-1 on T cells and its ligand PD-L1 on tumor cells.²¹ When PD-1 binds to PD-L1 on tumor cells, there is inhibition of T-cell proliferation, a decrease in cytokine production, and induction of T-cell cytolysis.²² The Figure summarizes the dynamics for T-cell regulation.

Naturally, tumor-infiltrating T cells trigger their own inhibition by binding to PD-L1. However, certain tumor cells constitutively upregulate the expression of PD-L1. With that, the tumor cells gain the ability to suppress T cells and avoid T cell–mediated cytotoxicity,²³ which is known as the adoptive immune resistance mechanism. There have been several studies in the literature investigating the PD-1 signaling pathway in EMPD as a way to determine if EMPD would be susceptible to immune checkpoint blockade. The success of checkpoint inhibitor immunotherapy generally correlates with increased PD-L1 expression by tumor cells.

One study evaluated the expression of PD-L1 in tumor cells and tumor-infiltrating T cells in 18 cases of EMPD.⁶ The authors identified that even though tumor cell PD-L1 expression was detected in only 3 (17%) cases, tumor-infiltrating lymphocytes expressed PD-L1 in the majority of the cases analyzed and in all of the cases positive for tumor cell PD-L1.⁶

Another study evaluated PD-1 and PD-L1 expression in EMPD tumor cells and tumor-associated immune infiltrate.⁵ They found that PD-1 was expressed heavily by the tumor-associated immune infiltrate in all EMPD cases analyzed. Similar to the previously mentioned study,⁶ PD-L1 was expressed by tumor cells in a few cases only. Interestingly, they found that the density of CD3 in the tumor-associated immune infiltrate was significantly (P=.049) higher in patients who were alive than in those who died, suggesting the importance of an exuberant T-cell response for survival in EMPD.⁵

A third study investigated protein expression of the B7 family members as well as PD-1 and PD-L1/2 in 55 EMPD samples. In this study the authors also found that tumor cell PD-L1 was minimal. Interestingly, they also found that tumor cells expressed B7 proteins in the majority of the cases.⁷

Finally, another study examined activity levels of T cells in EMPD by measuring the number and expression levels of cytotoxic T-cell cytokines.²⁴ The authors first found that EMPD tumors had a significantly higher number of CD8⁺ tumor-infiltrating lymphocytes compared to peripheral blood (P<.01). These CD8⁺ tumor-infiltrating lymphocytes also had a significantly higher expression of PD-1 (P<.01). They also found that tumor cells produced an immunosuppressive molecule called indoleamine 2,3-dyoxygenae that functions by suppressing T-cell activity levels. They concluded that in EMPD, tumor-specific T lymphocytes have an exhausted phenotype due to PD-1 activation as well as indoleamine 2,3-dyoxygenase release to the tumor microenvironment.²⁴

These studies highlight that restoring the effector functions of tumor-specific T lymphocytes could be an effective treatment strategy for EMPD. In fact, immunotherapy has been used with success for EMPD in the form of topical immunomodulators such as imiquimod.^16,25 More than 40 cases of EMPD treated with imiquimod 5% have been published; of these, only 6 were considered nonresponders,⁵ which suggests that EMPD may respond to other immunotherapies such as checkpoint inhibitors. It is an exciting time for immunotherapy as more checkpoint inhibitors are being developed. Among the newer agents is cemiplimab, which is a PD-1 inhibitor now US Food and Drug Administration approved for the treatment of locally advanced or metastatic cutaneous squamous cell carcinoma in patients who are not candidates for curative surgery or curative radiation.²⁶ Programmed cell death receptor 1 signaling can serve as a potential target in EMPD, and further studies need to be performed to test the clinical efficacy, especially in unresectable or invasive/metastatic EMPD. As the PD-1 pathway is more studied in EMPD, and as more PD-1 inhibitors get developed, it would be a clinical need to establish clinical studies for PD-1 inhibitors in EMPD.

Primary extramammary Paget disease (EMPD) is an adnexal carcinoma of the apocrine gland ducts that presents as an erythematous patch on cutaneous sites rich with apocrine glands.¹ Primary EMPD can be in situ or invasive with the potential to become metastatic.² Treatment of primary EMPD is challenging due to the difficulty of achieving clear surgical margins, as the tumor has microscopic spread throughout the epidermis in a skipping fashion.³ Mohs micrographic surgery is the treatment of choice; however, there is a clinical need to identify additional treatment modalities, especially for patients with unresectable, invasive, or metastatic primary EMPD,⁴ which partly is due to lack of data to understand the pathogenesis of primary EMPD. Recently, there have been studies investigating the genetic characteristics of EMPD tumors. The interaction between the programmed cell death receptor 1 (PD-1) and its ligand (PD-L1) is one of the pathways recently studied and has been reported to be a potential target in EMPD.^5-7 Programmed cell death receptor 1 signaling constitutes an immune checkpoint pathway that regulates the activation of tumor-specific T cells.⁸ In several malignancies, cancer cells express PD-L1 on their surface to activate PD-1 signaling in T cells as a mechanism to dampen the tumor-specific immune response and evade antitumor immunity.⁹ Thus, blocking PD-1 signaling widely is used to activate tumor-specific T cells and decrease tumor burden.¹⁰ Given the advances of immunotherapy in many neoplasms and the paucity of effective agents to treat EMPD, this article serves to shed light on recent data studying PD-1 signaling in EMPD and highlights the potential clinical use of immunotherapy for EMPD.

EMPD and Its Subtypes

Extramammary Paget disease is a rare adenocarcinoma typically affecting older patients (age >60 years) in cutaneous sites with abundant apocrine glands such as the genital and perianal skin.³ Extramammary Paget disease presents as an erythematous patch and frequently is treated initially as a skin dermatosis, resulting in a delay in diagnosis. Histologically, EMPD is characterized by the presence of single cells or a nest of cells having abundant pale cytoplasm and large vesicular nuclei distributed in the epidermis in a pagetoid fashion.¹¹

Extramammary Paget disease can be primary or secondary; the 2 subtypes behave differently both clinically and prognostically. Although primary EMPD is considered to be an adnexal carcinoma of the apocrine gland ducts, secondary EMPD is considered to be an intraepithelial extension of malignant cells from an underlying internal neoplasm.¹² The underlying malignancies usually are located within dermal adnexal glands or organs in the vicinity of the cutaneous lesion, such as the colon in the case of perianal EMPD. Histologically, primary and secondary EMPD can be differentiated based on their immunophenotypic staining profiles. Although all cases of EMPD show positive immunohistochemistry staining for cytokeratin 7, carcinoembryonic antigen, and epithelial membrane antigen, only primary EMPD will additionally stain for GCDFP-15 (gross cystic disease fluid protein 15) and GATA.¹¹ Regardless of the immunohistochemistry stains, every patient newly diagnosed with EMPD deserves a full workup for malignancy screening, including a colonoscopy, cystoscopy, mammography and Papanicolaou test in women, pelvic ultrasound, and computed tomography of the abdomen and pelvis.¹³

The first-line treatment of EMPD is surgery; however, obtaining clear surgical margins can be a challenge, with high recurrence rates due to the microscopic spread of the disease throughout the epidermis.⁴ In addition, anatomic location affects the surgical approach and patient survival. Recent studies on EMPD mortality outcomes in women show that mortality is higher in patients with vaginal EMPD than in those with vulvar/labial EMPD, partly due to the sensitive location that makes it difficult to perform wide local excisions.^13,14 Assessing the entire margins with tissue preservation using Mohs micrographic surgery has been shown to be successful in decreasing the recurrence rate, especially when coupled with the use of cytokeratin 7 immunohistochemistry.⁴ Other treatment modalities include radiation, topical imiquimod, and photodynamic therapy.^15,16 Regardless of treatment modality, EMPD requires long‐term follow-up to monitor for disease recurrence, regional lymphadenopathy, distant metastasis, or development of an internal malignancy.

The pathogenesis of primary EMPD remains unclear. The tumor is thought to be derived from Toker cells, which are pluripotent adnexal stem cells located in the epidermis that normally give rise to apocrine glands.¹⁷ There have been few studies investigating the genetic characteristics of EMPD lesions in an attempt to understand pathogenesis as well as to find druggable targets. Current data for targeted therapy have focused on HER2 (human epidermal growth factor receptor 2) hormone receptor expression,¹⁸ ERBB (erythroblastic oncogene B) amplification,¹⁹ CDK4 (cyclin-dependent kinase 4)–cyclin D1 signaling,²⁰ and most recently PD-1/PD-L1 pathway.^5-7

PD-1 Expression in EMPD: Implication for Immunotherapy

Most tumors display novel antigens that are recognized by the host immune system and thus stimulate cell-mediated and humoral pathways. The immune system naturally provides regulatory immune checkpoints to T cell–mediated immune responses. One of these checkpoints involves the interaction between PD-1 on T cells and its ligand PD-L1 on tumor cells.²¹ When PD-1 binds to PD-L1 on tumor cells, there is inhibition of T-cell proliferation, a decrease in cytokine production, and induction of T-cell cytolysis.²² The Figure summarizes the dynamics for T-cell regulation.

Naturally, tumor-infiltrating T cells trigger their own inhibition by binding to PD-L1. However, certain tumor cells constitutively upregulate the expression of PD-L1. With that, the tumor cells gain the ability to suppress T cells and avoid T cell–mediated cytotoxicity,²³ which is known as the adoptive immune resistance mechanism. There have been several studies in the literature investigating the PD-1 signaling pathway in EMPD as a way to determine if EMPD would be susceptible to immune checkpoint blockade. The success of checkpoint inhibitor immunotherapy generally correlates with increased PD-L1 expression by tumor cells.

One study evaluated the expression of PD-L1 in tumor cells and tumor-infiltrating T cells in 18 cases of EMPD.⁶ The authors identified that even though tumor cell PD-L1 expression was detected in only 3 (17%) cases, tumor-infiltrating lymphocytes expressed PD-L1 in the majority of the cases analyzed and in all of the cases positive for tumor cell PD-L1.⁶

Another study evaluated PD-1 and PD-L1 expression in EMPD tumor cells and tumor-associated immune infiltrate.⁵ They found that PD-1 was expressed heavily by the tumor-associated immune infiltrate in all EMPD cases analyzed. Similar to the previously mentioned study,⁶ PD-L1 was expressed by tumor cells in a few cases only. Interestingly, they found that the density of CD3 in the tumor-associated immune infiltrate was significantly (P=.049) higher in patients who were alive than in those who died, suggesting the importance of an exuberant T-cell response for survival in EMPD.⁵

A third study investigated protein expression of the B7 family members as well as PD-1 and PD-L1/2 in 55 EMPD samples. In this study the authors also found that tumor cell PD-L1 was minimal. Interestingly, they also found that tumor cells expressed B7 proteins in the majority of the cases.⁷

Finally, another study examined activity levels of T cells in EMPD by measuring the number and expression levels of cytotoxic T-cell cytokines.²⁴ The authors first found that EMPD tumors had a significantly higher number of CD8⁺ tumor-infiltrating lymphocytes compared to peripheral blood (P<.01). These CD8⁺ tumor-infiltrating lymphocytes also had a significantly higher expression of PD-1 (P<.01). They also found that tumor cells produced an immunosuppressive molecule called indoleamine 2,3-dyoxygenae that functions by suppressing T-cell activity levels. They concluded that in EMPD, tumor-specific T lymphocytes have an exhausted phenotype due to PD-1 activation as well as indoleamine 2,3-dyoxygenase release to the tumor microenvironment.²⁴

These studies highlight that restoring the effector functions of tumor-specific T lymphocytes could be an effective treatment strategy for EMPD. In fact, immunotherapy has been used with success for EMPD in the form of topical immunomodulators such as imiquimod.^16,25 More than 40 cases of EMPD treated with imiquimod 5% have been published; of these, only 6 were considered nonresponders,⁵ which suggests that EMPD may respond to other immunotherapies such as checkpoint inhibitors. It is an exciting time for immunotherapy as more checkpoint inhibitors are being developed. Among the newer agents is cemiplimab, which is a PD-1 inhibitor now US Food and Drug Administration approved for the treatment of locally advanced or metastatic cutaneous squamous cell carcinoma in patients who are not candidates for curative surgery or curative radiation.²⁶ Programmed cell death receptor 1 signaling can serve as a potential target in EMPD, and further studies need to be performed to test the clinical efficacy, especially in unresectable or invasive/metastatic EMPD. As the PD-1 pathway is more studied in EMPD, and as more PD-1 inhibitors get developed, it would be a clinical need to establish clinical studies for PD-1 inhibitors in EMPD.

Primary extramammary Paget disease (EMPD) is an adnexal carcinoma of the apocrine gland ducts that presents as an erythematous patch on cutaneous sites rich with apocrine glands.¹ Primary EMPD can be in situ or invasive with the potential to become metastatic.² Treatment of primary EMPD is challenging due to the difficulty of achieving clear surgical margins, as the tumor has microscopic spread throughout the epidermis in a skipping fashion.³ Mohs micrographic surgery is the treatment of choice; however, there is a clinical need to identify additional treatment modalities, especially for patients with unresectable, invasive, or metastatic primary EMPD,⁴ which partly is due to lack of data to understand the pathogenesis of primary EMPD. Recently, there have been studies investigating the genetic characteristics of EMPD tumors. The interaction between the programmed cell death receptor 1 (PD-1) and its ligand (PD-L1) is one of the pathways recently studied and has been reported to be a potential target in EMPD.^5-7 Programmed cell death receptor 1 signaling constitutes an immune checkpoint pathway that regulates the activation of tumor-specific T cells.⁸ In several malignancies, cancer cells express PD-L1 on their surface to activate PD-1 signaling in T cells as a mechanism to dampen the tumor-specific immune response and evade antitumor immunity.⁹ Thus, blocking PD-1 signaling widely is used to activate tumor-specific T cells and decrease tumor burden.¹⁰ Given the advances of immunotherapy in many neoplasms and the paucity of effective agents to treat EMPD, this article serves to shed light on recent data studying PD-1 signaling in EMPD and highlights the potential clinical use of immunotherapy for EMPD.

EMPD and Its Subtypes

Extramammary Paget disease is a rare adenocarcinoma typically affecting older patients (age >60 years) in cutaneous sites with abundant apocrine glands such as the genital and perianal skin.³ Extramammary Paget disease presents as an erythematous patch and frequently is treated initially as a skin dermatosis, resulting in a delay in diagnosis. Histologically, EMPD is characterized by the presence of single cells or a nest of cells having abundant pale cytoplasm and large vesicular nuclei distributed in the epidermis in a pagetoid fashion.¹¹

Extramammary Paget disease can be primary or secondary; the 2 subtypes behave differently both clinically and prognostically. Although primary EMPD is considered to be an adnexal carcinoma of the apocrine gland ducts, secondary EMPD is considered to be an intraepithelial extension of malignant cells from an underlying internal neoplasm.¹² The underlying malignancies usually are located within dermal adnexal glands or organs in the vicinity of the cutaneous lesion, such as the colon in the case of perianal EMPD. Histologically, primary and secondary EMPD can be differentiated based on their immunophenotypic staining profiles. Although all cases of EMPD show positive immunohistochemistry staining for cytokeratin 7, carcinoembryonic antigen, and epithelial membrane antigen, only primary EMPD will additionally stain for GCDFP-15 (gross cystic disease fluid protein 15) and GATA.¹¹ Regardless of the immunohistochemistry stains, every patient newly diagnosed with EMPD deserves a full workup for malignancy screening, including a colonoscopy, cystoscopy, mammography and Papanicolaou test in women, pelvic ultrasound, and computed tomography of the abdomen and pelvis.¹³

The first-line treatment of EMPD is surgery; however, obtaining clear surgical margins can be a challenge, with high recurrence rates due to the microscopic spread of the disease throughout the epidermis.⁴ In addition, anatomic location affects the surgical approach and patient survival. Recent studies on EMPD mortality outcomes in women show that mortality is higher in patients with vaginal EMPD than in those with vulvar/labial EMPD, partly due to the sensitive location that makes it difficult to perform wide local excisions.^13,14 Assessing the entire margins with tissue preservation using Mohs micrographic surgery has been shown to be successful in decreasing the recurrence rate, especially when coupled with the use of cytokeratin 7 immunohistochemistry.⁴ Other treatment modalities include radiation, topical imiquimod, and photodynamic therapy.^15,16 Regardless of treatment modality, EMPD requires long‐term follow-up to monitor for disease recurrence, regional lymphadenopathy, distant metastasis, or development of an internal malignancy.

The pathogenesis of primary EMPD remains unclear. The tumor is thought to be derived from Toker cells, which are pluripotent adnexal stem cells located in the epidermis that normally give rise to apocrine glands.¹⁷ There have been few studies investigating the genetic characteristics of EMPD lesions in an attempt to understand pathogenesis as well as to find druggable targets. Current data for targeted therapy have focused on HER2 (human epidermal growth factor receptor 2) hormone receptor expression,¹⁸ ERBB (erythroblastic oncogene B) amplification,¹⁹ CDK4 (cyclin-dependent kinase 4)–cyclin D1 signaling,²⁰ and most recently PD-1/PD-L1 pathway.^5-7

PD-1 Expression in EMPD: Implication for Immunotherapy

Most tumors display novel antigens that are recognized by the host immune system and thus stimulate cell-mediated and humoral pathways. The immune system naturally provides regulatory immune checkpoints to T cell–mediated immune responses. One of these checkpoints involves the interaction between PD-1 on T cells and its ligand PD-L1 on tumor cells.²¹ When PD-1 binds to PD-L1 on tumor cells, there is inhibition of T-cell proliferation, a decrease in cytokine production, and induction of T-cell cytolysis.²² The Figure summarizes the dynamics for T-cell regulation.

Naturally, tumor-infiltrating T cells trigger their own inhibition by binding to PD-L1. However, certain tumor cells constitutively upregulate the expression of PD-L1. With that, the tumor cells gain the ability to suppress T cells and avoid T cell–mediated cytotoxicity,²³ which is known as the adoptive immune resistance mechanism. There have been several studies in the literature investigating the PD-1 signaling pathway in EMPD as a way to determine if EMPD would be susceptible to immune checkpoint blockade. The success of checkpoint inhibitor immunotherapy generally correlates with increased PD-L1 expression by tumor cells.

One study evaluated the expression of PD-L1 in tumor cells and tumor-infiltrating T cells in 18 cases of EMPD.⁶ The authors identified that even though tumor cell PD-L1 expression was detected in only 3 (17%) cases, tumor-infiltrating lymphocytes expressed PD-L1 in the majority of the cases analyzed and in all of the cases positive for tumor cell PD-L1.⁶

Another study evaluated PD-1 and PD-L1 expression in EMPD tumor cells and tumor-associated immune infiltrate.⁵ They found that PD-1 was expressed heavily by the tumor-associated immune infiltrate in all EMPD cases analyzed. Similar to the previously mentioned study,⁶ PD-L1 was expressed by tumor cells in a few cases only. Interestingly, they found that the density of CD3 in the tumor-associated immune infiltrate was significantly (P=.049) higher in patients who were alive than in those who died, suggesting the importance of an exuberant T-cell response for survival in EMPD.⁵

A third study investigated protein expression of the B7 family members as well as PD-1 and PD-L1/2 in 55 EMPD samples. In this study the authors also found that tumor cell PD-L1 was minimal. Interestingly, they also found that tumor cells expressed B7 proteins in the majority of the cases.⁷

Finally, another study examined activity levels of T cells in EMPD by measuring the number and expression levels of cytotoxic T-cell cytokines.²⁴ The authors first found that EMPD tumors had a significantly higher number of CD8⁺ tumor-infiltrating lymphocytes compared to peripheral blood (P<.01). These CD8⁺ tumor-infiltrating lymphocytes also had a significantly higher expression of PD-1 (P<.01). They also found that tumor cells produced an immunosuppressive molecule called indoleamine 2,3-dyoxygenae that functions by suppressing T-cell activity levels. They concluded that in EMPD, tumor-specific T lymphocytes have an exhausted phenotype due to PD-1 activation as well as indoleamine 2,3-dyoxygenase release to the tumor microenvironment.²⁴

These studies highlight that restoring the effector functions of tumor-specific T lymphocytes could be an effective treatment strategy for EMPD. In fact, immunotherapy has been used with success for EMPD in the form of topical immunomodulators such as imiquimod.^16,25 More than 40 cases of EMPD treated with imiquimod 5% have been published; of these, only 6 were considered nonresponders,⁵ which suggests that EMPD may respond to other immunotherapies such as checkpoint inhibitors. It is an exciting time for immunotherapy as more checkpoint inhibitors are being developed. Among the newer agents is cemiplimab, which is a PD-1 inhibitor now US Food and Drug Administration approved for the treatment of locally advanced or metastatic cutaneous squamous cell carcinoma in patients who are not candidates for curative surgery or curative radiation.²⁶ Programmed cell death receptor 1 signaling can serve as a potential target in EMPD, and further studies need to be performed to test the clinical efficacy, especially in unresectable or invasive/metastatic EMPD. As the PD-1 pathway is more studied in EMPD, and as more PD-1 inhibitors get developed, it would be a clinical need to establish clinical studies for PD-1 inhibitors in EMPD.

A recent teleconference brought together an ad hoc panel of pediatric hospitalists, with more than 100 diverse voices discussing whether there ought to be an additional professional recognition or designation for the subspecialty, apart from the new pediatric hospital medicine (PHM) board certification that was launched in 2019.

The heterogeneity of PHM was on display during the discussion, as participants included university-based pediatric hospitalists and those from community hospitals, physicians trained in combined medicine and pediatrics or in family medicine, doctors who completed a general pediatric residency before going straight into PHM, niche practitioners such as newborn hospitalists, trainees, and a small but growing number of graduates of PHM fellowship programs. There are 61 PHM fellowships, and these programs graduate approximately 70 new fellows per year.

Although a route to some kind of professional designation for PHM – separate from board certification – was the centerpiece of the conference call, there is no proposal actively under consideration for developing such a designation, said Weijen W. Chang, MD, FAAP, SFHM, chief of pediatric hospital medicine at Baystate Medical Center in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts–Baystate Campus.

Who might develop such a proposal? “The hope is that the three major professional societies involved in pediatric hospital medicine – the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association – would jointly develop such a designation,” Dr. Chang said. However, it is not clear whether the three societies could agree on this. An online survey of 551 pediatric hospitalists, shared during the conference call, found that the majority would like to see some kind of alternate designation.

The reality of the boards

The pediatric subspecialty of PHM was recognized by the American Board of Medical Specialties in 2015 following a petition by a group of PHM leaders seeking a way to credential their unique skill set. The first PHM board certification exam was offered by the American Board of Pediatrics on Nov. 12, 2019, with 1,491 hospitalists sitting for the exam and 84% passing. An estimated 4,000 pediatric hospitalists currently work in the field.

Certification as a subspecialty typically requires completing a fellowship, but new subspecialties often offer a “practice pathway” allowing those who already have experience working in the field to sit for the exam. A PHM practice pathway, and a combined fellowship and experience option for those whose fellowship training was less than 2 years, was offered for last year’s exam and will be offered again in 2021 and 2023. After that, board certification will only be available to graduates of recognized fellowships.

But concerns began to emerge last summer in advance of ABM’s initial PHM board exam, when some applicants were told that they weren’t eligible to sit for it, said H. Barrett Fromme, MD, associate dean for faculty development in medical education and section chief for pediatric hospital medicine at the University of Chicago. She also chairs the section of hospital medicine for the AAP.

Concerns including unintended gender bias against women, such as those hospitalists whose training is interrupted for maternity leave, were raised in a petition to ABP. The board promptly responded that gender bias was not supported by the facts, although its response did not account for selection bias in the data. But the ABP removed its practice interruption criteria.^1,2

There are various reasons why a pediatric hospitalist might not be able or willing to pursue a 2-year fellowship or otherwise qualify for certification, Dr. Fromme said, including time and cost. For some, the practice pathway’s requirements, including a minimum number of hours worked in pediatrics in the previous 4 years, may be impossible to meet. Pediatric hospitalists boarded in family medicine are not eligible.

For hospitalists who can’t achieve board certification, what might that mean in terms of their future salary, employment opportunities, reimbursement, other career goals? Might they find themselves unable to qualify for PHM jobs at some university-based medical centers? The answers are not yet known.

What might self-designation look like?

PHM is distinct from adult hospital medicine by virtue of its designation as a board-certified subspecialty. But it can look to the broader HM field for examples of designations that bestow a kind of professional recognition, Dr. Chang said. These include SHM’s merit-based Fellow in Hospital Medicine program and the American Board of Medical Specialties’ Focused Practice in Hospital Medicine, a pathway for board recertification in internal medicine and family medicine, he said.

But PHM self-designation is not necessarily a pathway to hospital privileges. “If we build it, will they come? If they come, will it mean anything to them? That’s the million-dollar question?” Dr. Chang said.

Hospitalists need to appreciate that this issue is important to all three PHM professional societies, SHM, AAP, and APA, Dr. Fromme said. “We are concerned about how to support all of our members – certified, noncertified, nonphysician. Alternate designation is one idea, but we need time to understand it. We need a lot more conversations and a lot of people thinking about it.”

Dr. Fromme is part of the Council on Pediatric Hospital Medicine, a small circle of leaders of PHM interest groups within the three professional associations. It meets quarterly and will be reviewing the results of the conference call.

“I personally think we don’t understand the scope of the problem or the needs of pediatric hospitalists who are not able to sit for boards or pursue a fellowship,” she said. “We have empathy and concern for our colleagues who can’t take the boards. We don’t want them to feel excluded, and that includes advanced practice nurses and residents. But does an alternative designation actually provide what people think it provides?”

There are other ways to demonstrate that professionals are engaged with and serious about developing their practice. If they are looking to better themselves at quality improvement, leadership, education, and other elements of PHM practice, the associations can endeavor to provide more educational opportunities, Dr. Fromme said. “But if it’s about how they look as a candidate for hire, relative to board-certified candidates, that’s a different beast, and we need to think about what can help them the most.”
 

References

1. American Board of Pediatrics, Response to the Pediatric Hospital Medicine Petition. 2019 Aug 20. https://www.abp.org/sites/abp/files/phm-petition-response.pdf.

2. Chang WW et al. J Hosp Med. 2019 Oct;14(10):589-90.

A recent teleconference brought together an ad hoc panel of pediatric hospitalists, with more than 100 diverse voices discussing whether there ought to be an additional professional recognition or designation for the subspecialty, apart from the new pediatric hospital medicine (PHM) board certification that was launched in 2019.

The heterogeneity of PHM was on display during the discussion, as participants included university-based pediatric hospitalists and those from community hospitals, physicians trained in combined medicine and pediatrics or in family medicine, doctors who completed a general pediatric residency before going straight into PHM, niche practitioners such as newborn hospitalists, trainees, and a small but growing number of graduates of PHM fellowship programs. There are 61 PHM fellowships, and these programs graduate approximately 70 new fellows per year.

Although a route to some kind of professional designation for PHM – separate from board certification – was the centerpiece of the conference call, there is no proposal actively under consideration for developing such a designation, said Weijen W. Chang, MD, FAAP, SFHM, chief of pediatric hospital medicine at Baystate Medical Center in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts–Baystate Campus.

Who might develop such a proposal? “The hope is that the three major professional societies involved in pediatric hospital medicine – the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association – would jointly develop such a designation,” Dr. Chang said. However, it is not clear whether the three societies could agree on this. An online survey of 551 pediatric hospitalists, shared during the conference call, found that the majority would like to see some kind of alternate designation.

The reality of the boards

The pediatric subspecialty of PHM was recognized by the American Board of Medical Specialties in 2015 following a petition by a group of PHM leaders seeking a way to credential their unique skill set. The first PHM board certification exam was offered by the American Board of Pediatrics on Nov. 12, 2019, with 1,491 hospitalists sitting for the exam and 84% passing. An estimated 4,000 pediatric hospitalists currently work in the field.

Certification as a subspecialty typically requires completing a fellowship, but new subspecialties often offer a “practice pathway” allowing those who already have experience working in the field to sit for the exam. A PHM practice pathway, and a combined fellowship and experience option for those whose fellowship training was less than 2 years, was offered for last year’s exam and will be offered again in 2021 and 2023. After that, board certification will only be available to graduates of recognized fellowships.

But concerns began to emerge last summer in advance of ABM’s initial PHM board exam, when some applicants were told that they weren’t eligible to sit for it, said H. Barrett Fromme, MD, associate dean for faculty development in medical education and section chief for pediatric hospital medicine at the University of Chicago. She also chairs the section of hospital medicine for the AAP.

Concerns including unintended gender bias against women, such as those hospitalists whose training is interrupted for maternity leave, were raised in a petition to ABP. The board promptly responded that gender bias was not supported by the facts, although its response did not account for selection bias in the data. But the ABP removed its practice interruption criteria.^1,2

There are various reasons why a pediatric hospitalist might not be able or willing to pursue a 2-year fellowship or otherwise qualify for certification, Dr. Fromme said, including time and cost. For some, the practice pathway’s requirements, including a minimum number of hours worked in pediatrics in the previous 4 years, may be impossible to meet. Pediatric hospitalists boarded in family medicine are not eligible.

For hospitalists who can’t achieve board certification, what might that mean in terms of their future salary, employment opportunities, reimbursement, other career goals? Might they find themselves unable to qualify for PHM jobs at some university-based medical centers? The answers are not yet known.

What might self-designation look like?

PHM is distinct from adult hospital medicine by virtue of its designation as a board-certified subspecialty. But it can look to the broader HM field for examples of designations that bestow a kind of professional recognition, Dr. Chang said. These include SHM’s merit-based Fellow in Hospital Medicine program and the American Board of Medical Specialties’ Focused Practice in Hospital Medicine, a pathway for board recertification in internal medicine and family medicine, he said.

But PHM self-designation is not necessarily a pathway to hospital privileges. “If we build it, will they come? If they come, will it mean anything to them? That’s the million-dollar question?” Dr. Chang said.

Hospitalists need to appreciate that this issue is important to all three PHM professional societies, SHM, AAP, and APA, Dr. Fromme said. “We are concerned about how to support all of our members – certified, noncertified, nonphysician. Alternate designation is one idea, but we need time to understand it. We need a lot more conversations and a lot of people thinking about it.”

Dr. Fromme is part of the Council on Pediatric Hospital Medicine, a small circle of leaders of PHM interest groups within the three professional associations. It meets quarterly and will be reviewing the results of the conference call.

“I personally think we don’t understand the scope of the problem or the needs of pediatric hospitalists who are not able to sit for boards or pursue a fellowship,” she said. “We have empathy and concern for our colleagues who can’t take the boards. We don’t want them to feel excluded, and that includes advanced practice nurses and residents. But does an alternative designation actually provide what people think it provides?”

There are other ways to demonstrate that professionals are engaged with and serious about developing their practice. If they are looking to better themselves at quality improvement, leadership, education, and other elements of PHM practice, the associations can endeavor to provide more educational opportunities, Dr. Fromme said. “But if it’s about how they look as a candidate for hire, relative to board-certified candidates, that’s a different beast, and we need to think about what can help them the most.”
 

References

1. American Board of Pediatrics, Response to the Pediatric Hospital Medicine Petition. 2019 Aug 20. https://www.abp.org/sites/abp/files/phm-petition-response.pdf.

2. Chang WW et al. J Hosp Med. 2019 Oct;14(10):589-90.

A recent teleconference brought together an ad hoc panel of pediatric hospitalists, with more than 100 diverse voices discussing whether there ought to be an additional professional recognition or designation for the subspecialty, apart from the new pediatric hospital medicine (PHM) board certification that was launched in 2019.

The heterogeneity of PHM was on display during the discussion, as participants included university-based pediatric hospitalists and those from community hospitals, physicians trained in combined medicine and pediatrics or in family medicine, doctors who completed a general pediatric residency before going straight into PHM, niche practitioners such as newborn hospitalists, trainees, and a small but growing number of graduates of PHM fellowship programs. There are 61 PHM fellowships, and these programs graduate approximately 70 new fellows per year.

Although a route to some kind of professional designation for PHM – separate from board certification – was the centerpiece of the conference call, there is no proposal actively under consideration for developing such a designation, said Weijen W. Chang, MD, FAAP, SFHM, chief of pediatric hospital medicine at Baystate Medical Center in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts–Baystate Campus.

Who might develop such a proposal? “The hope is that the three major professional societies involved in pediatric hospital medicine – the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association – would jointly develop such a designation,” Dr. Chang said. However, it is not clear whether the three societies could agree on this. An online survey of 551 pediatric hospitalists, shared during the conference call, found that the majority would like to see some kind of alternate designation.

The reality of the boards

The pediatric subspecialty of PHM was recognized by the American Board of Medical Specialties in 2015 following a petition by a group of PHM leaders seeking a way to credential their unique skill set. The first PHM board certification exam was offered by the American Board of Pediatrics on Nov. 12, 2019, with 1,491 hospitalists sitting for the exam and 84% passing. An estimated 4,000 pediatric hospitalists currently work in the field.

Certification as a subspecialty typically requires completing a fellowship, but new subspecialties often offer a “practice pathway” allowing those who already have experience working in the field to sit for the exam. A PHM practice pathway, and a combined fellowship and experience option for those whose fellowship training was less than 2 years, was offered for last year’s exam and will be offered again in 2021 and 2023. After that, board certification will only be available to graduates of recognized fellowships.

But concerns began to emerge last summer in advance of ABM’s initial PHM board exam, when some applicants were told that they weren’t eligible to sit for it, said H. Barrett Fromme, MD, associate dean for faculty development in medical education and section chief for pediatric hospital medicine at the University of Chicago. She also chairs the section of hospital medicine for the AAP.

Concerns including unintended gender bias against women, such as those hospitalists whose training is interrupted for maternity leave, were raised in a petition to ABP. The board promptly responded that gender bias was not supported by the facts, although its response did not account for selection bias in the data. But the ABP removed its practice interruption criteria.^1,2

There are various reasons why a pediatric hospitalist might not be able or willing to pursue a 2-year fellowship or otherwise qualify for certification, Dr. Fromme said, including time and cost. For some, the practice pathway’s requirements, including a minimum number of hours worked in pediatrics in the previous 4 years, may be impossible to meet. Pediatric hospitalists boarded in family medicine are not eligible.

For hospitalists who can’t achieve board certification, what might that mean in terms of their future salary, employment opportunities, reimbursement, other career goals? Might they find themselves unable to qualify for PHM jobs at some university-based medical centers? The answers are not yet known.

What might self-designation look like?

PHM is distinct from adult hospital medicine by virtue of its designation as a board-certified subspecialty. But it can look to the broader HM field for examples of designations that bestow a kind of professional recognition, Dr. Chang said. These include SHM’s merit-based Fellow in Hospital Medicine program and the American Board of Medical Specialties’ Focused Practice in Hospital Medicine, a pathway for board recertification in internal medicine and family medicine, he said.

But PHM self-designation is not necessarily a pathway to hospital privileges. “If we build it, will they come? If they come, will it mean anything to them? That’s the million-dollar question?” Dr. Chang said.

Hospitalists need to appreciate that this issue is important to all three PHM professional societies, SHM, AAP, and APA, Dr. Fromme said. “We are concerned about how to support all of our members – certified, noncertified, nonphysician. Alternate designation is one idea, but we need time to understand it. We need a lot more conversations and a lot of people thinking about it.”

Dr. Fromme is part of the Council on Pediatric Hospital Medicine, a small circle of leaders of PHM interest groups within the three professional associations. It meets quarterly and will be reviewing the results of the conference call.

“I personally think we don’t understand the scope of the problem or the needs of pediatric hospitalists who are not able to sit for boards or pursue a fellowship,” she said. “We have empathy and concern for our colleagues who can’t take the boards. We don’t want them to feel excluded, and that includes advanced practice nurses and residents. But does an alternative designation actually provide what people think it provides?”

There are other ways to demonstrate that professionals are engaged with and serious about developing their practice. If they are looking to better themselves at quality improvement, leadership, education, and other elements of PHM practice, the associations can endeavor to provide more educational opportunities, Dr. Fromme said. “But if it’s about how they look as a candidate for hire, relative to board-certified candidates, that’s a different beast, and we need to think about what can help them the most.”
 

References

1. American Board of Pediatrics, Response to the Pediatric Hospital Medicine Petition. 2019 Aug 20. https://www.abp.org/sites/abp/files/phm-petition-response.pdf.

2. Chang WW et al. J Hosp Med. 2019 Oct;14(10):589-90.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

“You are what you eat,” my mother always said, and structured our dinner plates according to the USDA food pyramid. We dutifully consumed leafy greens, and prior to medical school I invested time and money into healthy diet choices. I drank green smoothies, pureed baby food for my children, read up on the pH balancing diet, grew sprouts on windowsills, bought organic.

With the stressors and time constraints of managing medical school and a family, nutrition tumbled down the ladder of priorities until eventually my family was subsisting on chicken nuggets, pizza, and peanut butter. Intern year has only added the occasional candy bar from the doctors’ lounge. I experienced a vague sense of loss for something I had once valued, but simultaneously felt dismissive of trendy topics such as omega-3 fatty acids and antioxidants in the face of myocardial infarctions and liver failure. A biochemistry professor once scoffed at “the laypeople’s obsession with toxins,” and nutrition received zero attention in our medical school curriculum or board exams.

However, a clinical experience on the inpatient psychiatric unit made me reevaluate the importance nutrition should have in both our personal lives and the practice of medicine. This is the case of an otherwise healthy young man with no psychiatric history who suffered a psychotic break after ingesting an excess of a supplement he purchased online with the purpose of improving his performance at a high-stress job.

CASE REPORT

Mr. K, a 28-year-old computer programmer, was voluntarily admitted to the inpatient psychiatry unit for paranoia and persecutory delusions along with auditory hallucinations. His father reported that Mr. K had been behaving erratically for several days prior to admission and was subsequently found wandering in the street.

On admission, Mr. K was not oriented to place or situation. He was unkempt and guarded, and claimed people were following him. His urine toxicology screen and blood alcohol levels were negative.

While hospitalized, Mr. K was hyperverbal and delusional. He related that at work he had been developing programs to make slaves in the computer, “algorithms for orchestration,” and that he was uncomfortable with the ethical implications. He eventually endorsed having purchased the supplement phenylethylamine (PEA) to improve his focus, and ingesting “two substantial scoops of the crystalline substance.”

We did not initiate any psychiatric medications. On the third day of his hospitalization, Mr. K was alert, oriented, euthymic, relaxed, and had a full range of affect; upon discharge we advised him to discard the PEA and avoid stimulants. He complied, quit his high-stress job, and had no subsequent psychotic symptoms in the 7 months since discharge.

Continue to: Dietary supplements carry risks

According to the FDA, dietary supplements are regulated as food, but many have strong biologic effects or may even contain drugs.¹ More than 18% of Americans use herbal or nutritional therapies as part of their health regimen.² However, many over-the-counter remedies have been found to exhibit psychotropic effects,³ and many more are purported to impact mental and physical health with little to no scientific research into these claims or potential adverse effects.

Phenylethylamine is sold as a nutritional supplement and marketed for its purported beneficial effects on weight loss, mood, and focus.⁴ However, PEA is known to act as a natural amphetamine and to play a role in the development of neuropsychiatric disorders.⁵ It is an endogenous psychotogenic molecule that has been previously theorized as a cause for primary psychosis.⁶ Phenylethylamine interacts with the same receptor ligand that responds to amphetamine and related compounds (such as methamphetamine and 3,4-methylenedioxy-methamphetamine [MDMA]), the genetic coding for which is located in an area of DNA associated with schizophrenia: chromosome 6q23.2.⁷ While the mechanisms and details of these interactions remain poorly understood, this case of PEA-induced psychosis represents a glimpse into the potential psychoactive properties of this readily available nutritional supplement.

This patient’s cautionary tale has given me pause regarding both my family’s nutrition and the oft-neglected dietary portion of the social history. Also, several subsequent patient experiences hearken back to my mother’s words regarding the importance of healthy eating. A patient with phenylketonuria presented with psychosis after running out of her formula and consuming junk food. Another patient with severely elevated blood glucose levels presented with confusion. I have come to realize that ingestion impacts presentation, or, in other words, you are what you eat.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

In December 2019, Seattle Seahawks wide receiver Josh Gordon was suspended indefinitely from the NFL for violation of the league’s substance abuse policy. Gordon, once known as one of the most promising wide receivers of the last few decades, had a tumultuous relationship with the NFL as a result of his struggles with substance use. However, the headlines from major sports and news outlets often describe Gordon and other professional and collegiate athletes who struggle with substance use as “violating policies of abuse.” Media coverage of such athletes frequently imposes labels such as “violation” and “abuse,” implying a greater level of personal responsibility and willful misconduct than the biological process of addiction would typically allow. Gordon’s story brought attention not only to the adversity and impairments of substance use, but also the stigmatizing language that often accompanies it.

Shifting to less stigmatizing terminology

In DMS-5, use of the terminology substance use disorder fosters a more biologically-based model of behavior, and encourages recovery-oriented terminology.¹ However, for most collegiate and professional sports leagues, the policies regarding substance use often use the term substance abuse, which can perpetuate stigma and a misunderstanding of the underpinnings of substance use, insinuating a sense of personal responsibility, deliberate misconduct, and criminality. When an individual is referred to as an “abuser” of substances, this might suggest that they are willful perpetrators of the disease on themselves, and thus may be undeserving of care.² Individuals referred to as “substance abusers” rather than having a substance use disorder are more likely to be subjected to negative perceptions and evaluations of their behaviors, particularly by clinicians.

Individuals with substance use disorders are often viewed more negatively than individuals with physical or other psychiatric disorders, and are among the most stigmatized and marginalized groups in health care.^4,5 Today, lawmakers, advocates, and health care professionals across the country are working to integrate destigmatizing language into media, policy, and educational settings in order to characterize substance use as a neurobiological process rather than a moral fault.⁶ For example, legislation in Maine passed in 2018 removed references to stigmatizing terms in policies related to substance use, replacing substance abuse and drug addict with recovery-oriented terminology such as substance use disorder and person with a substance use disorder.⁷

Individuals with substance use disorders often fear judgment and stigma during clinical encounters, and commonly cite this as a reason to avoid seeking care.⁸ Words matter, and if we are not careful, the language we use can convey meaning and attitudes that perpetuate the stigma that prevents so many from accessing treatment.^9,10 Individuals with a substance use disorder should feel institutionally supported, and the language of policies and the clinicians who treat these patients should reflect this as well.

References

1. National Institute of Health. COVID-19 treatment guidelines: what’s new in the guidelines? Updated June 25, 2020. www.covid19treatmentguidelines.nih.gov/whats-new/. Accessed June 26, 2020.
2. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Remdesivir for treating hospitalised patients with suspected or confirmed COVID-19. Evidence summary [ES27]. Published June 5, 2020. www.nice.org.uk/advice/es27/chapter/Key-messages. Accessed June 26, 2020.
3. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. Evidence summary [ES24]. Published May 21, 2020. www.nice.org.uk/advice/es24/chapter/Key-messages. Accessed June 26, 2020.
4. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. Evidence summary [ES25]. Published May 21, 2020. www.nice.org.uk/advice/es25/chapter/Key-messages. Accessed June 26, 2020.
5. Hernandez AV, Roman YM, Pasupuleti V, et al. Hydroxychloroquine or chloroquine for treatment or prophylaxis of COVID-19: a living systematic review. Ann Intern Med. 2020 May 27. doi: 10.7326/M20-2496. Online ahead of print.

References

1. National Institute of Health. COVID-19 treatment guidelines: what’s new in the guidelines? Updated June 25, 2020. www.covid19treatmentguidelines.nih.gov/whats-new/. Accessed June 26, 2020.
2. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Remdesivir for treating hospitalised patients with suspected or confirmed COVID-19. Evidence summary [ES27]. Published June 5, 2020. www.nice.org.uk/advice/es27/chapter/Key-messages. Accessed June 26, 2020.
3. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. Evidence summary [ES24]. Published May 21, 2020. www.nice.org.uk/advice/es24/chapter/Key-messages. Accessed June 26, 2020.
4. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. Evidence summary [ES25]. Published May 21, 2020. www.nice.org.uk/advice/es25/chapter/Key-messages. Accessed June 26, 2020.
5. Hernandez AV, Roman YM, Pasupuleti V, et al. Hydroxychloroquine or chloroquine for treatment or prophylaxis of COVID-19: a living systematic review. Ann Intern Med. 2020 May 27. doi: 10.7326/M20-2496. Online ahead of print.

References

1. National Institute of Health. COVID-19 treatment guidelines: what’s new in the guidelines? Updated June 25, 2020. www.covid19treatmentguidelines.nih.gov/whats-new/. Accessed June 26, 2020.
2. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Remdesivir for treating hospitalised patients with suspected or confirmed COVID-19. Evidence summary [ES27]. Published June 5, 2020. www.nice.org.uk/advice/es27/chapter/Key-messages. Accessed June 26, 2020.
3. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in people with or at risk of COVID-19. Evidence summary [ES24]. Published May 21, 2020. www.nice.org.uk/advice/es24/chapter/Key-messages. Accessed June 26, 2020.
4. National Institute for Health Care and Excellence. COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19. Evidence summary [ES25]. Published May 21, 2020. www.nice.org.uk/advice/es25/chapter/Key-messages. Accessed June 26, 2020.
5. Hernandez AV, Roman YM, Pasupuleti V, et al. Hydroxychloroquine or chloroquine for treatment or prophylaxis of COVID-19: a living systematic review. Ann Intern Med. 2020 May 27. doi: 10.7326/M20-2496. Online ahead of print.

Dermatologic treatment of patients with skin of color offers specific challenges. Studies have reported structural, morphologic, and physiologic distinctions among different ethnic groups,¹ which may account for distinct clinical presentations of skin disease seen in patients with skin of color. Patients with skin of color are at increased risk for specific dermatologic conditions, such as postinflammatory hyperpigmentation, keloid development, and central centrifugal cicatricial alopecia.^2,3 Furthermore, although skin cancer is less prevalent in patients with skin of color, it often presents at a more advanced stage and with a worse prognosis compared to white patients.⁴

Individuals with skin of color make up the majority of the world’s population and a rapidly expanding portion of the US population. By the year 2044, more than half of all Americans are projected to belong to an ethnic group that is currently a minority. By 2060, the population of citizens identifying with 2 or more races will increase by 226%, the Asian population is projected to grow by 128%, the Hispanic population will increase by 115%, and the black population will increase by 42%.⁵ The racial and ethnic composition of the United States is evolving, and dermatologic care must evolve accordingly to address patients’ unique concerns. It is essential for future dermatologists to be knowledgeable about dermatologic conditions presenting in patients of various ethnic backgrounds.

Prior studies have demonstrated the need for increased exposure, education, and training in diseases pertaining to skin of color in US dermatology residency programs.^6-8 The aim of this study was to assess if dermatologists in-training feel that their residency curriculum sufficiently educates them on the needs of patients with skin of color.

Methods

A 10-question anonymous survey was emailed to 109 dermatology residency programs to evaluate the attitudes of dermatology residents about their exposure to patients with skin of color and their skin-of-color curriculum. The study included individuals 18 years or older who were current residents in a dermatology program accredited by the Accreditation Council for Graduate Medical Education. Responses were measured on a 1 to 3 Likert scale, ranging from agree, neutral, and disagree. Data were analyzed using the Fisher exact test, and the statistical significance was set at P<.05.

Results

Forty-three dermatology residents completed the survey. Respondents self-selected their regions, with 8 (19%) from the Northeast (NE), 7 (16%) from the Southeast (SE), 12 (28%) from the Midwest (MW), 8 (19%) from the Southwest (SW), and 8 (18%) from the Northwest (NW)(Table 1). Overall, 31 (72%) respondents agreed that their practice treats a diverse patient population. Respondents who agreed most often were from the NE, SE, and SW. Less than two-thirds of respondents from the MW agreed, and only half of respondents from the NW agreed (Table 2). Although 37% of all respondents agreed that a dedicated multiethnic skin clinic is important for residents, 5 (63%) NE residents disagreed with this statement compared to 5 (42%) MW residents and 5 (63%) NW residents who agreed (P<.005). Overall, 39 (91%) respondents agreed that dedicated lectures on skin conditions in skin of color patients are important to gain competence in treating patients. Only 4 respondents were neutral to this question, 2 (17%) MW residents and 2 (25%) SW residents. When asked if reading textbook chapters on multiethnic skin is important to gain competence, 36 (83%) respondents agreed. Two respondents disagreed, 1 (13%) from the NE and 1 (8%) from the MW. Overall, 23% of respondents agreed that a rotation dedicated to skin of color is important to build competency. There was a significant difference in responses between the NE and MW (P=.032) and between the NE and NW (P=.019). Furthermore, 19 (44%) respondents agreed that having a faculty member or departmental expert is important for residents to gain competence in treating conditions affecting skin of color. Again, there was a significant difference in responses between the NE and MW (P=.003) and between the SE and MW (P=.009).

When asked the number of hours of lecture per month necessary to gain competence in conditions affecting patients with skin of color, 67% agreed that 1 to 5 hours was sufficient (Table 3). There were significant differences in the responses between the NE and SE (P=.024) and the SE and MW (P=.007). Of all respondents, 53% reported 1 to 5 months of clinical training are needed to gain competence in treating conditions affecting patients with skin of color, with significant differences in responses between the NE and MW (P<.001), the NE and SW (P=.019), and the SE and MW (P=.015)(Table 4).

Comment

Responses varied by practicing region. Less ethnically diverse regions, such as the MW and NW, were more likely to agree that dedicated clinics and rotations are important to gain competence compared to more ethnically diverse regions such as the NE, SE, and SW. Overall, more residents reported that dedicated lectures and textbook chapters were important to gain competency compared to dedicated clinics or rotations.

Although interactive lectures and textbook readings are important for obtaining a foundational understanding of dermatologic disease, they cannot substitute for clinical interactions and hands-on experience treating patients with skin of color.⁹ Not only do clinical interactions encourage independent reading and the study of encountered diagnoses, but intercommunication with patients may have a more profound and lasting impact on residents’ education.

Different regions of the United States have varying distributions of patients with skin of color, and dermatology residency program training reflects these disparities.⁶ In areas of less diversity, dermatology residents examine, diagnose, and treat substantially fewer patients with skin of color. The desire for more diverse training supports the prior findings of Nijhawan et al⁶ and is reflected in the responses we received in our study, whereby residents from the less ethnically diversified regions of the MW and NW were more likely to agree that clinics and rotations were necessary for training in preparation to sufficiently address the needs of patients with skin of color.

One way to compensate for the lack of ethnic diversity encountered in areas such as the MW and NW would be to develop educational programs featuring experts on skin of color.⁶ These specialists would not only train dermatology residents in areas of the country currently lacking ethnic diversity but also expand the expertise for treating patients with skin of color. Additionally, dedicated multiethnic skin clinics and externships devoted solely to treating patients with skin of color could be encouraged for residency training.⁶ Finally, community outreach through volunteer clinics may provide residents exposure to patients with skin of color seeking dermatologic care.¹⁰

This study was limited by the small number of respondents, but we were able to extract important trends and data from the collected responses. It is possible that respondents felt strongly about topics involving patients with skin of color, and the results were skewed to reflect individual bias. Additional limitations included not asking respondents for program names and population density (eg, urban, suburban, rural). Future studies should be directed toward analyzing how the diversity of the local population influences training in patients with skin of color, comparing program directors’ perceptions with residents’ perceptions on training in skin of color, and assessing patient perception of residents’ training in skin of color.

Conclusion

In the last decade it has become increasingly apparent that the US population is diversifying and that patients with skin of color will comprise a substantial proportion of the future population,^8,11 which emphasizes the need for dermatology residency programs to ensure that residents receive adequate training and exposure to patients with skin of color as well as the distinct skin diseases seen more commonly in these populations.¹²

Dermatologic treatment of patients with skin of color offers specific challenges. Studies have reported structural, morphologic, and physiologic distinctions among different ethnic groups,¹ which may account for distinct clinical presentations of skin disease seen in patients with skin of color. Patients with skin of color are at increased risk for specific dermatologic conditions, such as postinflammatory hyperpigmentation, keloid development, and central centrifugal cicatricial alopecia.^2,3 Furthermore, although skin cancer is less prevalent in patients with skin of color, it often presents at a more advanced stage and with a worse prognosis compared to white patients.⁴

Individuals with skin of color make up the majority of the world’s population and a rapidly expanding portion of the US population. By the year 2044, more than half of all Americans are projected to belong to an ethnic group that is currently a minority. By 2060, the population of citizens identifying with 2 or more races will increase by 226%, the Asian population is projected to grow by 128%, the Hispanic population will increase by 115%, and the black population will increase by 42%.⁵ The racial and ethnic composition of the United States is evolving, and dermatologic care must evolve accordingly to address patients’ unique concerns. It is essential for future dermatologists to be knowledgeable about dermatologic conditions presenting in patients of various ethnic backgrounds.

Prior studies have demonstrated the need for increased exposure, education, and training in diseases pertaining to skin of color in US dermatology residency programs.^6-8 The aim of this study was to assess if dermatologists in-training feel that their residency curriculum sufficiently educates them on the needs of patients with skin of color.

Methods

A 10-question anonymous survey was emailed to 109 dermatology residency programs to evaluate the attitudes of dermatology residents about their exposure to patients with skin of color and their skin-of-color curriculum. The study included individuals 18 years or older who were current residents in a dermatology program accredited by the Accreditation Council for Graduate Medical Education. Responses were measured on a 1 to 3 Likert scale, ranging from agree, neutral, and disagree. Data were analyzed using the Fisher exact test, and the statistical significance was set at P<.05.

Results

Forty-three dermatology residents completed the survey. Respondents self-selected their regions, with 8 (19%) from the Northeast (NE), 7 (16%) from the Southeast (SE), 12 (28%) from the Midwest (MW), 8 (19%) from the Southwest (SW), and 8 (18%) from the Northwest (NW)(Table 1). Overall, 31 (72%) respondents agreed that their practice treats a diverse patient population. Respondents who agreed most often were from the NE, SE, and SW. Less than two-thirds of respondents from the MW agreed, and only half of respondents from the NW agreed (Table 2). Although 37% of all respondents agreed that a dedicated multiethnic skin clinic is important for residents, 5 (63%) NE residents disagreed with this statement compared to 5 (42%) MW residents and 5 (63%) NW residents who agreed (P<.005). Overall, 39 (91%) respondents agreed that dedicated lectures on skin conditions in skin of color patients are important to gain competence in treating patients. Only 4 respondents were neutral to this question, 2 (17%) MW residents and 2 (25%) SW residents. When asked if reading textbook chapters on multiethnic skin is important to gain competence, 36 (83%) respondents agreed. Two respondents disagreed, 1 (13%) from the NE and 1 (8%) from the MW. Overall, 23% of respondents agreed that a rotation dedicated to skin of color is important to build competency. There was a significant difference in responses between the NE and MW (P=.032) and between the NE and NW (P=.019). Furthermore, 19 (44%) respondents agreed that having a faculty member or departmental expert is important for residents to gain competence in treating conditions affecting skin of color. Again, there was a significant difference in responses between the NE and MW (P=.003) and between the SE and MW (P=.009).

When asked the number of hours of lecture per month necessary to gain competence in conditions affecting patients with skin of color, 67% agreed that 1 to 5 hours was sufficient (Table 3). There were significant differences in the responses between the NE and SE (P=.024) and the SE and MW (P=.007). Of all respondents, 53% reported 1 to 5 months of clinical training are needed to gain competence in treating conditions affecting patients with skin of color, with significant differences in responses between the NE and MW (P<.001), the NE and SW (P=.019), and the SE and MW (P=.015)(Table 4).

Comment

Responses varied by practicing region. Less ethnically diverse regions, such as the MW and NW, were more likely to agree that dedicated clinics and rotations are important to gain competence compared to more ethnically diverse regions such as the NE, SE, and SW. Overall, more residents reported that dedicated lectures and textbook chapters were important to gain competency compared to dedicated clinics or rotations.

Although interactive lectures and textbook readings are important for obtaining a foundational understanding of dermatologic disease, they cannot substitute for clinical interactions and hands-on experience treating patients with skin of color.⁹ Not only do clinical interactions encourage independent reading and the study of encountered diagnoses, but intercommunication with patients may have a more profound and lasting impact on residents’ education.

Different regions of the United States have varying distributions of patients with skin of color, and dermatology residency program training reflects these disparities.⁶ In areas of less diversity, dermatology residents examine, diagnose, and treat substantially fewer patients with skin of color. The desire for more diverse training supports the prior findings of Nijhawan et al⁶ and is reflected in the responses we received in our study, whereby residents from the less ethnically diversified regions of the MW and NW were more likely to agree that clinics and rotations were necessary for training in preparation to sufficiently address the needs of patients with skin of color.

One way to compensate for the lack of ethnic diversity encountered in areas such as the MW and NW would be to develop educational programs featuring experts on skin of color.⁶ These specialists would not only train dermatology residents in areas of the country currently lacking ethnic diversity but also expand the expertise for treating patients with skin of color. Additionally, dedicated multiethnic skin clinics and externships devoted solely to treating patients with skin of color could be encouraged for residency training.⁶ Finally, community outreach through volunteer clinics may provide residents exposure to patients with skin of color seeking dermatologic care.¹⁰

This study was limited by the small number of respondents, but we were able to extract important trends and data from the collected responses. It is possible that respondents felt strongly about topics involving patients with skin of color, and the results were skewed to reflect individual bias. Additional limitations included not asking respondents for program names and population density (eg, urban, suburban, rural). Future studies should be directed toward analyzing how the diversity of the local population influences training in patients with skin of color, comparing program directors’ perceptions with residents’ perceptions on training in skin of color, and assessing patient perception of residents’ training in skin of color.

Conclusion

In the last decade it has become increasingly apparent that the US population is diversifying and that patients with skin of color will comprise a substantial proportion of the future population,^8,11 which emphasizes the need for dermatology residency programs to ensure that residents receive adequate training and exposure to patients with skin of color as well as the distinct skin diseases seen more commonly in these populations.¹²

Dermatologic treatment of patients with skin of color offers specific challenges. Studies have reported structural, morphologic, and physiologic distinctions among different ethnic groups,¹ which may account for distinct clinical presentations of skin disease seen in patients with skin of color. Patients with skin of color are at increased risk for specific dermatologic conditions, such as postinflammatory hyperpigmentation, keloid development, and central centrifugal cicatricial alopecia.^2,3 Furthermore, although skin cancer is less prevalent in patients with skin of color, it often presents at a more advanced stage and with a worse prognosis compared to white patients.⁴

Individuals with skin of color make up the majority of the world’s population and a rapidly expanding portion of the US population. By the year 2044, more than half of all Americans are projected to belong to an ethnic group that is currently a minority. By 2060, the population of citizens identifying with 2 or more races will increase by 226%, the Asian population is projected to grow by 128%, the Hispanic population will increase by 115%, and the black population will increase by 42%.⁵ The racial and ethnic composition of the United States is evolving, and dermatologic care must evolve accordingly to address patients’ unique concerns. It is essential for future dermatologists to be knowledgeable about dermatologic conditions presenting in patients of various ethnic backgrounds.

Prior studies have demonstrated the need for increased exposure, education, and training in diseases pertaining to skin of color in US dermatology residency programs.^6-8 The aim of this study was to assess if dermatologists in-training feel that their residency curriculum sufficiently educates them on the needs of patients with skin of color.

Methods

A 10-question anonymous survey was emailed to 109 dermatology residency programs to evaluate the attitudes of dermatology residents about their exposure to patients with skin of color and their skin-of-color curriculum. The study included individuals 18 years or older who were current residents in a dermatology program accredited by the Accreditation Council for Graduate Medical Education. Responses were measured on a 1 to 3 Likert scale, ranging from agree, neutral, and disagree. Data were analyzed using the Fisher exact test, and the statistical significance was set at P<.05.

Results

Forty-three dermatology residents completed the survey. Respondents self-selected their regions, with 8 (19%) from the Northeast (NE), 7 (16%) from the Southeast (SE), 12 (28%) from the Midwest (MW), 8 (19%) from the Southwest (SW), and 8 (18%) from the Northwest (NW)(Table 1). Overall, 31 (72%) respondents agreed that their practice treats a diverse patient population. Respondents who agreed most often were from the NE, SE, and SW. Less than two-thirds of respondents from the MW agreed, and only half of respondents from the NW agreed (Table 2). Although 37% of all respondents agreed that a dedicated multiethnic skin clinic is important for residents, 5 (63%) NE residents disagreed with this statement compared to 5 (42%) MW residents and 5 (63%) NW residents who agreed (P<.005). Overall, 39 (91%) respondents agreed that dedicated lectures on skin conditions in skin of color patients are important to gain competence in treating patients. Only 4 respondents were neutral to this question, 2 (17%) MW residents and 2 (25%) SW residents. When asked if reading textbook chapters on multiethnic skin is important to gain competence, 36 (83%) respondents agreed. Two respondents disagreed, 1 (13%) from the NE and 1 (8%) from the MW. Overall, 23% of respondents agreed that a rotation dedicated to skin of color is important to build competency. There was a significant difference in responses between the NE and MW (P=.032) and between the NE and NW (P=.019). Furthermore, 19 (44%) respondents agreed that having a faculty member or departmental expert is important for residents to gain competence in treating conditions affecting skin of color. Again, there was a significant difference in responses between the NE and MW (P=.003) and between the SE and MW (P=.009).

When asked the number of hours of lecture per month necessary to gain competence in conditions affecting patients with skin of color, 67% agreed that 1 to 5 hours was sufficient (Table 3). There were significant differences in the responses between the NE and SE (P=.024) and the SE and MW (P=.007). Of all respondents, 53% reported 1 to 5 months of clinical training are needed to gain competence in treating conditions affecting patients with skin of color, with significant differences in responses between the NE and MW (P<.001), the NE and SW (P=.019), and the SE and MW (P=.015)(Table 4).

Comment

Responses varied by practicing region. Less ethnically diverse regions, such as the MW and NW, were more likely to agree that dedicated clinics and rotations are important to gain competence compared to more ethnically diverse regions such as the NE, SE, and SW. Overall, more residents reported that dedicated lectures and textbook chapters were important to gain competency compared to dedicated clinics or rotations.

Although interactive lectures and textbook readings are important for obtaining a foundational understanding of dermatologic disease, they cannot substitute for clinical interactions and hands-on experience treating patients with skin of color.⁹ Not only do clinical interactions encourage independent reading and the study of encountered diagnoses, but intercommunication with patients may have a more profound and lasting impact on residents’ education.

Different regions of the United States have varying distributions of patients with skin of color, and dermatology residency program training reflects these disparities.⁶ In areas of less diversity, dermatology residents examine, diagnose, and treat substantially fewer patients with skin of color. The desire for more diverse training supports the prior findings of Nijhawan et al⁶ and is reflected in the responses we received in our study, whereby residents from the less ethnically diversified regions of the MW and NW were more likely to agree that clinics and rotations were necessary for training in preparation to sufficiently address the needs of patients with skin of color.

One way to compensate for the lack of ethnic diversity encountered in areas such as the MW and NW would be to develop educational programs featuring experts on skin of color.⁶ These specialists would not only train dermatology residents in areas of the country currently lacking ethnic diversity but also expand the expertise for treating patients with skin of color. Additionally, dedicated multiethnic skin clinics and externships devoted solely to treating patients with skin of color could be encouraged for residency training.⁶ Finally, community outreach through volunteer clinics may provide residents exposure to patients with skin of color seeking dermatologic care.¹⁰

This study was limited by the small number of respondents, but we were able to extract important trends and data from the collected responses. It is possible that respondents felt strongly about topics involving patients with skin of color, and the results were skewed to reflect individual bias. Additional limitations included not asking respondents for program names and population density (eg, urban, suburban, rural). Future studies should be directed toward analyzing how the diversity of the local population influences training in patients with skin of color, comparing program directors’ perceptions with residents’ perceptions on training in skin of color, and assessing patient perception of residents’ training in skin of color.

Conclusion

In the last decade it has become increasingly apparent that the US population is diversifying and that patients with skin of color will comprise a substantial proportion of the future population,^8,11 which emphasizes the need for dermatology residency programs to ensure that residents receive adequate training and exposure to patients with skin of color as well as the distinct skin diseases seen more commonly in these populations.¹²

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Compounding is a way of mixing or combining medications in formulations that are not widely available. Because dermatology is a field that includes a variety of topical treatments, compounding topicals is a way to create unique and customized treatment options for patients.

Advantages

Custom compounding topical medications has many benefits in comparison to traditional topical formulations. Compounding is a way of personalizing prescriptions to best suit the individual needs of each patient. Multiple ingredients with different mechanisms of action can be combined in a single medication for patients to use, which ultimately can simplify their treatment regimen.¹ For rare conditions with uncommon treatments, compounding pharmacies can provide medications that are not widely available in retail pharmacies. Compounding topical medications also can be an efficient way of prescribing medications without dealing with the uncertainty of prior authorizations or how much the co-pay will be.

Disadvantages

One of the major disadvantages of compounding topical medications is the lack of safety data. Although most active drugs have been tested independently, there is little data on the safety of compounding 2 or more active drugs. Furthermore, the vehicle used may change the permeability of the topical formulation, and systemic absorption may be possible. Two deaths were reported with the application of compounded topical lidocaine and tetracaine gel due to systemic absorption. In these cases, the gel was used before laser hair removal, and it was applied under occlusion to greater than 50% of the body surface area, leading to fatal systemic absorption.^1,2

One of the hypothetical benefits of compounding topicals is being able to avoid side effects of systemic medications. However, depending on the skin intactness and the strength of the medication used, systemic adverse effects have been reported.¹ In a case series of 2 patients detailing the use of amitriptyline cream 5% and 10% for neuropathic pain, the patient using 10% cream experienced systemic effects of drowsiness and discontinued treatment.³

Another major disadvantage of compounding topicals is a lack of published data about the efficacy, especially given the unique nature of what is being compounded. When combining multiple medications, there are little to no published data about the efficacy of these formulations and how they compare to monotherapy. Although there may be data about the efficacy of an oral agent, it does not translate to the topical form being safe and efficacious. Much of the published data of topical formulations is limited to case reports and case series.

Finally, many compounded medications are not covered by insurance, and the out-of-pocket cost may be prohibitive for some patients. Compounding pharmacies typically will give patients a price estimate before the prescription is filled. When compounding topicals for patient use, it is important to counsel patients about the following:the unknown safety profile; lack of data regarding efficacy; and cost, as the medication likely will not be covered by insurance.

Pharmaceutical Regulations

After a contaminated product at a compounding pharmacy in New England led to an outbreak of fungal meningitis, there has been increased regulation by the US Food and Drug Administration.⁴ To meet safety regulations, compounding pharmacies must adhere to the standards set by the US Pharmacopeia. The US Food and Drug Administration says that physicians are not to prescribe compounded medications that are “unapproved, adulterated, or misbranded drugs,” which has been interpreted to mean that compounded medications should not mimic a branded medication but should instead be a unique formulation or strength.^4,5 Thus, while compounding topicals may provide an alternative when a specific medication is not covered by insurance, it cannot be the same as a branded medication.

Pharmaceutical Options

Most major cities have custom compounding pharmacies or apothecaries. One of the benefits of using a local compounding pharmacy is that you typically can speak directly with the pharmacist about your patient’s diagnosis and his/her specific needs. The pharmacist can guide you through which formulations to compound, which strength to choose, and the best vehicle to use as a base. This expertise is invaluable in the compounding process. There also are online compounding pharmacies available.

Options for Bases

Dermatologists can request for their medications to be compounded in traditional over-the-counter emollients or petrolatum-based products, which work by passively diffusing through the stratum corneum into the superficial epidermis to treat skin conditions.¹ For a topical drug to be absorbed effectively through the skin and into the general circulation, the vehicle needs to have affinity for both lipid and aqueous environments. Lipophilic drugs will absorb better through the stratum corneum, while hydrophilic drugs will absorb better through the aqueous layer of the epidermis. For a topical formulation to be both hydrophobic and hydrophilic, components such as viscosity enhancers and permeation enhancers can be added.¹ Many compounding pharmacies also have proprietary bases that can be used.

Final Thoughts

Compounding topical medications in dermatology provides dermatologists with the ability to provide unique formulations to best suit their patients’ individual needs. However, dermatologists must keep in mind the limitations of compounding topicals, including a lack of data on efficacy and safety.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.

An underappreciated problem

Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.¹ Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.²

While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.³ In a survey at one institution, 60% of medical students reported burnout.⁴ It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?

A recent study found burnout among medical students peaks during the third year of medical school.⁵ This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.

How residents can help

Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.

The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.⁶ Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.⁷ A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”

So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.

Continue to: It's as important to be proactive...

It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.

It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.

One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,¹ I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.

Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.

What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?

Fostering human connection

To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.

Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.

Over-the-counter (OTC) topical products commonly are discussed during dermatology encounters. Unsurprisingly, dermatologists recommend OTC topical formulations at the highest rate of all medical specialists.^1,2 These products may aid in the treatment of skin disease and include shampoo for seborrheic dermatitis, moisturizer for atopic dermatitis, and an armamentarium of products for acne. Conversely, an incorrect selection of OTC topicals can cause or exacerbate skin conditions or result in systemic toxicity. This article addresses how dermatology residents may become familiar with the safety, utility, and tolerability of these products.

Safety and Regulation

Over-the-counter products fall into one or more US Food and Drug Administration (FDA) categories, each of which is subject to a unique set of regulations. The FDA website (www.fda.gov/cosmetics and www.fda.gov/drugs) is an excellent resource for comprehensive and up-to-date information about categorization, safety, and regulation of these products.

Many OTC products are categorized as drugs, including topical steroids, antimicrobials, and sunscreens.3 Most of these products previously were available by prescription and became available OTC after sufficient postmarketing safety information.⁴ Once a drug becomes available OTC, monitoring relies on reporting from health care professionals.⁵ Notably, the safety of chemical sunscreens is being re-evaluated in light of recent data demonstrating serum levels in humans above the FDA limit for drugs exempt from further testing for carcinogenicity and reproductive and developmental effects.^6-8

Cosmetics include moisturizers, cleansing shampoos, deodorants, makeup, perfume, and hair colors.⁹ For cosmetics, the FDA prohibits use of 11 categories of ingredients, encourages manufacturers to perform safety testing, and has the legal authority to inspect manufacturing facilities.^9,10 The FDA does not require approval, testing, or disclosure of safety data prior to products going to market.⁹ Interestingly, soap represents a separate category with its own regulations, defined by its ingredients and its intended purpose.³

The FDA has the authority to regulate imported cosmetic products.¹¹ Unfortunately, imported cosmetic products have been reported to contain ingredients banned in the United States. For example, there recently have been several cases of mercury poisoning from bleaching creams imported from Mexico resulting in catastrophic neurologic damage.¹² Additionally, imported products sold OTC in the United States containing clobetasol were reported in the literature in 1994 and remain an ongoing issue.¹³

Another category relevant to dermatologists includes dietary supplements. The FDA is responsible for evaluating safety and labeling of products before marketing and taking action against any adulterated or misbranded dietary supplement.¹⁴ The FDA does not directly test products, though third-party agencies including NSF International and United States Pharmacopeia impart certification after verification that labeled ingredients are present in the product and test for contaminants.^15,16

Utility and Pharmacology

Dermatology residents may have less experience and comfort with the safety profiles and indications of nondrug ingredients in topical products. The textbook Comprehensive Dermatologic Drug Therapy¹⁷ is an excellent initial resource for learning about the mechanism of action, efficacy, pharmacology, and side effects of such ingredients, including hydroxy acids, shampoos, cleansers, sunscreens, insect repellents, and topical antioxidants. Dermatology residents also need to be familiar with ingredients causing allergic contact dermatitis, and Fisher’s Contact Dermatitis¹⁸ is an excellent resource.

When patients indicate use of a particular product, clinicians may not be certain about specific ingredients. In this case, they may refer to the Walgreens website (www.walgreens.com), which provides an ingredient list for all products that they sell. Additionally, the Environmental Working Group’s Skin Deep program (www.ewg.org/skindeep) maintains a database of more than 85,000 personal care products, which may be accessed online or using their mobile application (Healthy Living), which allows one to scan a product’s barcode.

Trying Them Out

Lastly, it is helpful for dermatologists to be personally familiar with a variety of products to address patients’ concerns regarding tolerability of products (eg, greasiness, inability to “rub in,” sunscreens leaving a white cast, drying effect of cleansers). Samples at conferences including the annual meeting of the American Academy of Dermatology provide a cost-effective way for residents to try out a variety of products. Additionally, residents may purchase different products each time they restock their own supply of personal care products to sample a variety.

Final Thoughts

The FDA website contains up-to-date information on the safety of OTC products, which is constantly in flux. This article provides additional references for dermatology residents to begin to learn about the safety, utility, and pharmacology of topical OTC products. Firsthand experience by sampling products helps dermatologists answer questions regarding tolerability.

Over-the-counter (OTC) topical products commonly are discussed during dermatology encounters. Unsurprisingly, dermatologists recommend OTC topical formulations at the highest rate of all medical specialists.^1,2 These products may aid in the treatment of skin disease and include shampoo for seborrheic dermatitis, moisturizer for atopic dermatitis, and an armamentarium of products for acne. Conversely, an incorrect selection of OTC topicals can cause or exacerbate skin conditions or result in systemic toxicity. This article addresses how dermatology residents may become familiar with the safety, utility, and tolerability of these products.

Safety and Regulation

Over-the-counter products fall into one or more US Food and Drug Administration (FDA) categories, each of which is subject to a unique set of regulations. The FDA website (www.fda.gov/cosmetics and www.fda.gov/drugs) is an excellent resource for comprehensive and up-to-date information about categorization, safety, and regulation of these products.

Many OTC products are categorized as drugs, including topical steroids, antimicrobials, and sunscreens.3 Most of these products previously were available by prescription and became available OTC after sufficient postmarketing safety information.⁴ Once a drug becomes available OTC, monitoring relies on reporting from health care professionals.⁵ Notably, the safety of chemical sunscreens is being re-evaluated in light of recent data demonstrating serum levels in humans above the FDA limit for drugs exempt from further testing for carcinogenicity and reproductive and developmental effects.^6-8

Cosmetics include moisturizers, cleansing shampoos, deodorants, makeup, perfume, and hair colors.⁹ For cosmetics, the FDA prohibits use of 11 categories of ingredients, encourages manufacturers to perform safety testing, and has the legal authority to inspect manufacturing facilities.^9,10 The FDA does not require approval, testing, or disclosure of safety data prior to products going to market.⁹ Interestingly, soap represents a separate category with its own regulations, defined by its ingredients and its intended purpose.³

The FDA has the authority to regulate imported cosmetic products.¹¹ Unfortunately, imported cosmetic products have been reported to contain ingredients banned in the United States. For example, there recently have been several cases of mercury poisoning from bleaching creams imported from Mexico resulting in catastrophic neurologic damage.¹² Additionally, imported products sold OTC in the United States containing clobetasol were reported in the literature in 1994 and remain an ongoing issue.¹³

Another category relevant to dermatologists includes dietary supplements. The FDA is responsible for evaluating safety and labeling of products before marketing and taking action against any adulterated or misbranded dietary supplement.¹⁴ The FDA does not directly test products, though third-party agencies including NSF International and United States Pharmacopeia impart certification after verification that labeled ingredients are present in the product and test for contaminants.^15,16

Utility and Pharmacology

Dermatology residents may have less experience and comfort with the safety profiles and indications of nondrug ingredients in topical products. The textbook Comprehensive Dermatologic Drug Therapy¹⁷ is an excellent initial resource for learning about the mechanism of action, efficacy, pharmacology, and side effects of such ingredients, including hydroxy acids, shampoos, cleansers, sunscreens, insect repellents, and topical antioxidants. Dermatology residents also need to be familiar with ingredients causing allergic contact dermatitis, and Fisher’s Contact Dermatitis¹⁸ is an excellent resource.

When patients indicate use of a particular product, clinicians may not be certain about specific ingredients. In this case, they may refer to the Walgreens website (www.walgreens.com), which provides an ingredient list for all products that they sell. Additionally, the Environmental Working Group’s Skin Deep program (www.ewg.org/skindeep) maintains a database of more than 85,000 personal care products, which may be accessed online or using their mobile application (Healthy Living), which allows one to scan a product’s barcode.

Trying Them Out

Lastly, it is helpful for dermatologists to be personally familiar with a variety of products to address patients’ concerns regarding tolerability of products (eg, greasiness, inability to “rub in,” sunscreens leaving a white cast, drying effect of cleansers). Samples at conferences including the annual meeting of the American Academy of Dermatology provide a cost-effective way for residents to try out a variety of products. Additionally, residents may purchase different products each time they restock their own supply of personal care products to sample a variety.

Final Thoughts

The FDA website contains up-to-date information on the safety of OTC products, which is constantly in flux. This article provides additional references for dermatology residents to begin to learn about the safety, utility, and pharmacology of topical OTC products. Firsthand experience by sampling products helps dermatologists answer questions regarding tolerability.

Over-the-counter (OTC) topical products commonly are discussed during dermatology encounters. Unsurprisingly, dermatologists recommend OTC topical formulations at the highest rate of all medical specialists.^1,2 These products may aid in the treatment of skin disease and include shampoo for seborrheic dermatitis, moisturizer for atopic dermatitis, and an armamentarium of products for acne. Conversely, an incorrect selection of OTC topicals can cause or exacerbate skin conditions or result in systemic toxicity. This article addresses how dermatology residents may become familiar with the safety, utility, and tolerability of these products.

Safety and Regulation

Over-the-counter products fall into one or more US Food and Drug Administration (FDA) categories, each of which is subject to a unique set of regulations. The FDA website (www.fda.gov/cosmetics and www.fda.gov/drugs) is an excellent resource for comprehensive and up-to-date information about categorization, safety, and regulation of these products.

Many OTC products are categorized as drugs, including topical steroids, antimicrobials, and sunscreens.3 Most of these products previously were available by prescription and became available OTC after sufficient postmarketing safety information.⁴ Once a drug becomes available OTC, monitoring relies on reporting from health care professionals.⁵ Notably, the safety of chemical sunscreens is being re-evaluated in light of recent data demonstrating serum levels in humans above the FDA limit for drugs exempt from further testing for carcinogenicity and reproductive and developmental effects.^6-8

Cosmetics include moisturizers, cleansing shampoos, deodorants, makeup, perfume, and hair colors.⁹ For cosmetics, the FDA prohibits use of 11 categories of ingredients, encourages manufacturers to perform safety testing, and has the legal authority to inspect manufacturing facilities.^9,10 The FDA does not require approval, testing, or disclosure of safety data prior to products going to market.⁹ Interestingly, soap represents a separate category with its own regulations, defined by its ingredients and its intended purpose.³

The FDA has the authority to regulate imported cosmetic products.¹¹ Unfortunately, imported cosmetic products have been reported to contain ingredients banned in the United States. For example, there recently have been several cases of mercury poisoning from bleaching creams imported from Mexico resulting in catastrophic neurologic damage.¹² Additionally, imported products sold OTC in the United States containing clobetasol were reported in the literature in 1994 and remain an ongoing issue.¹³

Another category relevant to dermatologists includes dietary supplements. The FDA is responsible for evaluating safety and labeling of products before marketing and taking action against any adulterated or misbranded dietary supplement.¹⁴ The FDA does not directly test products, though third-party agencies including NSF International and United States Pharmacopeia impart certification after verification that labeled ingredients are present in the product and test for contaminants.^15,16

Utility and Pharmacology

Dermatology residents may have less experience and comfort with the safety profiles and indications of nondrug ingredients in topical products. The textbook Comprehensive Dermatologic Drug Therapy¹⁷ is an excellent initial resource for learning about the mechanism of action, efficacy, pharmacology, and side effects of such ingredients, including hydroxy acids, shampoos, cleansers, sunscreens, insect repellents, and topical antioxidants. Dermatology residents also need to be familiar with ingredients causing allergic contact dermatitis, and Fisher’s Contact Dermatitis¹⁸ is an excellent resource.

When patients indicate use of a particular product, clinicians may not be certain about specific ingredients. In this case, they may refer to the Walgreens website (www.walgreens.com), which provides an ingredient list for all products that they sell. Additionally, the Environmental Working Group’s Skin Deep program (www.ewg.org/skindeep) maintains a database of more than 85,000 personal care products, which may be accessed online or using their mobile application (Healthy Living), which allows one to scan a product’s barcode.

Trying Them Out

Lastly, it is helpful for dermatologists to be personally familiar with a variety of products to address patients’ concerns regarding tolerability of products (eg, greasiness, inability to “rub in,” sunscreens leaving a white cast, drying effect of cleansers). Samples at conferences including the annual meeting of the American Academy of Dermatology provide a cost-effective way for residents to try out a variety of products. Additionally, residents may purchase different products each time they restock their own supply of personal care products to sample a variety.

Final Thoughts

The FDA website contains up-to-date information on the safety of OTC products, which is constantly in flux. This article provides additional references for dermatology residents to begin to learn about the safety, utility, and pharmacology of topical OTC products. Firsthand experience by sampling products helps dermatologists answer questions regarding tolerability.