Article

Psoriasis, one of the most researched diseases in dermatology, has a complex pathogenesis that is not yet fully understood. One of the most important stages of psoriasis pathogenesis is the proliferation of T helper (Th) 17 cells by IL-23 released from myeloid dendritic cells. Cytokines such as tumor necrosis factor (TNF) α released from Th1 cells and IL-17 and IL-22 released from Th17 cells are known to induce the proliferation of keratinocytes and the release of chemokines responsible for neutrophil chemotaxis.¹

Although secondary messengers such as cytokines and chemokines, which provide cell interaction with the extracellular matrix (ECM), have their own specific receptors, it is known that syndecans (SDCs) play a role in ECM and cell interactions and have receptor or coreceptor functions.² In humans, 4 types of SDCs have been identified (SDC1-SDC4), which are type I transmembrane proteoglycans found in all nucleated cells. Syndecans consist of heparan sulfate glycosaminoglycan chains that are structurally linked to a core protein sequence. The molecule has cytoplasmic, transmembrane, and extracellular domains.^2,3 While SDCs often are described as coreceptors for integrins and growth factor and hormone receptors, they also are capable of acting as signaling receptors by engaging intracellular messengers, including actin-related proteins and protein kinases.⁴ 

Prior research has indicated that the release of heparanase from the lysosomes of leukocytes during infection, inflammation, and endothelial damage causes cleavage of heparan sulfate glycosaminoglycans from the extracellular domains of SDCs. The peptide chains at the SDC core then are separated by matrix metalloproteinases in a process known as shedding. The shed SDCs may have either a stimulating or a suppressive effect on their receptor activity. Several cytokines are known to cause SDC shedding.^5,6 Many studies in recent years have reported that SDCs play a role in the pathogenesis of inflammatory diseases, for which serum levels of soluble SDCs can be biomarkers.⁷

In this study, we aimed to evaluate and compare serum SDC1, SDC4, TNF-α, and IL-17A levels in patients with psoriasis vs healthy controls. Additionally, by reviewing the literature data, we analyzed whether SDCs can be implicated in the pathogenesis of psoriasis and their potential role in this process.

Methods

The study population consisted of 40 patients with psoriasis and 40 healthy controls. Age and sex characteristics were similar between the 2 groups, but weight distribution was not. The psoriasis group included patients older than 18 years who had received a clinical and/or ­histologic diagnosis, had no systemic disease other than psoriasis in their medical history, and had not used any systemic treatment or phototherapy for the past 3 months. Healthy patients older than 18 years who had no medical history of inflammatory disease were included in the control group. Participants provided signed consent.

Data such as medical history, laboratory findings, and physical specifications were recorded. A Psoriasis Area and Severity Index (PASI) score of 10 or lower was considered mild disease, and a score higher than 10 was considered moderate to severe disease. An enzyme-linked immunosorbent assay was used to measure SDC1, SDC4, TNF-α, and IL-17A levels. 

The data were evaluated using the IBM SPSS Statistics V22.0 statistical package program. A P value of <.05 was considered statistically significant. The conformity of the data to a normal distribution was examined using a Shapiro-Wilk test. Normally distributed variables were expressed as mean (SD) and nonnormally distributed variables were expressed as median (interquartile range [IQR]). Data were compared between the 2 study groups using either a student t test (normal distribution) or Mann-Whitney U test (nonnormal distribution). Categorical variables were expressed as numbers and percentages. Categorical data were compared using a χ² test. Associations among SDC1, SDC4, TNF-α, IL-17A, and other variables were assessed using Spearman rank correlation. A binary logistic regression analysis was used to determine whether serum SDC1 and SDC4 levels were independent risk factors for psoriasis.

Results

The 2 study groups showed similar demographic characteristics in terms of sex (P=.67) and age (P=.22) distribution. The mean (SD) PASI score in the psoriasis group was 12.33 (7.62); the mean (SD) disease duration was 11.10 (8.00) years. Body weight and BMI were both significantly higher in the psoriasis group (P=.027 and P=.029, respectively) compared with the control group (eTable 1).

The mean (SD) serum SDC1 level was 119.52 ng/mL (69.53 ng/mL) in the psoriasis group, which was significantly higher than the control group (82.81 ng/mL [51.85 ng/mL])(P=.011)(eTable 2)(eFigure 1). The median (IQR) serum SDC4 level also was significantly higher in the psoriasis group compared with the control group (5.78 ng/mL [7.09 ng/mL] vs 3.92 ng/mL [2.88 ng/mL])(P=.030)(eTable 2)(eFigure 2). The median (IQR) IL-17A value was 59.94 pg/mL (12.97 pg/mL) in the psoriasis group, which was significantly higher than the control group (37.74 pg/mL [15.10 pg/mL])(P<.001)(eTable 2)(eFigure 3). The median (IQR) serum TNF-α level was 25.07 pg/mL (41.70 pg/mL) in the psoriasis group and 18.21 pg/mL (48.51 pg/mL) in the control group; however, the difference was not statistically significance (P=.444)(eTable 2)(eFigure 4). 

A significant positive correlation was found between serum SDC1 and PASI score (p=0.064; P=.03). Furthermore, significant positive correlations were ­identified between serum SDC1 and body weight (p=0.404; P<.001), disease duration (p=0.377; P=.008), and C-reactive protein (p=0.327; P=.002). A significant positive correlation also was identified between SDC4 and IL-17A (p=0.265; P=.009). Serum TNF-α was positively correlated with IL-17A (p=0.384; P<.001) and BMI (p=0.234; P=.020)(eTable 3).

Logistic regression analysis showed that high SDC1 levels were independently associated with the development of psoriasis (odds ratio [OR], 1.009; 95% CI, 1.000-1.017; P=.049)(eTable 4).

Comment

Tumor necrosis factor α and IL-17A are key cytokines whose roles in the pathogenesis of psoriasis are well established. Arican et al,⁸ Kyriakou et al,⁹ and Xuan et al¹⁰ previously reported a lack of any correlation between TNF-α and IL-17A in the pathogenesis of psoriasis; however, we observed a positive correlation between TNF-α and IL-17A in our study. This finding may be due to the abundant TNF-α production by myeloid dendritic cells involved in the transformation of naive T lymphocytes into IL-17A–secreting Th17 lymphocytes, which can also secrete TNF-α.

After the molecular cloning of SDCs by Saunders et al¹¹ in 1989, SDCs gained attention and have been the focus of many studies for their part in the pathogenesis of conditions such as inflammatory diseases, carcinogenesis, infections, sepsis, and trauma.^6,12 Among the inflammatory diseases sharing similar pathogenetic features to psoriasis, serum SDC4 levels are found to be elevated in rheumatoid arthritis and are correlated with disease activity.¹³ Cekic et al¹⁴ reported that serum SDC1 levels were significantly higher in patients with Crohn disease than controls (P=.03). Additionally, serum SDC1 levels were higher in patients with active disease compared with those who were in remission. Correlations between SDC1 and disease severity and C-reactive protein also have been found.¹⁴ Serum SDC-1 levels found to be elevated in patients with systemic lupus erythematosus were compared to the controls and were correlated with disease activity.¹⁵ Nakao et al¹⁶ reported that the serum SDC4 levels were significantly higher in patients with atopic dermatitis compared to controls (P<.01); further, SDC4 levels were correlated with severity of the disease.

Jaiswal et al¹⁷ reported that SDC1 is abundant on the surface of IL-17A–secreting γδ T lymphocytes (Tγδ17), whose contribution to psoriasis pathogenesis is known. When subjected to treatment with imiquimod, SDC1-suppressed mice displayed increased psoriasiform dermatitis compared with wild-type counterparts. The authors stated that SDC1 may play a role in controlling homeostasis of Tγδ17.¹⁷

In a study examining changes in the ECM in patients with psoriasis, it was observed that the expression of heparanase and metalloproteinase enzymes, which are responsible for SDC shedding, was higher in psoriasis plaques vs unaffected skin; furthermore, heparanase, metalloproteinases, and SDC1 expression were higher in unaffected skin samples from patients with psoriasis compared with tissues obtained from individuals without psoriasis.¹⁸ These data support our results, as increased serum SDC levels reflect increased shedding from the cell surface by heparanase and metalloproteinase activity. Pointing to the role of SDC1 in psoriasis, another study reported that upregulation of the metalloproteinase meprin β leads to increased SDC1 shedding; in turn, this shedding leads to impaired adhesion and differentiation of keratinocytes, resulting in psoriasislike skin changes in a mouse model.¹⁹

A study conducted by Koliakou et al²⁰ showed that, in healthy skin, SDC1 was expressed in almost the full thickness of the epidermis, but lowest expression was in the basal-layer keratinocytes. In a psoriatic epidermis, unlike the normal epidermis, SDC1 was found to be more intensely expressed in the keratinocytes of the basal layer, where keratinocyte proliferation occurs. In this study, SDC4 was expressed mainly at lower levels in a healthy epidermis, especially in the spinous and the basal layers. In a psoriatic epidermis, SDC4 was absent from all the layers. In the same study, gelatin-based carriers containing anti–TNF-α and anti–IL-17A were applied to a full-thickness epidermis with psoriatic lesions, after which SDC1 expression was observed to decrease almost completely in the psoriatic epidermis; there was no change in SDC4 expression, which also was not seen in the psoriatic epidermis. The authors claimed the application of these gelatin-based carriers could be a possible treatment modality for psoriasis, and the study provides evidence for the involvement of SDC1 and/or SDC4 in the pathogenesis of psoriasis.²⁰ Supporting these findings, another study showed that phototherapy can reduce SDC1 expression in psoriatic skin.²¹ In our study, a significant positive correlation was found between serum SDC4 and IL-17A (P=.009). IL-17A is known to be the key cytokine that stimulates keratinocyte proliferation in affected skin. Koliakou et al²⁰ reported that SDC4 was present on the surface of keratinocytes in normal skin but not in the psoriatic epidermis. This raises the question if IL-17A might lead to an increase in the shedding of SDC4; thus, SDC4 may mediate the effects of IL-17A.

Limitations of the current study include small sample size, lack of longitudinal data, lack of tissue testing of these molecules, and lack of external validation.

Conclusion

Overall, research has shown that SDCs play important roles in inflammatory processes, and more widespread inflammation has been associated with increased shedding of these molecules into the ECM and higher serum levels. In our study, serum SDC1, SDC4, and IL-17A levels were increased in patients with psoriasis compared to the healthy controls. A logistic regression analysis indicated that high serum SDC1 levels may be an independent risk factor for development of psoriasis. The increase in serum SDC1 and SDC4 levels and the positive correlation between SDC1 levels and disease severity observed in our study strongly implicate SDCs in the inflammatory disease psoriasis. The precise role of SDCs in the pathogenesis of psoriasis and the implications of targeting these molecules are the subject of more in-depth studies in the future.

Psoriasis, one of the most researched diseases in dermatology, has a complex pathogenesis that is not yet fully understood. One of the most important stages of psoriasis pathogenesis is the proliferation of T helper (Th) 17 cells by IL-23 released from myeloid dendritic cells. Cytokines such as tumor necrosis factor (TNF) α released from Th1 cells and IL-17 and IL-22 released from Th17 cells are known to induce the proliferation of keratinocytes and the release of chemokines responsible for neutrophil chemotaxis.¹

Although secondary messengers such as cytokines and chemokines, which provide cell interaction with the extracellular matrix (ECM), have their own specific receptors, it is known that syndecans (SDCs) play a role in ECM and cell interactions and have receptor or coreceptor functions.² In humans, 4 types of SDCs have been identified (SDC1-SDC4), which are type I transmembrane proteoglycans found in all nucleated cells. Syndecans consist of heparan sulfate glycosaminoglycan chains that are structurally linked to a core protein sequence. The molecule has cytoplasmic, transmembrane, and extracellular domains.^2,3 While SDCs often are described as coreceptors for integrins and growth factor and hormone receptors, they also are capable of acting as signaling receptors by engaging intracellular messengers, including actin-related proteins and protein kinases.⁴ 

Prior research has indicated that the release of heparanase from the lysosomes of leukocytes during infection, inflammation, and endothelial damage causes cleavage of heparan sulfate glycosaminoglycans from the extracellular domains of SDCs. The peptide chains at the SDC core then are separated by matrix metalloproteinases in a process known as shedding. The shed SDCs may have either a stimulating or a suppressive effect on their receptor activity. Several cytokines are known to cause SDC shedding.^5,6 Many studies in recent years have reported that SDCs play a role in the pathogenesis of inflammatory diseases, for which serum levels of soluble SDCs can be biomarkers.⁷

In this study, we aimed to evaluate and compare serum SDC1, SDC4, TNF-α, and IL-17A levels in patients with psoriasis vs healthy controls. Additionally, by reviewing the literature data, we analyzed whether SDCs can be implicated in the pathogenesis of psoriasis and their potential role in this process.

Methods

The study population consisted of 40 patients with psoriasis and 40 healthy controls. Age and sex characteristics were similar between the 2 groups, but weight distribution was not. The psoriasis group included patients older than 18 years who had received a clinical and/or ­histologic diagnosis, had no systemic disease other than psoriasis in their medical history, and had not used any systemic treatment or phototherapy for the past 3 months. Healthy patients older than 18 years who had no medical history of inflammatory disease were included in the control group. Participants provided signed consent.

Data such as medical history, laboratory findings, and physical specifications were recorded. A Psoriasis Area and Severity Index (PASI) score of 10 or lower was considered mild disease, and a score higher than 10 was considered moderate to severe disease. An enzyme-linked immunosorbent assay was used to measure SDC1, SDC4, TNF-α, and IL-17A levels. 

The data were evaluated using the IBM SPSS Statistics V22.0 statistical package program. A P value of <.05 was considered statistically significant. The conformity of the data to a normal distribution was examined using a Shapiro-Wilk test. Normally distributed variables were expressed as mean (SD) and nonnormally distributed variables were expressed as median (interquartile range [IQR]). Data were compared between the 2 study groups using either a student t test (normal distribution) or Mann-Whitney U test (nonnormal distribution). Categorical variables were expressed as numbers and percentages. Categorical data were compared using a χ² test. Associations among SDC1, SDC4, TNF-α, IL-17A, and other variables were assessed using Spearman rank correlation. A binary logistic regression analysis was used to determine whether serum SDC1 and SDC4 levels were independent risk factors for psoriasis.

Results

The 2 study groups showed similar demographic characteristics in terms of sex (P=.67) and age (P=.22) distribution. The mean (SD) PASI score in the psoriasis group was 12.33 (7.62); the mean (SD) disease duration was 11.10 (8.00) years. Body weight and BMI were both significantly higher in the psoriasis group (P=.027 and P=.029, respectively) compared with the control group (eTable 1).

The mean (SD) serum SDC1 level was 119.52 ng/mL (69.53 ng/mL) in the psoriasis group, which was significantly higher than the control group (82.81 ng/mL [51.85 ng/mL])(P=.011)(eTable 2)(eFigure 1). The median (IQR) serum SDC4 level also was significantly higher in the psoriasis group compared with the control group (5.78 ng/mL [7.09 ng/mL] vs 3.92 ng/mL [2.88 ng/mL])(P=.030)(eTable 2)(eFigure 2). The median (IQR) IL-17A value was 59.94 pg/mL (12.97 pg/mL) in the psoriasis group, which was significantly higher than the control group (37.74 pg/mL [15.10 pg/mL])(P<.001)(eTable 2)(eFigure 3). The median (IQR) serum TNF-α level was 25.07 pg/mL (41.70 pg/mL) in the psoriasis group and 18.21 pg/mL (48.51 pg/mL) in the control group; however, the difference was not statistically significance (P=.444)(eTable 2)(eFigure 4). 

A significant positive correlation was found between serum SDC1 and PASI score (p=0.064; P=.03). Furthermore, significant positive correlations were ­identified between serum SDC1 and body weight (p=0.404; P<.001), disease duration (p=0.377; P=.008), and C-reactive protein (p=0.327; P=.002). A significant positive correlation also was identified between SDC4 and IL-17A (p=0.265; P=.009). Serum TNF-α was positively correlated with IL-17A (p=0.384; P<.001) and BMI (p=0.234; P=.020)(eTable 3).

Logistic regression analysis showed that high SDC1 levels were independently associated with the development of psoriasis (odds ratio [OR], 1.009; 95% CI, 1.000-1.017; P=.049)(eTable 4).

Comment

Tumor necrosis factor α and IL-17A are key cytokines whose roles in the pathogenesis of psoriasis are well established. Arican et al,⁸ Kyriakou et al,⁹ and Xuan et al¹⁰ previously reported a lack of any correlation between TNF-α and IL-17A in the pathogenesis of psoriasis; however, we observed a positive correlation between TNF-α and IL-17A in our study. This finding may be due to the abundant TNF-α production by myeloid dendritic cells involved in the transformation of naive T lymphocytes into IL-17A–secreting Th17 lymphocytes, which can also secrete TNF-α.

After the molecular cloning of SDCs by Saunders et al¹¹ in 1989, SDCs gained attention and have been the focus of many studies for their part in the pathogenesis of conditions such as inflammatory diseases, carcinogenesis, infections, sepsis, and trauma.^6,12 Among the inflammatory diseases sharing similar pathogenetic features to psoriasis, serum SDC4 levels are found to be elevated in rheumatoid arthritis and are correlated with disease activity.¹³ Cekic et al¹⁴ reported that serum SDC1 levels were significantly higher in patients with Crohn disease than controls (P=.03). Additionally, serum SDC1 levels were higher in patients with active disease compared with those who were in remission. Correlations between SDC1 and disease severity and C-reactive protein also have been found.¹⁴ Serum SDC-1 levels found to be elevated in patients with systemic lupus erythematosus were compared to the controls and were correlated with disease activity.¹⁵ Nakao et al¹⁶ reported that the serum SDC4 levels were significantly higher in patients with atopic dermatitis compared to controls (P<.01); further, SDC4 levels were correlated with severity of the disease.

Jaiswal et al¹⁷ reported that SDC1 is abundant on the surface of IL-17A–secreting γδ T lymphocytes (Tγδ17), whose contribution to psoriasis pathogenesis is known. When subjected to treatment with imiquimod, SDC1-suppressed mice displayed increased psoriasiform dermatitis compared with wild-type counterparts. The authors stated that SDC1 may play a role in controlling homeostasis of Tγδ17.¹⁷

In a study examining changes in the ECM in patients with psoriasis, it was observed that the expression of heparanase and metalloproteinase enzymes, which are responsible for SDC shedding, was higher in psoriasis plaques vs unaffected skin; furthermore, heparanase, metalloproteinases, and SDC1 expression were higher in unaffected skin samples from patients with psoriasis compared with tissues obtained from individuals without psoriasis.¹⁸ These data support our results, as increased serum SDC levels reflect increased shedding from the cell surface by heparanase and metalloproteinase activity. Pointing to the role of SDC1 in psoriasis, another study reported that upregulation of the metalloproteinase meprin β leads to increased SDC1 shedding; in turn, this shedding leads to impaired adhesion and differentiation of keratinocytes, resulting in psoriasislike skin changes in a mouse model.¹⁹

A study conducted by Koliakou et al²⁰ showed that, in healthy skin, SDC1 was expressed in almost the full thickness of the epidermis, but lowest expression was in the basal-layer keratinocytes. In a psoriatic epidermis, unlike the normal epidermis, SDC1 was found to be more intensely expressed in the keratinocytes of the basal layer, where keratinocyte proliferation occurs. In this study, SDC4 was expressed mainly at lower levels in a healthy epidermis, especially in the spinous and the basal layers. In a psoriatic epidermis, SDC4 was absent from all the layers. In the same study, gelatin-based carriers containing anti–TNF-α and anti–IL-17A were applied to a full-thickness epidermis with psoriatic lesions, after which SDC1 expression was observed to decrease almost completely in the psoriatic epidermis; there was no change in SDC4 expression, which also was not seen in the psoriatic epidermis. The authors claimed the application of these gelatin-based carriers could be a possible treatment modality for psoriasis, and the study provides evidence for the involvement of SDC1 and/or SDC4 in the pathogenesis of psoriasis.²⁰ Supporting these findings, another study showed that phototherapy can reduce SDC1 expression in psoriatic skin.²¹ In our study, a significant positive correlation was found between serum SDC4 and IL-17A (P=.009). IL-17A is known to be the key cytokine that stimulates keratinocyte proliferation in affected skin. Koliakou et al²⁰ reported that SDC4 was present on the surface of keratinocytes in normal skin but not in the psoriatic epidermis. This raises the question if IL-17A might lead to an increase in the shedding of SDC4; thus, SDC4 may mediate the effects of IL-17A.

Limitations of the current study include small sample size, lack of longitudinal data, lack of tissue testing of these molecules, and lack of external validation.

Conclusion

Overall, research has shown that SDCs play important roles in inflammatory processes, and more widespread inflammation has been associated with increased shedding of these molecules into the ECM and higher serum levels. In our study, serum SDC1, SDC4, and IL-17A levels were increased in patients with psoriasis compared to the healthy controls. A logistic regression analysis indicated that high serum SDC1 levels may be an independent risk factor for development of psoriasis. The increase in serum SDC1 and SDC4 levels and the positive correlation between SDC1 levels and disease severity observed in our study strongly implicate SDCs in the inflammatory disease psoriasis. The precise role of SDCs in the pathogenesis of psoriasis and the implications of targeting these molecules are the subject of more in-depth studies in the future.

Psoriasis, one of the most researched diseases in dermatology, has a complex pathogenesis that is not yet fully understood. One of the most important stages of psoriasis pathogenesis is the proliferation of T helper (Th) 17 cells by IL-23 released from myeloid dendritic cells. Cytokines such as tumor necrosis factor (TNF) α released from Th1 cells and IL-17 and IL-22 released from Th17 cells are known to induce the proliferation of keratinocytes and the release of chemokines responsible for neutrophil chemotaxis.¹

Although secondary messengers such as cytokines and chemokines, which provide cell interaction with the extracellular matrix (ECM), have their own specific receptors, it is known that syndecans (SDCs) play a role in ECM and cell interactions and have receptor or coreceptor functions.² In humans, 4 types of SDCs have been identified (SDC1-SDC4), which are type I transmembrane proteoglycans found in all nucleated cells. Syndecans consist of heparan sulfate glycosaminoglycan chains that are structurally linked to a core protein sequence. The molecule has cytoplasmic, transmembrane, and extracellular domains.^2,3 While SDCs often are described as coreceptors for integrins and growth factor and hormone receptors, they also are capable of acting as signaling receptors by engaging intracellular messengers, including actin-related proteins and protein kinases.⁴ 

Prior research has indicated that the release of heparanase from the lysosomes of leukocytes during infection, inflammation, and endothelial damage causes cleavage of heparan sulfate glycosaminoglycans from the extracellular domains of SDCs. The peptide chains at the SDC core then are separated by matrix metalloproteinases in a process known as shedding. The shed SDCs may have either a stimulating or a suppressive effect on their receptor activity. Several cytokines are known to cause SDC shedding.^5,6 Many studies in recent years have reported that SDCs play a role in the pathogenesis of inflammatory diseases, for which serum levels of soluble SDCs can be biomarkers.⁷

In this study, we aimed to evaluate and compare serum SDC1, SDC4, TNF-α, and IL-17A levels in patients with psoriasis vs healthy controls. Additionally, by reviewing the literature data, we analyzed whether SDCs can be implicated in the pathogenesis of psoriasis and their potential role in this process.

Methods

The study population consisted of 40 patients with psoriasis and 40 healthy controls. Age and sex characteristics were similar between the 2 groups, but weight distribution was not. The psoriasis group included patients older than 18 years who had received a clinical and/or ­histologic diagnosis, had no systemic disease other than psoriasis in their medical history, and had not used any systemic treatment or phototherapy for the past 3 months. Healthy patients older than 18 years who had no medical history of inflammatory disease were included in the control group. Participants provided signed consent.

Data such as medical history, laboratory findings, and physical specifications were recorded. A Psoriasis Area and Severity Index (PASI) score of 10 or lower was considered mild disease, and a score higher than 10 was considered moderate to severe disease. An enzyme-linked immunosorbent assay was used to measure SDC1, SDC4, TNF-α, and IL-17A levels. 

The data were evaluated using the IBM SPSS Statistics V22.0 statistical package program. A P value of <.05 was considered statistically significant. The conformity of the data to a normal distribution was examined using a Shapiro-Wilk test. Normally distributed variables were expressed as mean (SD) and nonnormally distributed variables were expressed as median (interquartile range [IQR]). Data were compared between the 2 study groups using either a student t test (normal distribution) or Mann-Whitney U test (nonnormal distribution). Categorical variables were expressed as numbers and percentages. Categorical data were compared using a χ² test. Associations among SDC1, SDC4, TNF-α, IL-17A, and other variables were assessed using Spearman rank correlation. A binary logistic regression analysis was used to determine whether serum SDC1 and SDC4 levels were independent risk factors for psoriasis.

Results

The 2 study groups showed similar demographic characteristics in terms of sex (P=.67) and age (P=.22) distribution. The mean (SD) PASI score in the psoriasis group was 12.33 (7.62); the mean (SD) disease duration was 11.10 (8.00) years. Body weight and BMI were both significantly higher in the psoriasis group (P=.027 and P=.029, respectively) compared with the control group (eTable 1).

The mean (SD) serum SDC1 level was 119.52 ng/mL (69.53 ng/mL) in the psoriasis group, which was significantly higher than the control group (82.81 ng/mL [51.85 ng/mL])(P=.011)(eTable 2)(eFigure 1). The median (IQR) serum SDC4 level also was significantly higher in the psoriasis group compared with the control group (5.78 ng/mL [7.09 ng/mL] vs 3.92 ng/mL [2.88 ng/mL])(P=.030)(eTable 2)(eFigure 2). The median (IQR) IL-17A value was 59.94 pg/mL (12.97 pg/mL) in the psoriasis group, which was significantly higher than the control group (37.74 pg/mL [15.10 pg/mL])(P<.001)(eTable 2)(eFigure 3). The median (IQR) serum TNF-α level was 25.07 pg/mL (41.70 pg/mL) in the psoriasis group and 18.21 pg/mL (48.51 pg/mL) in the control group; however, the difference was not statistically significance (P=.444)(eTable 2)(eFigure 4). 

A significant positive correlation was found between serum SDC1 and PASI score (p=0.064; P=.03). Furthermore, significant positive correlations were ­identified between serum SDC1 and body weight (p=0.404; P<.001), disease duration (p=0.377; P=.008), and C-reactive protein (p=0.327; P=.002). A significant positive correlation also was identified between SDC4 and IL-17A (p=0.265; P=.009). Serum TNF-α was positively correlated with IL-17A (p=0.384; P<.001) and BMI (p=0.234; P=.020)(eTable 3).

Logistic regression analysis showed that high SDC1 levels were independently associated with the development of psoriasis (odds ratio [OR], 1.009; 95% CI, 1.000-1.017; P=.049)(eTable 4).

Comment

Tumor necrosis factor α and IL-17A are key cytokines whose roles in the pathogenesis of psoriasis are well established. Arican et al,⁸ Kyriakou et al,⁹ and Xuan et al¹⁰ previously reported a lack of any correlation between TNF-α and IL-17A in the pathogenesis of psoriasis; however, we observed a positive correlation between TNF-α and IL-17A in our study. This finding may be due to the abundant TNF-α production by myeloid dendritic cells involved in the transformation of naive T lymphocytes into IL-17A–secreting Th17 lymphocytes, which can also secrete TNF-α.

After the molecular cloning of SDCs by Saunders et al¹¹ in 1989, SDCs gained attention and have been the focus of many studies for their part in the pathogenesis of conditions such as inflammatory diseases, carcinogenesis, infections, sepsis, and trauma.^6,12 Among the inflammatory diseases sharing similar pathogenetic features to psoriasis, serum SDC4 levels are found to be elevated in rheumatoid arthritis and are correlated with disease activity.¹³ Cekic et al¹⁴ reported that serum SDC1 levels were significantly higher in patients with Crohn disease than controls (P=.03). Additionally, serum SDC1 levels were higher in patients with active disease compared with those who were in remission. Correlations between SDC1 and disease severity and C-reactive protein also have been found.¹⁴ Serum SDC-1 levels found to be elevated in patients with systemic lupus erythematosus were compared to the controls and were correlated with disease activity.¹⁵ Nakao et al¹⁶ reported that the serum SDC4 levels were significantly higher in patients with atopic dermatitis compared to controls (P<.01); further, SDC4 levels were correlated with severity of the disease.

Jaiswal et al¹⁷ reported that SDC1 is abundant on the surface of IL-17A–secreting γδ T lymphocytes (Tγδ17), whose contribution to psoriasis pathogenesis is known. When subjected to treatment with imiquimod, SDC1-suppressed mice displayed increased psoriasiform dermatitis compared with wild-type counterparts. The authors stated that SDC1 may play a role in controlling homeostasis of Tγδ17.¹⁷

In a study examining changes in the ECM in patients with psoriasis, it was observed that the expression of heparanase and metalloproteinase enzymes, which are responsible for SDC shedding, was higher in psoriasis plaques vs unaffected skin; furthermore, heparanase, metalloproteinases, and SDC1 expression were higher in unaffected skin samples from patients with psoriasis compared with tissues obtained from individuals without psoriasis.¹⁸ These data support our results, as increased serum SDC levels reflect increased shedding from the cell surface by heparanase and metalloproteinase activity. Pointing to the role of SDC1 in psoriasis, another study reported that upregulation of the metalloproteinase meprin β leads to increased SDC1 shedding; in turn, this shedding leads to impaired adhesion and differentiation of keratinocytes, resulting in psoriasislike skin changes in a mouse model.¹⁹

A study conducted by Koliakou et al²⁰ showed that, in healthy skin, SDC1 was expressed in almost the full thickness of the epidermis, but lowest expression was in the basal-layer keratinocytes. In a psoriatic epidermis, unlike the normal epidermis, SDC1 was found to be more intensely expressed in the keratinocytes of the basal layer, where keratinocyte proliferation occurs. In this study, SDC4 was expressed mainly at lower levels in a healthy epidermis, especially in the spinous and the basal layers. In a psoriatic epidermis, SDC4 was absent from all the layers. In the same study, gelatin-based carriers containing anti–TNF-α and anti–IL-17A were applied to a full-thickness epidermis with psoriatic lesions, after which SDC1 expression was observed to decrease almost completely in the psoriatic epidermis; there was no change in SDC4 expression, which also was not seen in the psoriatic epidermis. The authors claimed the application of these gelatin-based carriers could be a possible treatment modality for psoriasis, and the study provides evidence for the involvement of SDC1 and/or SDC4 in the pathogenesis of psoriasis.²⁰ Supporting these findings, another study showed that phototherapy can reduce SDC1 expression in psoriatic skin.²¹ In our study, a significant positive correlation was found between serum SDC4 and IL-17A (P=.009). IL-17A is known to be the key cytokine that stimulates keratinocyte proliferation in affected skin. Koliakou et al²⁰ reported that SDC4 was present on the surface of keratinocytes in normal skin but not in the psoriatic epidermis. This raises the question if IL-17A might lead to an increase in the shedding of SDC4; thus, SDC4 may mediate the effects of IL-17A.

Limitations of the current study include small sample size, lack of longitudinal data, lack of tissue testing of these molecules, and lack of external validation.

Conclusion

Overall, research has shown that SDCs play important roles in inflammatory processes, and more widespread inflammation has been associated with increased shedding of these molecules into the ECM and higher serum levels. In our study, serum SDC1, SDC4, and IL-17A levels were increased in patients with psoriasis compared to the healthy controls. A logistic regression analysis indicated that high serum SDC1 levels may be an independent risk factor for development of psoriasis. The increase in serum SDC1 and SDC4 levels and the positive correlation between SDC1 levels and disease severity observed in our study strongly implicate SDCs in the inflammatory disease psoriasis. The precise role of SDCs in the pathogenesis of psoriasis and the implications of targeting these molecules are the subject of more in-depth studies in the future.

What clinical signs suggest antimicrobial resistance is affecting acne treatment response, and how can dermatologists identify them early? 

DR. ROSAMILIA: Antibiotic resistance is a difficult phenomenon to define clinically for acne due to many pathogenic contributors, namely the increase in sebum production stoked by hormonal changes, which further provokes Cutibacterium acnes biofilms, follicular plugs, and various inflammatory cascades. The sequence and primacy of these steps are enigmatic in each patient, therefore the role and extent of true antimicrobial therapy are debatable. Acne is more complex than other conditions that utilize antimicrobials, such as tinea corporis. In acne, lack of treatment response may be due to various factors, including long-term adherence challenges (such as inconsistent home dosing and trending complex over-the-counter [OTC] regimens), hormonal fluctuation, and confounders such as gram-negative or pityrosporum folliculitis. Therefore, determining if resistant bacteria are “causal” in acne recalcitrance or exacerbation is vague. In older patients (or younger patients with chronic conditions), proof of bacterial resistance from wound, pulmonary, or gastrointestinal studies might be available, but a typical acne patient would not present with these data. 

Do you routinely rotate patients off oral antibiotics after a fixed treatment period, or is it symptom based? How do you balance the risk for disease recurrence with resistance concerns? 

DR. ROSAMILIA: For my patients, the typical “triple threat” for moderate acne—oral antibiotics, topical benzoyl peroxide, and topical retinoids—still is tried and true. I typically prescribe 6 weeks of low-dose antibiotic therapy (doxycycline 50 mg daily) and arrange a telemedicine visit at 4 to 6 weeks to assess progress and adherence. Subsequently, I might substitute topical for oral antibiotics, with long-term plans to discontinue all antibiotics. In females, I might add spironolactone and/or oral contraceptive pills, and for recalcitrant or progressive acne, I would discuss isotretinoin. If the patient’s acne is under good control without antibiotics but they still experience intermittent deeper papules, I consider adding burst therapy of low-dose doxycycline for 1 week as needed, or for instance, during sports seasons. I try to maintain the lowest possible dosage of doxycycline while toeing the line between short-term antibacterial and longer-term anti-inflammatory control. In fact, I typically recommend that patients take it with their morning meal to absorb slightly less than the full 50-mg dosage, mitigate adverse effects, and increase adherence. All of these regimens include a benzoyl peroxide wash for its many anti-acne properties and in the context of this discussion to mitigate C acnes on acne-prone skin without creating antibiotic resistance. 

Do you see a future for point-of-care microbiome or resistance testing in acne management? 

DR. ROSAMILIA: I think we should be receptive to the evolution of these tests, and depending on the patient’s insurance coverage, efficient collection methods, and applicability to all patients, we someday may approach antimicrobial pharmacotherapy in a more personalized way. The microbiome is a broad topic with protean approaches to testing and prebiotic/probiotic supplementation, so openminded but cautious and well-studied utilization is key. 

What language do you find effective when setting expectations for acne treatment that avoids overreliance on antibiotics? 

DR. ROSAMILIA: I find it important to first determine the patient’s prior therapies. Many patients with acne present to dermatology after taking a full dosage of various antibiotics for broad amounts of time, and they may have experienced acne exacerbation (or at least perception of such) when the refills ran out. Also, I ask them to outline their past and current OTC regimens, which provides context for where and how the patient gets their information and advice. I like providing the patient’s next steps in written form, even telling them to tape the instructions to their bathroom mirror. It is just as vital to take time at the first office visit to explain the expected time to improvement and why acne is a multifactorial condition for which antibiotics are only part of the approach with benzoyl peroxide and retinoids. 

What are your top practical tips for incoming dermatologists to practice antibiotic stewardship in acne management? 

DR. ROSAMILIA: The American Academy of Dermatology (AAD) guidelines recommend 3 to 4 months as the maximum threshold for systemic antibiotics for moderate to severe acne, with tetracyclines having the best evidence for efficacy and safety. The AAD recommends never utilizing these as monotherapy and always including concomitant benzoyl peroxide to avoid bacterial resistance and topicals such as retinoids to provide a bridge to a maintenance phase without antibiotics. Starting there gives trainees structure within which to build their own acne management approach and style for their patient population. Some dermatologists might prescribe middle to high antibiotic dosages at first followed by a taper or initiate low antibiotic dosages with a standard 3- to 4-month follow-up, or a bit of a hybrid of these, as outlined in my approach. As mentioned, standardized testing for resistance to guide our dosing is not mainstream. There are countless ways to apply these guardrails, consider a place for hormonal or future isotretinoin therapy, and include the many varieties of OTC and prescription acne topicals to round out a personalized regimen for each patient based on their schedule, medication intolerances, skin type, fertility plans, and lifestyle. 

What’s the single most impactful change a busy dermatology clinic could make right now to reduce antibiotic overuse in acne care? 

DR. ROSAMILIA: I think telemedicine or in-person check-ins at the 1- or 2-month mark are vital to the assessment of the patient’s and/or family’s understanding of the treatment schedule, their ability to procure the prescription and OTC products successfully, and their consistency in using them. This is a good opportunity to remind them that our goal is to see true acne improvement; take fewer medications, not more; and create a reality where their acne regimen is intuitive and safe.

What clinical signs suggest antimicrobial resistance is affecting acne treatment response, and how can dermatologists identify them early? 

DR. ROSAMILIA: Antibiotic resistance is a difficult phenomenon to define clinically for acne due to many pathogenic contributors, namely the increase in sebum production stoked by hormonal changes, which further provokes Cutibacterium acnes biofilms, follicular plugs, and various inflammatory cascades. The sequence and primacy of these steps are enigmatic in each patient, therefore the role and extent of true antimicrobial therapy are debatable. Acne is more complex than other conditions that utilize antimicrobials, such as tinea corporis. In acne, lack of treatment response may be due to various factors, including long-term adherence challenges (such as inconsistent home dosing and trending complex over-the-counter [OTC] regimens), hormonal fluctuation, and confounders such as gram-negative or pityrosporum folliculitis. Therefore, determining if resistant bacteria are “causal” in acne recalcitrance or exacerbation is vague. In older patients (or younger patients with chronic conditions), proof of bacterial resistance from wound, pulmonary, or gastrointestinal studies might be available, but a typical acne patient would not present with these data. 

Do you routinely rotate patients off oral antibiotics after a fixed treatment period, or is it symptom based? How do you balance the risk for disease recurrence with resistance concerns? 

DR. ROSAMILIA: For my patients, the typical “triple threat” for moderate acne—oral antibiotics, topical benzoyl peroxide, and topical retinoids—still is tried and true. I typically prescribe 6 weeks of low-dose antibiotic therapy (doxycycline 50 mg daily) and arrange a telemedicine visit at 4 to 6 weeks to assess progress and adherence. Subsequently, I might substitute topical for oral antibiotics, with long-term plans to discontinue all antibiotics. In females, I might add spironolactone and/or oral contraceptive pills, and for recalcitrant or progressive acne, I would discuss isotretinoin. If the patient’s acne is under good control without antibiotics but they still experience intermittent deeper papules, I consider adding burst therapy of low-dose doxycycline for 1 week as needed, or for instance, during sports seasons. I try to maintain the lowest possible dosage of doxycycline while toeing the line between short-term antibacterial and longer-term anti-inflammatory control. In fact, I typically recommend that patients take it with their morning meal to absorb slightly less than the full 50-mg dosage, mitigate adverse effects, and increase adherence. All of these regimens include a benzoyl peroxide wash for its many anti-acne properties and in the context of this discussion to mitigate C acnes on acne-prone skin without creating antibiotic resistance. 

Do you see a future for point-of-care microbiome or resistance testing in acne management? 

DR. ROSAMILIA: I think we should be receptive to the evolution of these tests, and depending on the patient’s insurance coverage, efficient collection methods, and applicability to all patients, we someday may approach antimicrobial pharmacotherapy in a more personalized way. The microbiome is a broad topic with protean approaches to testing and prebiotic/probiotic supplementation, so openminded but cautious and well-studied utilization is key. 

What language do you find effective when setting expectations for acne treatment that avoids overreliance on antibiotics? 

DR. ROSAMILIA: I find it important to first determine the patient’s prior therapies. Many patients with acne present to dermatology after taking a full dosage of various antibiotics for broad amounts of time, and they may have experienced acne exacerbation (or at least perception of such) when the refills ran out. Also, I ask them to outline their past and current OTC regimens, which provides context for where and how the patient gets their information and advice. I like providing the patient’s next steps in written form, even telling them to tape the instructions to their bathroom mirror. It is just as vital to take time at the first office visit to explain the expected time to improvement and why acne is a multifactorial condition for which antibiotics are only part of the approach with benzoyl peroxide and retinoids. 

What are your top practical tips for incoming dermatologists to practice antibiotic stewardship in acne management? 

DR. ROSAMILIA: The American Academy of Dermatology (AAD) guidelines recommend 3 to 4 months as the maximum threshold for systemic antibiotics for moderate to severe acne, with tetracyclines having the best evidence for efficacy and safety. The AAD recommends never utilizing these as monotherapy and always including concomitant benzoyl peroxide to avoid bacterial resistance and topicals such as retinoids to provide a bridge to a maintenance phase without antibiotics. Starting there gives trainees structure within which to build their own acne management approach and style for their patient population. Some dermatologists might prescribe middle to high antibiotic dosages at first followed by a taper or initiate low antibiotic dosages with a standard 3- to 4-month follow-up, or a bit of a hybrid of these, as outlined in my approach. As mentioned, standardized testing for resistance to guide our dosing is not mainstream. There are countless ways to apply these guardrails, consider a place for hormonal or future isotretinoin therapy, and include the many varieties of OTC and prescription acne topicals to round out a personalized regimen for each patient based on their schedule, medication intolerances, skin type, fertility plans, and lifestyle. 

What’s the single most impactful change a busy dermatology clinic could make right now to reduce antibiotic overuse in acne care? 

DR. ROSAMILIA: I think telemedicine or in-person check-ins at the 1- or 2-month mark are vital to the assessment of the patient’s and/or family’s understanding of the treatment schedule, their ability to procure the prescription and OTC products successfully, and their consistency in using them. This is a good opportunity to remind them that our goal is to see true acne improvement; take fewer medications, not more; and create a reality where their acne regimen is intuitive and safe.

What clinical signs suggest antimicrobial resistance is affecting acne treatment response, and how can dermatologists identify them early? 

DR. ROSAMILIA: Antibiotic resistance is a difficult phenomenon to define clinically for acne due to many pathogenic contributors, namely the increase in sebum production stoked by hormonal changes, which further provokes Cutibacterium acnes biofilms, follicular plugs, and various inflammatory cascades. The sequence and primacy of these steps are enigmatic in each patient, therefore the role and extent of true antimicrobial therapy are debatable. Acne is more complex than other conditions that utilize antimicrobials, such as tinea corporis. In acne, lack of treatment response may be due to various factors, including long-term adherence challenges (such as inconsistent home dosing and trending complex over-the-counter [OTC] regimens), hormonal fluctuation, and confounders such as gram-negative or pityrosporum folliculitis. Therefore, determining if resistant bacteria are “causal” in acne recalcitrance or exacerbation is vague. In older patients (or younger patients with chronic conditions), proof of bacterial resistance from wound, pulmonary, or gastrointestinal studies might be available, but a typical acne patient would not present with these data. 

Do you routinely rotate patients off oral antibiotics after a fixed treatment period, or is it symptom based? How do you balance the risk for disease recurrence with resistance concerns? 

DR. ROSAMILIA: For my patients, the typical “triple threat” for moderate acne—oral antibiotics, topical benzoyl peroxide, and topical retinoids—still is tried and true. I typically prescribe 6 weeks of low-dose antibiotic therapy (doxycycline 50 mg daily) and arrange a telemedicine visit at 4 to 6 weeks to assess progress and adherence. Subsequently, I might substitute topical for oral antibiotics, with long-term plans to discontinue all antibiotics. In females, I might add spironolactone and/or oral contraceptive pills, and for recalcitrant or progressive acne, I would discuss isotretinoin. If the patient’s acne is under good control without antibiotics but they still experience intermittent deeper papules, I consider adding burst therapy of low-dose doxycycline for 1 week as needed, or for instance, during sports seasons. I try to maintain the lowest possible dosage of doxycycline while toeing the line between short-term antibacterial and longer-term anti-inflammatory control. In fact, I typically recommend that patients take it with their morning meal to absorb slightly less than the full 50-mg dosage, mitigate adverse effects, and increase adherence. All of these regimens include a benzoyl peroxide wash for its many anti-acne properties and in the context of this discussion to mitigate C acnes on acne-prone skin without creating antibiotic resistance. 

Do you see a future for point-of-care microbiome or resistance testing in acne management? 

DR. ROSAMILIA: I think we should be receptive to the evolution of these tests, and depending on the patient’s insurance coverage, efficient collection methods, and applicability to all patients, we someday may approach antimicrobial pharmacotherapy in a more personalized way. The microbiome is a broad topic with protean approaches to testing and prebiotic/probiotic supplementation, so openminded but cautious and well-studied utilization is key. 

What language do you find effective when setting expectations for acne treatment that avoids overreliance on antibiotics? 

DR. ROSAMILIA: I find it important to first determine the patient’s prior therapies. Many patients with acne present to dermatology after taking a full dosage of various antibiotics for broad amounts of time, and they may have experienced acne exacerbation (or at least perception of such) when the refills ran out. Also, I ask them to outline their past and current OTC regimens, which provides context for where and how the patient gets their information and advice. I like providing the patient’s next steps in written form, even telling them to tape the instructions to their bathroom mirror. It is just as vital to take time at the first office visit to explain the expected time to improvement and why acne is a multifactorial condition for which antibiotics are only part of the approach with benzoyl peroxide and retinoids. 

What are your top practical tips for incoming dermatologists to practice antibiotic stewardship in acne management? 

DR. ROSAMILIA: The American Academy of Dermatology (AAD) guidelines recommend 3 to 4 months as the maximum threshold for systemic antibiotics for moderate to severe acne, with tetracyclines having the best evidence for efficacy and safety. The AAD recommends never utilizing these as monotherapy and always including concomitant benzoyl peroxide to avoid bacterial resistance and topicals such as retinoids to provide a bridge to a maintenance phase without antibiotics. Starting there gives trainees structure within which to build their own acne management approach and style for their patient population. Some dermatologists might prescribe middle to high antibiotic dosages at first followed by a taper or initiate low antibiotic dosages with a standard 3- to 4-month follow-up, or a bit of a hybrid of these, as outlined in my approach. As mentioned, standardized testing for resistance to guide our dosing is not mainstream. There are countless ways to apply these guardrails, consider a place for hormonal or future isotretinoin therapy, and include the many varieties of OTC and prescription acne topicals to round out a personalized regimen for each patient based on their schedule, medication intolerances, skin type, fertility plans, and lifestyle. 

What’s the single most impactful change a busy dermatology clinic could make right now to reduce antibiotic overuse in acne care? 

DR. ROSAMILIA: I think telemedicine or in-person check-ins at the 1- or 2-month mark are vital to the assessment of the patient’s and/or family’s understanding of the treatment schedule, their ability to procure the prescription and OTC products successfully, and their consistency in using them. This is a good opportunity to remind them that our goal is to see true acne improvement; take fewer medications, not more; and create a reality where their acne regimen is intuitive and safe.

THE DIAGNOSIS: Seborrheic Keratosis

Histopathology revealed epidermal hyperplasia and hyperkeratosis with no notation of atypical melanocytic activity (Figure). There were no Kamino bodies, junctional nesting, or cytologic atypia. Based on these features as well as the clinical and dermoscopic findings, a diagnosis of an inflamed seborrheic keratosis (SK) was made. No further treatment was required following the shave biopsy, and the patient was reassured regarding the benign nature of the lesion.

Seborrheic keratoses are benign epidermal growths that can manifest on any area of the skin except the palms and soles. They present clinically as tan, yellow, gray, brown, or black with a smooth, waxy, or verrucous surface. They range from 1 mm to several centimeters in diameter. Although SKs traditionally manifest more frequently in individuals with lighter skin tones, pigmented variants, such as dermatosis papulosa nigra, have been reported to occur more commonly and at younger ages in patients with skin of color.¹

Dermoscopy of SK in patients with skin of color can present diagnostic challenges, as these lesions may display atypical pigmented patterns that overlap with melanocytic lesions, including Spitz nevi, particularly when starburstlike or globular structures are present.² What sets inflamed SKs apart from other SKs is the lack of a heavily keratinized surface on both clinical and dermoscopic evaluation. Common histopathologic diagnostic criteria for Spitz nevi include Kamino bodies, uniform nuclear enlargement, and spindled or epithelioid nevus cells, which were not noted in our patient.³ Therefore, in presentations such as this, histopathology remains the gold standard for diagnosis.

The differential diagnosis in this case included benign nevus, dysplastic nevus, melanoma, and Spitz nevus. Benign nevi typically demonstrate uniform pigmentation and symmetric dermoscopic patterns. Dysplastic nevi may show architectural disorder and cytologic atypia but lack invasive features.³ Melanoma often exhibits asymmetry, atypical network patterns, and irregular pigmentation.⁴ Spitz nevi characteristically demonstrate large epithelioid or spindle cells with Kamino bodies on histopathology, which were absent in our patient.

THE DIAGNOSIS: Seborrheic Keratosis

Histopathology revealed epidermal hyperplasia and hyperkeratosis with no notation of atypical melanocytic activity (Figure). There were no Kamino bodies, junctional nesting, or cytologic atypia. Based on these features as well as the clinical and dermoscopic findings, a diagnosis of an inflamed seborrheic keratosis (SK) was made. No further treatment was required following the shave biopsy, and the patient was reassured regarding the benign nature of the lesion.

Seborrheic keratoses are benign epidermal growths that can manifest on any area of the skin except the palms and soles. They present clinically as tan, yellow, gray, brown, or black with a smooth, waxy, or verrucous surface. They range from 1 mm to several centimeters in diameter. Although SKs traditionally manifest more frequently in individuals with lighter skin tones, pigmented variants, such as dermatosis papulosa nigra, have been reported to occur more commonly and at younger ages in patients with skin of color.¹

Dermoscopy of SK in patients with skin of color can present diagnostic challenges, as these lesions may display atypical pigmented patterns that overlap with melanocytic lesions, including Spitz nevi, particularly when starburstlike or globular structures are present.² What sets inflamed SKs apart from other SKs is the lack of a heavily keratinized surface on both clinical and dermoscopic evaluation. Common histopathologic diagnostic criteria for Spitz nevi include Kamino bodies, uniform nuclear enlargement, and spindled or epithelioid nevus cells, which were not noted in our patient.³ Therefore, in presentations such as this, histopathology remains the gold standard for diagnosis.

The differential diagnosis in this case included benign nevus, dysplastic nevus, melanoma, and Spitz nevus. Benign nevi typically demonstrate uniform pigmentation and symmetric dermoscopic patterns. Dysplastic nevi may show architectural disorder and cytologic atypia but lack invasive features.³ Melanoma often exhibits asymmetry, atypical network patterns, and irregular pigmentation.⁴ Spitz nevi characteristically demonstrate large epithelioid or spindle cells with Kamino bodies on histopathology, which were absent in our patient.

THE DIAGNOSIS: Seborrheic Keratosis

Histopathology revealed epidermal hyperplasia and hyperkeratosis with no notation of atypical melanocytic activity (Figure). There were no Kamino bodies, junctional nesting, or cytologic atypia. Based on these features as well as the clinical and dermoscopic findings, a diagnosis of an inflamed seborrheic keratosis (SK) was made. No further treatment was required following the shave biopsy, and the patient was reassured regarding the benign nature of the lesion.

Seborrheic keratoses are benign epidermal growths that can manifest on any area of the skin except the palms and soles. They present clinically as tan, yellow, gray, brown, or black with a smooth, waxy, or verrucous surface. They range from 1 mm to several centimeters in diameter. Although SKs traditionally manifest more frequently in individuals with lighter skin tones, pigmented variants, such as dermatosis papulosa nigra, have been reported to occur more commonly and at younger ages in patients with skin of color.¹

Dermoscopy of SK in patients with skin of color can present diagnostic challenges, as these lesions may display atypical pigmented patterns that overlap with melanocytic lesions, including Spitz nevi, particularly when starburstlike or globular structures are present.² What sets inflamed SKs apart from other SKs is the lack of a heavily keratinized surface on both clinical and dermoscopic evaluation. Common histopathologic diagnostic criteria for Spitz nevi include Kamino bodies, uniform nuclear enlargement, and spindled or epithelioid nevus cells, which were not noted in our patient.³ Therefore, in presentations such as this, histopathology remains the gold standard for diagnosis.

The differential diagnosis in this case included benign nevus, dysplastic nevus, melanoma, and Spitz nevus. Benign nevi typically demonstrate uniform pigmentation and symmetric dermoscopic patterns. Dysplastic nevi may show architectural disorder and cytologic atypia but lack invasive features.³ Melanoma often exhibits asymmetry, atypical network patterns, and irregular pigmentation.⁴ Spitz nevi characteristically demonstrate large epithelioid or spindle cells with Kamino bodies on histopathology, which were absent in our patient.

According to the US Department of Defense (DoD), proper wear of the military uniform and adherence to grooming standards are essential components of military discipline and unit cohesion.^1,2 The DoD posits that personal appearance reflects the professionalism, integrity, and accountability expected of all service members. These standards promote a shared identity and reinforce the discipline required for military organizations to operate as cohesive, unified, mission-oriented teams. Personal appearance embodies integrity, commitment to duty, and respect for institutional norms.^1,2 In some situations, grooming standards also carry critical operational relevance; for example, the DoD states that a clean-shaven face is necessary to ensure a proper seal for gas masks and other personal protective equipment used in combat environments, especially when chemical or biological weapons are used.³ The Uniform Code of Military Justice states that service members who fail to comply with grooming standards, unless exempted, are subject to disciplinary action.⁴

In early March 2025, new directives from the DoD prompted a comprehensive review of personal grooming standards and wear of military uniforms across the uniformed services. The stated goal of these revisions was to enhance discipline, professionalism, and military readiness.^5,6 These policy updates reversed several grooming accommodations introduced in prior administrations that allowed greater flexibility in personal appearance and hair-grooming practices for service members. The 2025 revised standards entail re-examination and rewriting regulations that govern grooming standards.

The new grooming regulations are likely to have major effects on service members with pseudofolliculitis barbae (PFB), a chronic inflammatory condition of the facial skin that often occurs due to and is aggravated by repeated close shaving. Through most of their histories, each US military branch has required a clean, smooth-shaven facial appearance that entailed regular (usually daily) shaving of facial hair; however, service-specific grooming instructions and medical guidelines have permitted commanders to authorize temporary or permanent ­exemptions or waivers for service members with PFB. To obtain a shaving waiver, individuals with PFB work closely with a military medical officer to design a shaving strategy that will not exacerbate PFB. If medical management was unsuccessful, the medical officer usually prepared a recommendation for a shaving waiver that also required approval from the service member’s commanding officer. Waivers were handled on a case-by-case basis and could be temporary (eg, for 3 months), recurring/­renewable, or permanent.

The recent policy shifts make it difficult for service members to obtain renewable and permanent shaving waivers, raising concerns about medical outcomes and readiness implications. In this article, we examine the updated facial hair grooming standards across the uniformed services with a focus on the medical, regulatory, and administrative management of PFB.

Background and Policy Shifts

In March 2025, the Secretary of Defense ordered a widespread review of grooming standards in the armed forces.⁶ In accordance with this directive, the Army, Navy, Air Force, and Marine Corps made revisions to their uniform and grooming regulations. In August 2025, the Secretary of Defense issued a memorandum that reinforced the expectation that service members remain clean shaven and introduced additional limits on medical waivers.⁷ Under this policy, medical officers must provide written recommendations, while commanders remain the final approval authority. Service members with approved shaving waivers for PFB also must participate in a medical treatment plan for the condition. Importantly, the memorandum directed unit commanders to initiate separation for service members in any branch who continue to require a shaving waiver after more than 1 year of medical management. This directive underscores the DoD’s emphasis on uniformity and cohesion as visible markers of professionalism and the “warrior ethos.”⁷

Regulatory Framework and Enforcement

Beginning in March 2025, centrally mandated revisions to existing directives introduced more restrictive grooming and appearance standards across all military services. A key area of enforcement involves strict management of medical shaving waivers, particularly those related to PFB, which indicates a reversal of previous accommodations. Because of the lack of effective treatment for intractable PFB, the DoD previously has permitted service members to obtain permanent shaving waivers. The use of long-term waivers reduced administrative burden by removing the need for repeated evaluations and routine renewal paperwork, thereby decreasing the workload for service members, medical officers, and commanders. In the Army and Marine Corps, new grooming standards^8,9 eliminate permanent waivers and prohibit pro forma renewals or extensions of existing waivers. Service members with PFB must seek a medical provider who will conduct a new full clinical evaluation, prepare new documentation requesting another temporary shaving waiver, and submit the application for the commander’s review and approval.

The Air Force also has adopted a stricter stance on shaving waivers. Under previous guidelines, service members diagnosed with PFB were eligible for a 5-year waiver that did not require annual renewal.¹⁰ However, the new 2025 guidelines eliminated this option. Now, waivers are subject to increased scrutiny and may be extended only for service members with severe, well-documented cases of PFB. In addition, the waiver must be approved by the commanding officer.¹¹ The updated policy does not specify whether an existing waiver can be continued (ie, rolled over) or if a complete de novo waiver is required.

The new policies that eliminate long-term waivers introduce logistical and administrative requirements that are likely to be time consuming, at multiple levels of the military. In the Army and Marine Corps, it is immaterial whether the request comes from a new recruit or from a seasoned service member who has had a shaving waiver for their entire career. Under the new policy, every waiver requires a formal medical appointment with a licensed health care provider, documentation and case review, completion of a standardized waiver form with the provider’s signature, and signed approval by the commanding officer.⁸

Across military services, available data indicate a substantial rise in shaving waivers over the past decade. Between 2021 and 2023, the number of active-duty Air Force personnel with PFB-related shaving waivers increased from 10,965 to 18,991.¹² Meanwhile, the Army has reported that more than 40,000 new shaving waivers were issued in 2024.¹³ While Black service members comprise roughly 15% of the active-duty force, they account for 66% of shaving waiver holders.¹⁴

Implications and Perspectives

Shaving waivers had provided a medically and administratively supported avenue for managing PFB within the relevant service requirements; however, the new policies have mandated a shift toward more regulated timelines for waiver evaluation and renewal, prohibition of permanent shaving waivers, and shortened durations of temporary shaving waivers.¹⁵ These changes impose higher time demands and administrative responsibilities on affected service members, on the chain of command, and on the US Army Medical Department.

The new guidelines reintroduced a command-level policy for PFB that differs from the clinically focused recommendations outlined in the Army’s official medical guidance on PFB.^8,15 The new directives also explicitly tie an individual’s potential eligibility to remain in the Army—across active, reserve, and National Guard components—to their ability to meet the new facial-hair grooming standards.⁸ The policy sets a clear benchmark for retention: failing to meet grooming standards for 12 or more months within a 24-month period automatically launches a process that leads to administrative separation. Similarly, a new Marine Corps directive authorizes administrative separation for Marines who require a medical grooming waiver for more than 1 year.¹¹ These branch-specific changes appear to implement a broader DoD policy outlined in the August 2025 memorandum, which represents a tightening of medical shaving waivers across all branches by limiting them to no more than 1 year in duration before triggering a review for administrative separation.⁷ Additional implications also may include increased utilization of laser hair removal (LHR) for service members for whom conservative management has failed and who wish to pursue more definitive options. Given the potential career implications of PFB, LHR may become a more frequently considered intervention among military and civilian dermatologists. In the civilian sector, TRICARE covers LHR for active-duty service members when deemed medically necessary and unavailable at their military treatment facility.¹⁴ Consequently, civilian dermatologists may see an increase in referrals from military personnel seeking LHR to maintain compliance with grooming standards under the new policy framework.

Final Thoughts

Military personnel, their chain of command, and the military medical system are keenly aware of the DoD’s newly mandated policy changes regarding grooming standards. There are many circumstances in which military personnel (eg, active-duty service members, reservists, National Guard members) receive medical care from civilian providers, who may not be up to date on changes in the military’s approach toward grooming. Civilian dermatologists may be the first to diagnose or treat PFB in prospective recruits and should be aware that under current DoD policy, failure to meet grooming standards can lead to premature separation from military service. Civilian providers who are aware that the DoD’s policies on shaving and waivers have changed dramatically can discuss these implications when evaluating or counseling patients with a history of or risk for PFB. Previously published guidelines for service members seeking a shaving waiver for PFB are listed in eTable 1.^10,16-23 The current changes, which remove various accommodations that previously had been introduced, are detailed in eTable 2.^7-9,15,24

The grooming policy changes, particularly in the Army and Marines, require de novo waivers, which are likely to increase health care costs as measured in time and dollars. Each waiver cycle involves medical evaluation, documentation, and chain-of-command review. The cumulative work of these recurring requirements becomes considerable when scaled across the force.

As the military’s grooming policies evolve, ongoing evaluation of their effects on service members and unit readiness remains important. Continued data collection, transparent communication, and collaboration among military institutions and health care providers may help ensure that future policy updates maintain operational standards while also supporting the health and well-being of the force.

According to the US Department of Defense (DoD), proper wear of the military uniform and adherence to grooming standards are essential components of military discipline and unit cohesion.^1,2 The DoD posits that personal appearance reflects the professionalism, integrity, and accountability expected of all service members. These standards promote a shared identity and reinforce the discipline required for military organizations to operate as cohesive, unified, mission-oriented teams. Personal appearance embodies integrity, commitment to duty, and respect for institutional norms.^1,2 In some situations, grooming standards also carry critical operational relevance; for example, the DoD states that a clean-shaven face is necessary to ensure a proper seal for gas masks and other personal protective equipment used in combat environments, especially when chemical or biological weapons are used.³ The Uniform Code of Military Justice states that service members who fail to comply with grooming standards, unless exempted, are subject to disciplinary action.⁴

In early March 2025, new directives from the DoD prompted a comprehensive review of personal grooming standards and wear of military uniforms across the uniformed services. The stated goal of these revisions was to enhance discipline, professionalism, and military readiness.^5,6 These policy updates reversed several grooming accommodations introduced in prior administrations that allowed greater flexibility in personal appearance and hair-grooming practices for service members. The 2025 revised standards entail re-examination and rewriting regulations that govern grooming standards.

The new grooming regulations are likely to have major effects on service members with pseudofolliculitis barbae (PFB), a chronic inflammatory condition of the facial skin that often occurs due to and is aggravated by repeated close shaving. Through most of their histories, each US military branch has required a clean, smooth-shaven facial appearance that entailed regular (usually daily) shaving of facial hair; however, service-specific grooming instructions and medical guidelines have permitted commanders to authorize temporary or permanent ­exemptions or waivers for service members with PFB. To obtain a shaving waiver, individuals with PFB work closely with a military medical officer to design a shaving strategy that will not exacerbate PFB. If medical management was unsuccessful, the medical officer usually prepared a recommendation for a shaving waiver that also required approval from the service member’s commanding officer. Waivers were handled on a case-by-case basis and could be temporary (eg, for 3 months), recurring/­renewable, or permanent.

The recent policy shifts make it difficult for service members to obtain renewable and permanent shaving waivers, raising concerns about medical outcomes and readiness implications. In this article, we examine the updated facial hair grooming standards across the uniformed services with a focus on the medical, regulatory, and administrative management of PFB.

Background and Policy Shifts

In March 2025, the Secretary of Defense ordered a widespread review of grooming standards in the armed forces.⁶ In accordance with this directive, the Army, Navy, Air Force, and Marine Corps made revisions to their uniform and grooming regulations. In August 2025, the Secretary of Defense issued a memorandum that reinforced the expectation that service members remain clean shaven and introduced additional limits on medical waivers.⁷ Under this policy, medical officers must provide written recommendations, while commanders remain the final approval authority. Service members with approved shaving waivers for PFB also must participate in a medical treatment plan for the condition. Importantly, the memorandum directed unit commanders to initiate separation for service members in any branch who continue to require a shaving waiver after more than 1 year of medical management. This directive underscores the DoD’s emphasis on uniformity and cohesion as visible markers of professionalism and the “warrior ethos.”⁷

Regulatory Framework and Enforcement

Beginning in March 2025, centrally mandated revisions to existing directives introduced more restrictive grooming and appearance standards across all military services. A key area of enforcement involves strict management of medical shaving waivers, particularly those related to PFB, which indicates a reversal of previous accommodations. Because of the lack of effective treatment for intractable PFB, the DoD previously has permitted service members to obtain permanent shaving waivers. The use of long-term waivers reduced administrative burden by removing the need for repeated evaluations and routine renewal paperwork, thereby decreasing the workload for service members, medical officers, and commanders. In the Army and Marine Corps, new grooming standards^8,9 eliminate permanent waivers and prohibit pro forma renewals or extensions of existing waivers. Service members with PFB must seek a medical provider who will conduct a new full clinical evaluation, prepare new documentation requesting another temporary shaving waiver, and submit the application for the commander’s review and approval.

The Air Force also has adopted a stricter stance on shaving waivers. Under previous guidelines, service members diagnosed with PFB were eligible for a 5-year waiver that did not require annual renewal.¹⁰ However, the new 2025 guidelines eliminated this option. Now, waivers are subject to increased scrutiny and may be extended only for service members with severe, well-documented cases of PFB. In addition, the waiver must be approved by the commanding officer.¹¹ The updated policy does not specify whether an existing waiver can be continued (ie, rolled over) or if a complete de novo waiver is required.

The new policies that eliminate long-term waivers introduce logistical and administrative requirements that are likely to be time consuming, at multiple levels of the military. In the Army and Marine Corps, it is immaterial whether the request comes from a new recruit or from a seasoned service member who has had a shaving waiver for their entire career. Under the new policy, every waiver requires a formal medical appointment with a licensed health care provider, documentation and case review, completion of a standardized waiver form with the provider’s signature, and signed approval by the commanding officer.⁸

Across military services, available data indicate a substantial rise in shaving waivers over the past decade. Between 2021 and 2023, the number of active-duty Air Force personnel with PFB-related shaving waivers increased from 10,965 to 18,991.¹² Meanwhile, the Army has reported that more than 40,000 new shaving waivers were issued in 2024.¹³ While Black service members comprise roughly 15% of the active-duty force, they account for 66% of shaving waiver holders.¹⁴

Implications and Perspectives

Shaving waivers had provided a medically and administratively supported avenue for managing PFB within the relevant service requirements; however, the new policies have mandated a shift toward more regulated timelines for waiver evaluation and renewal, prohibition of permanent shaving waivers, and shortened durations of temporary shaving waivers.¹⁵ These changes impose higher time demands and administrative responsibilities on affected service members, on the chain of command, and on the US Army Medical Department.

The new guidelines reintroduced a command-level policy for PFB that differs from the clinically focused recommendations outlined in the Army’s official medical guidance on PFB.^8,15 The new directives also explicitly tie an individual’s potential eligibility to remain in the Army—across active, reserve, and National Guard components—to their ability to meet the new facial-hair grooming standards.⁸ The policy sets a clear benchmark for retention: failing to meet grooming standards for 12 or more months within a 24-month period automatically launches a process that leads to administrative separation. Similarly, a new Marine Corps directive authorizes administrative separation for Marines who require a medical grooming waiver for more than 1 year.¹¹ These branch-specific changes appear to implement a broader DoD policy outlined in the August 2025 memorandum, which represents a tightening of medical shaving waivers across all branches by limiting them to no more than 1 year in duration before triggering a review for administrative separation.⁷ Additional implications also may include increased utilization of laser hair removal (LHR) for service members for whom conservative management has failed and who wish to pursue more definitive options. Given the potential career implications of PFB, LHR may become a more frequently considered intervention among military and civilian dermatologists. In the civilian sector, TRICARE covers LHR for active-duty service members when deemed medically necessary and unavailable at their military treatment facility.¹⁴ Consequently, civilian dermatologists may see an increase in referrals from military personnel seeking LHR to maintain compliance with grooming standards under the new policy framework.

Final Thoughts

Military personnel, their chain of command, and the military medical system are keenly aware of the DoD’s newly mandated policy changes regarding grooming standards. There are many circumstances in which military personnel (eg, active-duty service members, reservists, National Guard members) receive medical care from civilian providers, who may not be up to date on changes in the military’s approach toward grooming. Civilian dermatologists may be the first to diagnose or treat PFB in prospective recruits and should be aware that under current DoD policy, failure to meet grooming standards can lead to premature separation from military service. Civilian providers who are aware that the DoD’s policies on shaving and waivers have changed dramatically can discuss these implications when evaluating or counseling patients with a history of or risk for PFB. Previously published guidelines for service members seeking a shaving waiver for PFB are listed in eTable 1.^10,16-23 The current changes, which remove various accommodations that previously had been introduced, are detailed in eTable 2.^7-9,15,24

The grooming policy changes, particularly in the Army and Marines, require de novo waivers, which are likely to increase health care costs as measured in time and dollars. Each waiver cycle involves medical evaluation, documentation, and chain-of-command review. The cumulative work of these recurring requirements becomes considerable when scaled across the force.

As the military’s grooming policies evolve, ongoing evaluation of their effects on service members and unit readiness remains important. Continued data collection, transparent communication, and collaboration among military institutions and health care providers may help ensure that future policy updates maintain operational standards while also supporting the health and well-being of the force.

According to the US Department of Defense (DoD), proper wear of the military uniform and adherence to grooming standards are essential components of military discipline and unit cohesion.^1,2 The DoD posits that personal appearance reflects the professionalism, integrity, and accountability expected of all service members. These standards promote a shared identity and reinforce the discipline required for military organizations to operate as cohesive, unified, mission-oriented teams. Personal appearance embodies integrity, commitment to duty, and respect for institutional norms.^1,2 In some situations, grooming standards also carry critical operational relevance; for example, the DoD states that a clean-shaven face is necessary to ensure a proper seal for gas masks and other personal protective equipment used in combat environments, especially when chemical or biological weapons are used.³ The Uniform Code of Military Justice states that service members who fail to comply with grooming standards, unless exempted, are subject to disciplinary action.⁴

In early March 2025, new directives from the DoD prompted a comprehensive review of personal grooming standards and wear of military uniforms across the uniformed services. The stated goal of these revisions was to enhance discipline, professionalism, and military readiness.^5,6 These policy updates reversed several grooming accommodations introduced in prior administrations that allowed greater flexibility in personal appearance and hair-grooming practices for service members. The 2025 revised standards entail re-examination and rewriting regulations that govern grooming standards.

The new grooming regulations are likely to have major effects on service members with pseudofolliculitis barbae (PFB), a chronic inflammatory condition of the facial skin that often occurs due to and is aggravated by repeated close shaving. Through most of their histories, each US military branch has required a clean, smooth-shaven facial appearance that entailed regular (usually daily) shaving of facial hair; however, service-specific grooming instructions and medical guidelines have permitted commanders to authorize temporary or permanent ­exemptions or waivers for service members with PFB. To obtain a shaving waiver, individuals with PFB work closely with a military medical officer to design a shaving strategy that will not exacerbate PFB. If medical management was unsuccessful, the medical officer usually prepared a recommendation for a shaving waiver that also required approval from the service member’s commanding officer. Waivers were handled on a case-by-case basis and could be temporary (eg, for 3 months), recurring/­renewable, or permanent.

The recent policy shifts make it difficult for service members to obtain renewable and permanent shaving waivers, raising concerns about medical outcomes and readiness implications. In this article, we examine the updated facial hair grooming standards across the uniformed services with a focus on the medical, regulatory, and administrative management of PFB.

Background and Policy Shifts

In March 2025, the Secretary of Defense ordered a widespread review of grooming standards in the armed forces.⁶ In accordance with this directive, the Army, Navy, Air Force, and Marine Corps made revisions to their uniform and grooming regulations. In August 2025, the Secretary of Defense issued a memorandum that reinforced the expectation that service members remain clean shaven and introduced additional limits on medical waivers.⁷ Under this policy, medical officers must provide written recommendations, while commanders remain the final approval authority. Service members with approved shaving waivers for PFB also must participate in a medical treatment plan for the condition. Importantly, the memorandum directed unit commanders to initiate separation for service members in any branch who continue to require a shaving waiver after more than 1 year of medical management. This directive underscores the DoD’s emphasis on uniformity and cohesion as visible markers of professionalism and the “warrior ethos.”⁷

Regulatory Framework and Enforcement

Beginning in March 2025, centrally mandated revisions to existing directives introduced more restrictive grooming and appearance standards across all military services. A key area of enforcement involves strict management of medical shaving waivers, particularly those related to PFB, which indicates a reversal of previous accommodations. Because of the lack of effective treatment for intractable PFB, the DoD previously has permitted service members to obtain permanent shaving waivers. The use of long-term waivers reduced administrative burden by removing the need for repeated evaluations and routine renewal paperwork, thereby decreasing the workload for service members, medical officers, and commanders. In the Army and Marine Corps, new grooming standards^8,9 eliminate permanent waivers and prohibit pro forma renewals or extensions of existing waivers. Service members with PFB must seek a medical provider who will conduct a new full clinical evaluation, prepare new documentation requesting another temporary shaving waiver, and submit the application for the commander’s review and approval.

The Air Force also has adopted a stricter stance on shaving waivers. Under previous guidelines, service members diagnosed with PFB were eligible for a 5-year waiver that did not require annual renewal.¹⁰ However, the new 2025 guidelines eliminated this option. Now, waivers are subject to increased scrutiny and may be extended only for service members with severe, well-documented cases of PFB. In addition, the waiver must be approved by the commanding officer.¹¹ The updated policy does not specify whether an existing waiver can be continued (ie, rolled over) or if a complete de novo waiver is required.

The new policies that eliminate long-term waivers introduce logistical and administrative requirements that are likely to be time consuming, at multiple levels of the military. In the Army and Marine Corps, it is immaterial whether the request comes from a new recruit or from a seasoned service member who has had a shaving waiver for their entire career. Under the new policy, every waiver requires a formal medical appointment with a licensed health care provider, documentation and case review, completion of a standardized waiver form with the provider’s signature, and signed approval by the commanding officer.⁸

Across military services, available data indicate a substantial rise in shaving waivers over the past decade. Between 2021 and 2023, the number of active-duty Air Force personnel with PFB-related shaving waivers increased from 10,965 to 18,991.¹² Meanwhile, the Army has reported that more than 40,000 new shaving waivers were issued in 2024.¹³ While Black service members comprise roughly 15% of the active-duty force, they account for 66% of shaving waiver holders.¹⁴

Implications and Perspectives

Shaving waivers had provided a medically and administratively supported avenue for managing PFB within the relevant service requirements; however, the new policies have mandated a shift toward more regulated timelines for waiver evaluation and renewal, prohibition of permanent shaving waivers, and shortened durations of temporary shaving waivers.¹⁵ These changes impose higher time demands and administrative responsibilities on affected service members, on the chain of command, and on the US Army Medical Department.

The new guidelines reintroduced a command-level policy for PFB that differs from the clinically focused recommendations outlined in the Army’s official medical guidance on PFB.^8,15 The new directives also explicitly tie an individual’s potential eligibility to remain in the Army—across active, reserve, and National Guard components—to their ability to meet the new facial-hair grooming standards.⁸ The policy sets a clear benchmark for retention: failing to meet grooming standards for 12 or more months within a 24-month period automatically launches a process that leads to administrative separation. Similarly, a new Marine Corps directive authorizes administrative separation for Marines who require a medical grooming waiver for more than 1 year.¹¹ These branch-specific changes appear to implement a broader DoD policy outlined in the August 2025 memorandum, which represents a tightening of medical shaving waivers across all branches by limiting them to no more than 1 year in duration before triggering a review for administrative separation.⁷ Additional implications also may include increased utilization of laser hair removal (LHR) for service members for whom conservative management has failed and who wish to pursue more definitive options. Given the potential career implications of PFB, LHR may become a more frequently considered intervention among military and civilian dermatologists. In the civilian sector, TRICARE covers LHR for active-duty service members when deemed medically necessary and unavailable at their military treatment facility.¹⁴ Consequently, civilian dermatologists may see an increase in referrals from military personnel seeking LHR to maintain compliance with grooming standards under the new policy framework.

Final Thoughts

Military personnel, their chain of command, and the military medical system are keenly aware of the DoD’s newly mandated policy changes regarding grooming standards. There are many circumstances in which military personnel (eg, active-duty service members, reservists, National Guard members) receive medical care from civilian providers, who may not be up to date on changes in the military’s approach toward grooming. Civilian dermatologists may be the first to diagnose or treat PFB in prospective recruits and should be aware that under current DoD policy, failure to meet grooming standards can lead to premature separation from military service. Civilian providers who are aware that the DoD’s policies on shaving and waivers have changed dramatically can discuss these implications when evaluating or counseling patients with a history of or risk for PFB. Previously published guidelines for service members seeking a shaving waiver for PFB are listed in eTable 1.^10,16-23 The current changes, which remove various accommodations that previously had been introduced, are detailed in eTable 2.^7-9,15,24

The grooming policy changes, particularly in the Army and Marines, require de novo waivers, which are likely to increase health care costs as measured in time and dollars. Each waiver cycle involves medical evaluation, documentation, and chain-of-command review. The cumulative work of these recurring requirements becomes considerable when scaled across the force.

As the military’s grooming policies evolve, ongoing evaluation of their effects on service members and unit readiness remains important. Continued data collection, transparent communication, and collaboration among military institutions and health care providers may help ensure that future policy updates maintain operational standards while also supporting the health and well-being of the force.

In April 2024, the Federal Trade Commission (FTC) issued a nationwide rule to ban most employee noncompete agreements, including many used in health care¹; however, that rule never took effect. In August 2024, a federal district court ruled that the FTC had exceeded its statutory authority and blocked the ban,² and subsequent litigation and agency actions followed. On September 5, 2025, the FTC formally moved to accede to vacatur—in other words, it will not enforce the rule and backed away from defending it on appeal.³ As of December 2025, there is no active federal ban on physician noncompetes. The obligations of the physician employee are dictated by state law and the precise language of the contract that is signed.

In this article, we discuss the historical origins of noncompetes, employer and physician perspectives, and the downstream consequences for patient continuity, access, and health care costs.

Background

The concept of noncompete agreements is not new—this legal principle dates back several centuries, but it was not until several hundred years later, between the 1950s and 1980s, that noncompete agreements became routine in physician contracts. This trend emerged, at least in part, from the growing commoditization of medicine, the expansion of hospital infrastructure, and the rise of physicians employed by entities rather than owning a private practice. Medical practices, hospitals, and increasingly large private groups began using noncompete agreements to prevent physicians from leaving and establishing competing practices nearby. Since then, noncompetes have remained a contentious issue within both the legal system and the broader physician-employer relationship.

Employer vs Employee Perspective

From the employer’s perspective, health care systems and medical groups argue that noncompete agreements are necessary to protect legitimate business interests, citing physician training, established patient relationships, and proprietary information gained from employment with that entity as supporting reasons. Additionally, employers maintain that recouping the cost of recruitment and onboarding investments as well as sustaining continuity of care within the organization should take precedence. On occasion, health care systems will invest time and financial resources in recruiting physicians, provide administrative and clinical support, and integrate new employees into established referral pathways and patient populations. In this view, noncompetes serve as a tool to ensure stability within the health care system, discouraging abrupt departures that could fracture patient care or lead to unfair competition using institutional resources. While these arguments hold merit in certain cases, many physicians do not receive employer-funded education or training beyond what is required in residency and fellowship. As a result, the financial justifications for noncompetes often are overstated; on the contrary, the cost of a “buy-out” or the financial barrier imposed by a noncompete clause can amount to a considerable portion of a physician’s annual salary—sometimes multiple times that amount—creating an imbalance that favors the employer and limits professional mobility.

When a physician is prohibited from practicing in a specific area after leaving an employer, a complex web of adverse consequences can arise, impacting both the physician and the patients they serve. Physician mobility and career choice become restricted, effectively constraining the physicians’ livelihood and ability to provide for themselves and their dependents; in single-earner physician families, this can have devastating financial consequences. These limitations contribute to growing burnout and dissatisfaction within the medical profession, which already is facing unprecedented levels of stress and physician workforce shortages.⁴

Effect on Patients

When a physician is forced to relocate to a new geographic region because of a noncompete clause, their patients can experience substantial disruptions in care. Access to medical services may be affected, leading to longer wait-times and fewer available appointments, especially in areas that already have a shortage of providers. Patients may lose longstanding relationships with doctors who know their medical histories, which can interrupt treatment plans and increase the risk of complications. Those with chronic illnesses, complex conditions, or time-sensitive treatments are particularly vulnerable to adverse outcomes. Many patients must travel farther—sometimes out of their insurance network—to find replacement care, increasing both financial and logistical burdens. These abrupt transitions also can raise health care costs due to emergency department use, inefficient handoffs, and higher incidence of morbidity/mortality.⁵ Noncompete restrictions often prevent physicians from informing patients where they are relocating, creating confusion and fragmentation of care. As a result, trust in the health care system may decline when patients perceive that business agreements are being prioritized above their wellbeing. The impact may be even more severe in rural or underserved communities where alternative providers are scarce.

Final Thoughts

In recent years, noncompete agreements in health care have come under intensified scrutiny for their potential to stifle physician mobility, reduce competition, and inflate health care costs by limiting where and how physicians can practice. The trajectory of noncompetes in physician employment reflects broader shifts in how medicine is structured and delivered in the United States. In the latter half of the 20th century, what began as a centuries-old legal concept became a standard feature of physician employment contracts. That evolution largely was driven by the corporatization of medicine and large hospital group/private equity employment of physicians. As these agreements proliferated, public policy questions emerged: What does restricting a physician’s mobility do to patient access? To competition in provider markets? To the cost and availability of care? To the current epidemic of physician burnout?

These questions moved from the legal sidelines to center stage in the 2020s, when the FTC sought to tackle noncompetes across the entire economy—physicians included—on the theory they suppressed labor mobility, entrepreneurship, and competition. In February 2020, the American Medical Association submitted comments to the FTC on the utility of noncompete agreements in employee contracts stating that they restrict competition, can disrupt continuity of care, and may limit access to care.⁶ Although the FTC’s regulatory attempt in April 2024 provoked strong policy signals, it was challenged and ultimately blocked. Rather than a clear federal prohibition, the outcome is a more incremental state-based shift in rules governing physician noncompetes. For physicians today, this means more awareness and more leverage, but also more complexity. Whether a noncompete will be enforceable depends heavily on the state, the wording of the contract, the structure of the employer, and the specialty. From a negotiation standpoint, physicians need more guidance and awareness on the exact ramifications of their employee contract. For newly minted physicians, many of whom enter the workforce with considerable training debt, the priority often is securing employment to work toward financial stability, building a family, or both; however, all physicians should press for shorter durations, tighter geographic limits, narrower scopes of service, clear buy-out options, and explicit patient-continuity protections. Better yet, physicians can exercise the right of refusal to any noncompete clause at all. Becoming involved with a local medical organization or foundation can provide immense support, both in reviewing contracts as well as learning how to become advocates for physicians in this environment. As more physicians stand together to protect both practice autonomy and the right to quality care, we all become closer to rediscovering the beauty and fulfillment in the purest form of medicine.

In April 2024, the Federal Trade Commission (FTC) issued a nationwide rule to ban most employee noncompete agreements, including many used in health care¹; however, that rule never took effect. In August 2024, a federal district court ruled that the FTC had exceeded its statutory authority and blocked the ban,² and subsequent litigation and agency actions followed. On September 5, 2025, the FTC formally moved to accede to vacatur—in other words, it will not enforce the rule and backed away from defending it on appeal.³ As of December 2025, there is no active federal ban on physician noncompetes. The obligations of the physician employee are dictated by state law and the precise language of the contract that is signed.

In this article, we discuss the historical origins of noncompetes, employer and physician perspectives, and the downstream consequences for patient continuity, access, and health care costs.

Background

The concept of noncompete agreements is not new—this legal principle dates back several centuries, but it was not until several hundred years later, between the 1950s and 1980s, that noncompete agreements became routine in physician contracts. This trend emerged, at least in part, from the growing commoditization of medicine, the expansion of hospital infrastructure, and the rise of physicians employed by entities rather than owning a private practice. Medical practices, hospitals, and increasingly large private groups began using noncompete agreements to prevent physicians from leaving and establishing competing practices nearby. Since then, noncompetes have remained a contentious issue within both the legal system and the broader physician-employer relationship.

Employer vs Employee Perspective

From the employer’s perspective, health care systems and medical groups argue that noncompete agreements are necessary to protect legitimate business interests, citing physician training, established patient relationships, and proprietary information gained from employment with that entity as supporting reasons. Additionally, employers maintain that recouping the cost of recruitment and onboarding investments as well as sustaining continuity of care within the organization should take precedence. On occasion, health care systems will invest time and financial resources in recruiting physicians, provide administrative and clinical support, and integrate new employees into established referral pathways and patient populations. In this view, noncompetes serve as a tool to ensure stability within the health care system, discouraging abrupt departures that could fracture patient care or lead to unfair competition using institutional resources. While these arguments hold merit in certain cases, many physicians do not receive employer-funded education or training beyond what is required in residency and fellowship. As a result, the financial justifications for noncompetes often are overstated; on the contrary, the cost of a “buy-out” or the financial barrier imposed by a noncompete clause can amount to a considerable portion of a physician’s annual salary—sometimes multiple times that amount—creating an imbalance that favors the employer and limits professional mobility.

When a physician is prohibited from practicing in a specific area after leaving an employer, a complex web of adverse consequences can arise, impacting both the physician and the patients they serve. Physician mobility and career choice become restricted, effectively constraining the physicians’ livelihood and ability to provide for themselves and their dependents; in single-earner physician families, this can have devastating financial consequences. These limitations contribute to growing burnout and dissatisfaction within the medical profession, which already is facing unprecedented levels of stress and physician workforce shortages.⁴

Effect on Patients

When a physician is forced to relocate to a new geographic region because of a noncompete clause, their patients can experience substantial disruptions in care. Access to medical services may be affected, leading to longer wait-times and fewer available appointments, especially in areas that already have a shortage of providers. Patients may lose longstanding relationships with doctors who know their medical histories, which can interrupt treatment plans and increase the risk of complications. Those with chronic illnesses, complex conditions, or time-sensitive treatments are particularly vulnerable to adverse outcomes. Many patients must travel farther—sometimes out of their insurance network—to find replacement care, increasing both financial and logistical burdens. These abrupt transitions also can raise health care costs due to emergency department use, inefficient handoffs, and higher incidence of morbidity/mortality.⁵ Noncompete restrictions often prevent physicians from informing patients where they are relocating, creating confusion and fragmentation of care. As a result, trust in the health care system may decline when patients perceive that business agreements are being prioritized above their wellbeing. The impact may be even more severe in rural or underserved communities where alternative providers are scarce.

Final Thoughts

In recent years, noncompete agreements in health care have come under intensified scrutiny for their potential to stifle physician mobility, reduce competition, and inflate health care costs by limiting where and how physicians can practice. The trajectory of noncompetes in physician employment reflects broader shifts in how medicine is structured and delivered in the United States. In the latter half of the 20th century, what began as a centuries-old legal concept became a standard feature of physician employment contracts. That evolution largely was driven by the corporatization of medicine and large hospital group/private equity employment of physicians. As these agreements proliferated, public policy questions emerged: What does restricting a physician’s mobility do to patient access? To competition in provider markets? To the cost and availability of care? To the current epidemic of physician burnout?

These questions moved from the legal sidelines to center stage in the 2020s, when the FTC sought to tackle noncompetes across the entire economy—physicians included—on the theory they suppressed labor mobility, entrepreneurship, and competition. In February 2020, the American Medical Association submitted comments to the FTC on the utility of noncompete agreements in employee contracts stating that they restrict competition, can disrupt continuity of care, and may limit access to care.⁶ Although the FTC’s regulatory attempt in April 2024 provoked strong policy signals, it was challenged and ultimately blocked. Rather than a clear federal prohibition, the outcome is a more incremental state-based shift in rules governing physician noncompetes. For physicians today, this means more awareness and more leverage, but also more complexity. Whether a noncompete will be enforceable depends heavily on the state, the wording of the contract, the structure of the employer, and the specialty. From a negotiation standpoint, physicians need more guidance and awareness on the exact ramifications of their employee contract. For newly minted physicians, many of whom enter the workforce with considerable training debt, the priority often is securing employment to work toward financial stability, building a family, or both; however, all physicians should press for shorter durations, tighter geographic limits, narrower scopes of service, clear buy-out options, and explicit patient-continuity protections. Better yet, physicians can exercise the right of refusal to any noncompete clause at all. Becoming involved with a local medical organization or foundation can provide immense support, both in reviewing contracts as well as learning how to become advocates for physicians in this environment. As more physicians stand together to protect both practice autonomy and the right to quality care, we all become closer to rediscovering the beauty and fulfillment in the purest form of medicine.

In April 2024, the Federal Trade Commission (FTC) issued a nationwide rule to ban most employee noncompete agreements, including many used in health care¹; however, that rule never took effect. In August 2024, a federal district court ruled that the FTC had exceeded its statutory authority and blocked the ban,² and subsequent litigation and agency actions followed. On September 5, 2025, the FTC formally moved to accede to vacatur—in other words, it will not enforce the rule and backed away from defending it on appeal.³ As of December 2025, there is no active federal ban on physician noncompetes. The obligations of the physician employee are dictated by state law and the precise language of the contract that is signed.

In this article, we discuss the historical origins of noncompetes, employer and physician perspectives, and the downstream consequences for patient continuity, access, and health care costs.

Background

The concept of noncompete agreements is not new—this legal principle dates back several centuries, but it was not until several hundred years later, between the 1950s and 1980s, that noncompete agreements became routine in physician contracts. This trend emerged, at least in part, from the growing commoditization of medicine, the expansion of hospital infrastructure, and the rise of physicians employed by entities rather than owning a private practice. Medical practices, hospitals, and increasingly large private groups began using noncompete agreements to prevent physicians from leaving and establishing competing practices nearby. Since then, noncompetes have remained a contentious issue within both the legal system and the broader physician-employer relationship.

Employer vs Employee Perspective

From the employer’s perspective, health care systems and medical groups argue that noncompete agreements are necessary to protect legitimate business interests, citing physician training, established patient relationships, and proprietary information gained from employment with that entity as supporting reasons. Additionally, employers maintain that recouping the cost of recruitment and onboarding investments as well as sustaining continuity of care within the organization should take precedence. On occasion, health care systems will invest time and financial resources in recruiting physicians, provide administrative and clinical support, and integrate new employees into established referral pathways and patient populations. In this view, noncompetes serve as a tool to ensure stability within the health care system, discouraging abrupt departures that could fracture patient care or lead to unfair competition using institutional resources. While these arguments hold merit in certain cases, many physicians do not receive employer-funded education or training beyond what is required in residency and fellowship. As a result, the financial justifications for noncompetes often are overstated; on the contrary, the cost of a “buy-out” or the financial barrier imposed by a noncompete clause can amount to a considerable portion of a physician’s annual salary—sometimes multiple times that amount—creating an imbalance that favors the employer and limits professional mobility.

When a physician is prohibited from practicing in a specific area after leaving an employer, a complex web of adverse consequences can arise, impacting both the physician and the patients they serve. Physician mobility and career choice become restricted, effectively constraining the physicians’ livelihood and ability to provide for themselves and their dependents; in single-earner physician families, this can have devastating financial consequences. These limitations contribute to growing burnout and dissatisfaction within the medical profession, which already is facing unprecedented levels of stress and physician workforce shortages.⁴

Effect on Patients

When a physician is forced to relocate to a new geographic region because of a noncompete clause, their patients can experience substantial disruptions in care. Access to medical services may be affected, leading to longer wait-times and fewer available appointments, especially in areas that already have a shortage of providers. Patients may lose longstanding relationships with doctors who know their medical histories, which can interrupt treatment plans and increase the risk of complications. Those with chronic illnesses, complex conditions, or time-sensitive treatments are particularly vulnerable to adverse outcomes. Many patients must travel farther—sometimes out of their insurance network—to find replacement care, increasing both financial and logistical burdens. These abrupt transitions also can raise health care costs due to emergency department use, inefficient handoffs, and higher incidence of morbidity/mortality.⁵ Noncompete restrictions often prevent physicians from informing patients where they are relocating, creating confusion and fragmentation of care. As a result, trust in the health care system may decline when patients perceive that business agreements are being prioritized above their wellbeing. The impact may be even more severe in rural or underserved communities where alternative providers are scarce.

Final Thoughts

In recent years, noncompete agreements in health care have come under intensified scrutiny for their potential to stifle physician mobility, reduce competition, and inflate health care costs by limiting where and how physicians can practice. The trajectory of noncompetes in physician employment reflects broader shifts in how medicine is structured and delivered in the United States. In the latter half of the 20th century, what began as a centuries-old legal concept became a standard feature of physician employment contracts. That evolution largely was driven by the corporatization of medicine and large hospital group/private equity employment of physicians. As these agreements proliferated, public policy questions emerged: What does restricting a physician’s mobility do to patient access? To competition in provider markets? To the cost and availability of care? To the current epidemic of physician burnout?

These questions moved from the legal sidelines to center stage in the 2020s, when the FTC sought to tackle noncompetes across the entire economy—physicians included—on the theory they suppressed labor mobility, entrepreneurship, and competition. In February 2020, the American Medical Association submitted comments to the FTC on the utility of noncompete agreements in employee contracts stating that they restrict competition, can disrupt continuity of care, and may limit access to care.⁶ Although the FTC’s regulatory attempt in April 2024 provoked strong policy signals, it was challenged and ultimately blocked. Rather than a clear federal prohibition, the outcome is a more incremental state-based shift in rules governing physician noncompetes. For physicians today, this means more awareness and more leverage, but also more complexity. Whether a noncompete will be enforceable depends heavily on the state, the wording of the contract, the structure of the employer, and the specialty. From a negotiation standpoint, physicians need more guidance and awareness on the exact ramifications of their employee contract. For newly minted physicians, many of whom enter the workforce with considerable training debt, the priority often is securing employment to work toward financial stability, building a family, or both; however, all physicians should press for shorter durations, tighter geographic limits, narrower scopes of service, clear buy-out options, and explicit patient-continuity protections. Better yet, physicians can exercise the right of refusal to any noncompete clause at all. Becoming involved with a local medical organization or foundation can provide immense support, both in reviewing contracts as well as learning how to become advocates for physicians in this environment. As more physicians stand together to protect both practice autonomy and the right to quality care, we all become closer to rediscovering the beauty and fulfillment in the purest form of medicine.

Visible light is part of the electromagnetic spectrum and is confined to a range of 400 to 700 nm. Visible light phototherapy can be delivered across various wavelengths within this spectrum, with most research focusing on blue light (BL)(400-500 nm) and red light (RL)(600-700 nm). Blue light commonly is used to treat acne as well as actinic keratosis and other inflammatory disorders,^1,2 while RL largely targets signs of skin aging and fibrosis.^2,3 Because of its shorter wavelength, the clinically meaningful skin penetration of BL reaches up to1 mm and is confined to the epidermis; in contrast, RL can access the dermal adnexa due to its penetration depth of more than 2 mm.⁴ Therapeutically, visible light can be utilized alone (eg, photobiomodulation [PBM]) or in combination with a photosensitizing agent (eg, photodynamic therapy [PDT]).^5,6

Our laboratory’s prior research has contributed to a greater understanding of the safety profile of visible light at various wavelengths.^1,3 Specifically, our work has shown that BL (417 nm [range, 412-422 nm]) and RL (633 nm [range, 627-639 nm]) demonstrated no evidence of DNA damage—via no formation of cyclobutane pyrimidine dimers and/or 6-4 photoproducts, the hallmark photolesions caused by UV exposure—in human dermal fibroblasts following visible light exposure at all fluences tested.^1,3 This evidence reinforces the safety of visible light at clinically relevant wavelengths, supporting its integration into dermatologic practice. In this editorial, we highlight the key clinical applications of PBM and PDT and outline safety considerations for visible light-based therapies in dermatologic practice.

Photobiomodulation

Photobiomodulation is a noninvasive treatment in which low-level lasers or light-emitting diodes deliver photons from a nonionizing light source to endogenous photoreceptors, primarily cytochrome C oxidase.^7-9 On the visible light spectrum, PBM primarily encompasses RL.^7-9 Photoactivation leads to production of reactive oxygen species as well as mitochondrial alterations, with resulting modulation of cellular activity.^7-9 Upregulation of cellular activity generally occurs at lower fluences (ie, energy delivered per unit area) of light, whereas higher fluences cause downregulation of cellular activity.⁵

Recent consensus guidelines, established with expert colleagues, define additional key parameters that are crucial to optimizing PBM treatment, including distance from the light source, area of the light beam, wavelength, length of treatment time, and number of treatments.⁵ Understanding the effects of different parameter combinations is essential for clinicians to select the best treatment regimen for each patient. Our laboratory has conducted National Institutes of Health–funded phase 1 and phase 2 clinical trials to determine the safety and efficacy of red-light PBM.^10-13 Additionally, we completed several pilot phase 2 clinical studies with commercially available light-emitting diode face masks using PBM technology, which demonstrated a favorable safety profile and high patient satisfaction across multiple self-reported measures.^14,15 These findings highlight PBM as a reliable and well-tolerated therapeutic approach that can be administered in clinical settings or by patients at home.

Adverse effects of PBM therapy generally are mild and transient, most commonly manifesting as slight irritation and erythema.⁵ Overall, PBM is widely regarded as safe with a favorable and nontoxic profile across treatment settings. Growing evidence supports the role of PBM in managing wound healing, acne, alopecia, and skin aging, among other dermatologic concerns.⁸

Photodynamic Therapy

Photodynamic therapy is a noninvasive procedure during which a photosensitizer—typically 5-aminolevulinic acid (5-ALA) or a derivative, methyl aminolevulinate—reacts with a light source and oxygen, resulting in reactive oxygen species.^6,16 This reaction ultimately triggers targeted cellular destruction of the intended lesional skin but with negligible effects on adjacent nonlesional tissue.⁶ The efficacy of PDT is determined by several parameters, including composition and concentration of the photosensitizer, photosensitizer incubation temperature, and incubation time with the photosensitizer. Methyl aminolevulinate is a lipophilic molecule and may promote greater skin penetration and cellular uptake than 5-ALA, which is a hydrophilic molecule.⁶

Our research further demonstrated that apoptosis increases in a dose- and temperature-dependent manner following 5-ALA exposure, both in cutaneous and mucosal squamous cell carcinoma cells and in human dermal fibroblasts.^17,18 Our mechanistic insights have clinical relevance, as evidenced by an independent pilot study demonstrating that temperature-modulated PDT significantly improved actinic keratosis lesion clearance rates (P<.0001).¹⁹ Additionally, we determined that even short periods of incubation with 5-ALA (ie, 15-30 minutes) result in statistically significant increases in apoptosis (P<.05).²⁰ Thus, these findings highlight that the choice of photosensitizing agent and the administration parameters are critical in determining PDT efficacy as well as the need to optimize clinical protocols.

Photodynamic therapy also has demonstrated general clinical and genotoxic safety, with the most common potential adverse events limited to temporary inflammation, erythema, and discomfort.²¹ A study in murine skin and human keratinocytes revealed that 5-ALA PDT had a photoprotective effect against previous irradiation with UVB (a known inducer of DNA damage) via removal of cyclobutane pyrimidine dimers.²² Thus, PDT has been recognized as a safe and effective therapeutic modality with broad applications in dermatology, including treatment of actinic keratosis and nonmelanoma skin cancers.¹⁶

Clinical Safety, Photoprotection, and Precautions

While visible light has shown substantial therapeutic potential in dermatology, there are several safety measures and precautions to be aware of. Visible light constitutes approximately 44% of the solar output; therefore, precautions against both UV and visible light are recommended for the general population.²³ Cumulative exposure to visible light has been shown to trigger melanogenesis, resulting in persistent erythema, hyperpigmentation, and uneven skin tones across all Fitzpatrick skin types.²⁴ Individuals with skin of color are more photosensitive to visible light due to increased baseline melanin levels.²⁴ Similarly, patients with pigmentary conditions such as melasma and postinflammatory hyperpigmentation may experience worsening of their dermatologic symptoms due to underlying visible light photosensitivity.²⁵

Patients undergoing PBM or PDT could benefit from visible light protection. The primary form of photoprotection against visible light is tinted sunscreen, which contains iron oxides and titanium dioxide.²⁶ Iron (III) oxide is capable of blocking nearly all visible light damage.²⁶ Use of physical barriers such as wavelength-specific sunglasses and wide-brimmed hats also is important for preventing photodamage from visible light.²⁶

Final Thoughts

Visible light has a role in the treatment of a variety of skin conditions, including actinic keratosis, nonmelanoma skin cancers, acne, wound healing, skin fibrosis, and photodamage. Photobiomodulation and PDT represent 2 noninvasive phototherapeutic options that utilize visible light to enact cellular changes necessary to improve skin health. Integrating visible light phototherapy into standard clinical practice is important for enhancing patient outcomes. Clinicians should remain mindful of the rare pigmentary risks associated with visible light therapy devices. Future research should prioritize optimization of standardized protocols and expansion of clinical indications for visible light phototherapy.

Visible light is part of the electromagnetic spectrum and is confined to a range of 400 to 700 nm. Visible light phototherapy can be delivered across various wavelengths within this spectrum, with most research focusing on blue light (BL)(400-500 nm) and red light (RL)(600-700 nm). Blue light commonly is used to treat acne as well as actinic keratosis and other inflammatory disorders,^1,2 while RL largely targets signs of skin aging and fibrosis.^2,3 Because of its shorter wavelength, the clinically meaningful skin penetration of BL reaches up to1 mm and is confined to the epidermis; in contrast, RL can access the dermal adnexa due to its penetration depth of more than 2 mm.⁴ Therapeutically, visible light can be utilized alone (eg, photobiomodulation [PBM]) or in combination with a photosensitizing agent (eg, photodynamic therapy [PDT]).^5,6

Our laboratory’s prior research has contributed to a greater understanding of the safety profile of visible light at various wavelengths.^1,3 Specifically, our work has shown that BL (417 nm [range, 412-422 nm]) and RL (633 nm [range, 627-639 nm]) demonstrated no evidence of DNA damage—via no formation of cyclobutane pyrimidine dimers and/or 6-4 photoproducts, the hallmark photolesions caused by UV exposure—in human dermal fibroblasts following visible light exposure at all fluences tested.^1,3 This evidence reinforces the safety of visible light at clinically relevant wavelengths, supporting its integration into dermatologic practice. In this editorial, we highlight the key clinical applications of PBM and PDT and outline safety considerations for visible light-based therapies in dermatologic practice.

Photobiomodulation

Photobiomodulation is a noninvasive treatment in which low-level lasers or light-emitting diodes deliver photons from a nonionizing light source to endogenous photoreceptors, primarily cytochrome C oxidase.^7-9 On the visible light spectrum, PBM primarily encompasses RL.^7-9 Photoactivation leads to production of reactive oxygen species as well as mitochondrial alterations, with resulting modulation of cellular activity.^7-9 Upregulation of cellular activity generally occurs at lower fluences (ie, energy delivered per unit area) of light, whereas higher fluences cause downregulation of cellular activity.⁵

Recent consensus guidelines, established with expert colleagues, define additional key parameters that are crucial to optimizing PBM treatment, including distance from the light source, area of the light beam, wavelength, length of treatment time, and number of treatments.⁵ Understanding the effects of different parameter combinations is essential for clinicians to select the best treatment regimen for each patient. Our laboratory has conducted National Institutes of Health–funded phase 1 and phase 2 clinical trials to determine the safety and efficacy of red-light PBM.^10-13 Additionally, we completed several pilot phase 2 clinical studies with commercially available light-emitting diode face masks using PBM technology, which demonstrated a favorable safety profile and high patient satisfaction across multiple self-reported measures.^14,15 These findings highlight PBM as a reliable and well-tolerated therapeutic approach that can be administered in clinical settings or by patients at home.

Adverse effects of PBM therapy generally are mild and transient, most commonly manifesting as slight irritation and erythema.⁵ Overall, PBM is widely regarded as safe with a favorable and nontoxic profile across treatment settings. Growing evidence supports the role of PBM in managing wound healing, acne, alopecia, and skin aging, among other dermatologic concerns.⁸

Photodynamic Therapy

Photodynamic therapy is a noninvasive procedure during which a photosensitizer—typically 5-aminolevulinic acid (5-ALA) or a derivative, methyl aminolevulinate—reacts with a light source and oxygen, resulting in reactive oxygen species.^6,16 This reaction ultimately triggers targeted cellular destruction of the intended lesional skin but with negligible effects on adjacent nonlesional tissue.⁶ The efficacy of PDT is determined by several parameters, including composition and concentration of the photosensitizer, photosensitizer incubation temperature, and incubation time with the photosensitizer. Methyl aminolevulinate is a lipophilic molecule and may promote greater skin penetration and cellular uptake than 5-ALA, which is a hydrophilic molecule.⁶

Our research further demonstrated that apoptosis increases in a dose- and temperature-dependent manner following 5-ALA exposure, both in cutaneous and mucosal squamous cell carcinoma cells and in human dermal fibroblasts.^17,18 Our mechanistic insights have clinical relevance, as evidenced by an independent pilot study demonstrating that temperature-modulated PDT significantly improved actinic keratosis lesion clearance rates (P<.0001).¹⁹ Additionally, we determined that even short periods of incubation with 5-ALA (ie, 15-30 minutes) result in statistically significant increases in apoptosis (P<.05).²⁰ Thus, these findings highlight that the choice of photosensitizing agent and the administration parameters are critical in determining PDT efficacy as well as the need to optimize clinical protocols.

Photodynamic therapy also has demonstrated general clinical and genotoxic safety, with the most common potential adverse events limited to temporary inflammation, erythema, and discomfort.²¹ A study in murine skin and human keratinocytes revealed that 5-ALA PDT had a photoprotective effect against previous irradiation with UVB (a known inducer of DNA damage) via removal of cyclobutane pyrimidine dimers.²² Thus, PDT has been recognized as a safe and effective therapeutic modality with broad applications in dermatology, including treatment of actinic keratosis and nonmelanoma skin cancers.¹⁶

Clinical Safety, Photoprotection, and Precautions

While visible light has shown substantial therapeutic potential in dermatology, there are several safety measures and precautions to be aware of. Visible light constitutes approximately 44% of the solar output; therefore, precautions against both UV and visible light are recommended for the general population.²³ Cumulative exposure to visible light has been shown to trigger melanogenesis, resulting in persistent erythema, hyperpigmentation, and uneven skin tones across all Fitzpatrick skin types.²⁴ Individuals with skin of color are more photosensitive to visible light due to increased baseline melanin levels.²⁴ Similarly, patients with pigmentary conditions such as melasma and postinflammatory hyperpigmentation may experience worsening of their dermatologic symptoms due to underlying visible light photosensitivity.²⁵

Patients undergoing PBM or PDT could benefit from visible light protection. The primary form of photoprotection against visible light is tinted sunscreen, which contains iron oxides and titanium dioxide.²⁶ Iron (III) oxide is capable of blocking nearly all visible light damage.²⁶ Use of physical barriers such as wavelength-specific sunglasses and wide-brimmed hats also is important for preventing photodamage from visible light.²⁶

Final Thoughts

Visible light has a role in the treatment of a variety of skin conditions, including actinic keratosis, nonmelanoma skin cancers, acne, wound healing, skin fibrosis, and photodamage. Photobiomodulation and PDT represent 2 noninvasive phototherapeutic options that utilize visible light to enact cellular changes necessary to improve skin health. Integrating visible light phototherapy into standard clinical practice is important for enhancing patient outcomes. Clinicians should remain mindful of the rare pigmentary risks associated with visible light therapy devices. Future research should prioritize optimization of standardized protocols and expansion of clinical indications for visible light phototherapy.

Visible light is part of the electromagnetic spectrum and is confined to a range of 400 to 700 nm. Visible light phototherapy can be delivered across various wavelengths within this spectrum, with most research focusing on blue light (BL)(400-500 nm) and red light (RL)(600-700 nm). Blue light commonly is used to treat acne as well as actinic keratosis and other inflammatory disorders,^1,2 while RL largely targets signs of skin aging and fibrosis.^2,3 Because of its shorter wavelength, the clinically meaningful skin penetration of BL reaches up to1 mm and is confined to the epidermis; in contrast, RL can access the dermal adnexa due to its penetration depth of more than 2 mm.⁴ Therapeutically, visible light can be utilized alone (eg, photobiomodulation [PBM]) or in combination with a photosensitizing agent (eg, photodynamic therapy [PDT]).^5,6

Our laboratory’s prior research has contributed to a greater understanding of the safety profile of visible light at various wavelengths.^1,3 Specifically, our work has shown that BL (417 nm [range, 412-422 nm]) and RL (633 nm [range, 627-639 nm]) demonstrated no evidence of DNA damage—via no formation of cyclobutane pyrimidine dimers and/or 6-4 photoproducts, the hallmark photolesions caused by UV exposure—in human dermal fibroblasts following visible light exposure at all fluences tested.^1,3 This evidence reinforces the safety of visible light at clinically relevant wavelengths, supporting its integration into dermatologic practice. In this editorial, we highlight the key clinical applications of PBM and PDT and outline safety considerations for visible light-based therapies in dermatologic practice.

Photobiomodulation

Photobiomodulation is a noninvasive treatment in which low-level lasers or light-emitting diodes deliver photons from a nonionizing light source to endogenous photoreceptors, primarily cytochrome C oxidase.^7-9 On the visible light spectrum, PBM primarily encompasses RL.^7-9 Photoactivation leads to production of reactive oxygen species as well as mitochondrial alterations, with resulting modulation of cellular activity.^7-9 Upregulation of cellular activity generally occurs at lower fluences (ie, energy delivered per unit area) of light, whereas higher fluences cause downregulation of cellular activity.⁵

Recent consensus guidelines, established with expert colleagues, define additional key parameters that are crucial to optimizing PBM treatment, including distance from the light source, area of the light beam, wavelength, length of treatment time, and number of treatments.⁵ Understanding the effects of different parameter combinations is essential for clinicians to select the best treatment regimen for each patient. Our laboratory has conducted National Institutes of Health–funded phase 1 and phase 2 clinical trials to determine the safety and efficacy of red-light PBM.^10-13 Additionally, we completed several pilot phase 2 clinical studies with commercially available light-emitting diode face masks using PBM technology, which demonstrated a favorable safety profile and high patient satisfaction across multiple self-reported measures.^14,15 These findings highlight PBM as a reliable and well-tolerated therapeutic approach that can be administered in clinical settings or by patients at home.

Adverse effects of PBM therapy generally are mild and transient, most commonly manifesting as slight irritation and erythema.⁵ Overall, PBM is widely regarded as safe with a favorable and nontoxic profile across treatment settings. Growing evidence supports the role of PBM in managing wound healing, acne, alopecia, and skin aging, among other dermatologic concerns.⁸

Photodynamic Therapy

Photodynamic therapy is a noninvasive procedure during which a photosensitizer—typically 5-aminolevulinic acid (5-ALA) or a derivative, methyl aminolevulinate—reacts with a light source and oxygen, resulting in reactive oxygen species.^6,16 This reaction ultimately triggers targeted cellular destruction of the intended lesional skin but with negligible effects on adjacent nonlesional tissue.⁶ The efficacy of PDT is determined by several parameters, including composition and concentration of the photosensitizer, photosensitizer incubation temperature, and incubation time with the photosensitizer. Methyl aminolevulinate is a lipophilic molecule and may promote greater skin penetration and cellular uptake than 5-ALA, which is a hydrophilic molecule.⁶

Our research further demonstrated that apoptosis increases in a dose- and temperature-dependent manner following 5-ALA exposure, both in cutaneous and mucosal squamous cell carcinoma cells and in human dermal fibroblasts.^17,18 Our mechanistic insights have clinical relevance, as evidenced by an independent pilot study demonstrating that temperature-modulated PDT significantly improved actinic keratosis lesion clearance rates (P<.0001).¹⁹ Additionally, we determined that even short periods of incubation with 5-ALA (ie, 15-30 minutes) result in statistically significant increases in apoptosis (P<.05).²⁰ Thus, these findings highlight that the choice of photosensitizing agent and the administration parameters are critical in determining PDT efficacy as well as the need to optimize clinical protocols.

Photodynamic therapy also has demonstrated general clinical and genotoxic safety, with the most common potential adverse events limited to temporary inflammation, erythema, and discomfort.²¹ A study in murine skin and human keratinocytes revealed that 5-ALA PDT had a photoprotective effect against previous irradiation with UVB (a known inducer of DNA damage) via removal of cyclobutane pyrimidine dimers.²² Thus, PDT has been recognized as a safe and effective therapeutic modality with broad applications in dermatology, including treatment of actinic keratosis and nonmelanoma skin cancers.¹⁶

Clinical Safety, Photoprotection, and Precautions

While visible light has shown substantial therapeutic potential in dermatology, there are several safety measures and precautions to be aware of. Visible light constitutes approximately 44% of the solar output; therefore, precautions against both UV and visible light are recommended for the general population.²³ Cumulative exposure to visible light has been shown to trigger melanogenesis, resulting in persistent erythema, hyperpigmentation, and uneven skin tones across all Fitzpatrick skin types.²⁴ Individuals with skin of color are more photosensitive to visible light due to increased baseline melanin levels.²⁴ Similarly, patients with pigmentary conditions such as melasma and postinflammatory hyperpigmentation may experience worsening of their dermatologic symptoms due to underlying visible light photosensitivity.²⁵

Patients undergoing PBM or PDT could benefit from visible light protection. The primary form of photoprotection against visible light is tinted sunscreen, which contains iron oxides and titanium dioxide.²⁶ Iron (III) oxide is capable of blocking nearly all visible light damage.²⁶ Use of physical barriers such as wavelength-specific sunglasses and wide-brimmed hats also is important for preventing photodamage from visible light.²⁶

Final Thoughts

Visible light has a role in the treatment of a variety of skin conditions, including actinic keratosis, nonmelanoma skin cancers, acne, wound healing, skin fibrosis, and photodamage. Photobiomodulation and PDT represent 2 noninvasive phototherapeutic options that utilize visible light to enact cellular changes necessary to improve skin health. Integrating visible light phototherapy into standard clinical practice is important for enhancing patient outcomes. Clinicians should remain mindful of the rare pigmentary risks associated with visible light therapy devices. Future research should prioritize optimization of standardized protocols and expansion of clinical indications for visible light phototherapy.

Serving those who serve has been one of the most meaningful parts of my career. A career in military medicine offers dermatologists not only a chance to practice within a unique and diverse patient population but also an opportunity to contribute to something larger than themselves. Whether working with active-duty service members and their families within the Military Health System (MHS) or caring for veterans through the Department of Veterans Affairs (VA), the experience can be both enriching and rewarding. This article will explore the various pathways available to dermatologists to serve military communities, whether they are at the start of their careers or are looking for a change of pace within their established practice.

Care Pathways for Military and Veterans

To care for uniformed service members, their families, and retired personnel, dermatologists typically serve within the MHS—a global, integrated network of military hospitals and clinics dedicated to delivering health care to this population.¹ TRICARE is the health insurance program that covers those eligible for care within the system, including active-duty and retired service members.² In this context, it is important to clarify what the term retired actually means, as it differs from the term veteran when it comes to accessing health care options, and these terms frequently are conflated. A retired service member is an individual who completed at least 20 years of active-duty service or who has been medically retired because of a condition or injury incurred while on active duty.³ In contrast, a veteran may not have completed 20 years of service but has separated honorably after serving at least 24 continuous months.⁴ Veterans typically receive care through the VA system.⁵

Serving on Active Duty

In general, there are 2 main pathways to serve as a dermatologist within the MHS. The first is to commission in the military and serve on active duty. Most often, this pathway begins with a premedical student applying to medical school. Those considering military service typically explore scholarship programs such as the Health Professions Scholarship Program (HPSP)(https://www.medicineandthemilitary.com/applying-and-what-to-expect/medical-school-programs/hpsp) or the Health Services Collegiate Program (HSCP), or they apply to the Uniformed Services University of the Health Sciences (USU)(https://www.usuhs.edu/about). The HPSP and HSCP programs financially support medical students training at civilian medical schools, though in different ways—the HPSP covers tuition and fees, while the HSCP provides a salary during training but does not cover tuition.⁶ In contrast, students of USU attend the nation’s only military medical school, serving in uniform for 4 years while earning the pay and benefits of a junior officer in their respective service branch. Any premedical student considering the HPSP, HSCP or USU routes for service must meet the commissioning standards of their chosen branch—Army, Navy, or Air Force—and enter service as an officer before beginning medical school.

While direct commission prior to medical school is the most common route to active-duty service, board-certified dermatologists also can join a military branch later through what is called Direct Accession or Direct Commission; for example, the Navy offers a Residency to Direct Accession program, which commissions residents in their final year of training to join the Navy upon graduation. In some cases, commissioning at this stage includes a bonus of up to $600,000 in exchange for a 4-year active-duty commitment.⁷ The Army and Air Force offer similar direct commission programs, though specific incentives vary.⁸ Interested residents or practitioners can contact a local recruiting office within their branch of interest to learn more. Direct accession is open at many points in a dermatologist’s career—after residency, after fellowship, or even as an established civilian practitioner—and the initial commissioning rank and bonus generally reflect one’s level of experience.

Serving as a Civilian

Outside of uniformed service, dermatologists can find opportunities to provide care for active-duty service members, veterans, and military families through employment as General Schedule (GS) employees. The GS is a role classification and pay system that covers most federal employees in professional, administrative, and technical positions (eg, physicians). The GS system classifies most of these employees based on the complexity, responsibility, and qualifications required for their role.⁹ Such positions often are at the highest level of the GS pay scale, reflecting the expertise and years of education required to become a dermatologist, though pay varies by location and experience. In contrast, physicians employed through the VA system are classified as Title 38 federal employees, governed by a different pay structure and regulatory framework under the US Code of Federal Regulations.¹⁰ These regulations govern the hiring, retention, and firing guidelines for VA physicians, which differ from those of GS physicians. A full explanation is outside of the scope of this article, however.

Final Thoughts

In summary, uniformed or federal service as a dermatologist offers a meaningful and impactful way to give back to those who have served our country. Opportunities exist throughout the United States for dermatologists interested in serving within the MHS or VA. The most transparent and up-to-date resource for identifying open positions in both large metropolitan areas and smaller communities is USAJOBS.gov. While financial compensation may not always match that of private practice, the intangible benefits are considerable—stable employment, comprehensive benefits, malpractice coverage, and secure retirement, among others. There is something deeply fulfilling about using one’s medical skills in service of a larger mission. The relationships built with service members, the sense of shared purpose, and the opportunity to contribute to the readiness and well-being of those who serve all make this career path profoundly rewarding. For dermatologists seeking a practice that combines professional growth with purpose and patriotism, military medicine offers a truly special calling.

Serving those who serve has been one of the most meaningful parts of my career. A career in military medicine offers dermatologists not only a chance to practice within a unique and diverse patient population but also an opportunity to contribute to something larger than themselves. Whether working with active-duty service members and their families within the Military Health System (MHS) or caring for veterans through the Department of Veterans Affairs (VA), the experience can be both enriching and rewarding. This article will explore the various pathways available to dermatologists to serve military communities, whether they are at the start of their careers or are looking for a change of pace within their established practice.

Care Pathways for Military and Veterans

To care for uniformed service members, their families, and retired personnel, dermatologists typically serve within the MHS—a global, integrated network of military hospitals and clinics dedicated to delivering health care to this population.¹ TRICARE is the health insurance program that covers those eligible for care within the system, including active-duty and retired service members.² In this context, it is important to clarify what the term retired actually means, as it differs from the term veteran when it comes to accessing health care options, and these terms frequently are conflated. A retired service member is an individual who completed at least 20 years of active-duty service or who has been medically retired because of a condition or injury incurred while on active duty.³ In contrast, a veteran may not have completed 20 years of service but has separated honorably after serving at least 24 continuous months.⁴ Veterans typically receive care through the VA system.⁵

Serving on Active Duty

In general, there are 2 main pathways to serve as a dermatologist within the MHS. The first is to commission in the military and serve on active duty. Most often, this pathway begins with a premedical student applying to medical school. Those considering military service typically explore scholarship programs such as the Health Professions Scholarship Program (HPSP)(https://www.medicineandthemilitary.com/applying-and-what-to-expect/medical-school-programs/hpsp) or the Health Services Collegiate Program (HSCP), or they apply to the Uniformed Services University of the Health Sciences (USU)(https://www.usuhs.edu/about). The HPSP and HSCP programs financially support medical students training at civilian medical schools, though in different ways—the HPSP covers tuition and fees, while the HSCP provides a salary during training but does not cover tuition.⁶ In contrast, students of USU attend the nation’s only military medical school, serving in uniform for 4 years while earning the pay and benefits of a junior officer in their respective service branch. Any premedical student considering the HPSP, HSCP or USU routes for service must meet the commissioning standards of their chosen branch—Army, Navy, or Air Force—and enter service as an officer before beginning medical school.

While direct commission prior to medical school is the most common route to active-duty service, board-certified dermatologists also can join a military branch later through what is called Direct Accession or Direct Commission; for example, the Navy offers a Residency to Direct Accession program, which commissions residents in their final year of training to join the Navy upon graduation. In some cases, commissioning at this stage includes a bonus of up to $600,000 in exchange for a 4-year active-duty commitment.⁷ The Army and Air Force offer similar direct commission programs, though specific incentives vary.⁸ Interested residents or practitioners can contact a local recruiting office within their branch of interest to learn more. Direct accession is open at many points in a dermatologist’s career—after residency, after fellowship, or even as an established civilian practitioner—and the initial commissioning rank and bonus generally reflect one’s level of experience.

Serving as a Civilian

Outside of uniformed service, dermatologists can find opportunities to provide care for active-duty service members, veterans, and military families through employment as General Schedule (GS) employees. The GS is a role classification and pay system that covers most federal employees in professional, administrative, and technical positions (eg, physicians). The GS system classifies most of these employees based on the complexity, responsibility, and qualifications required for their role.⁹ Such positions often are at the highest level of the GS pay scale, reflecting the expertise and years of education required to become a dermatologist, though pay varies by location and experience. In contrast, physicians employed through the VA system are classified as Title 38 federal employees, governed by a different pay structure and regulatory framework under the US Code of Federal Regulations.¹⁰ These regulations govern the hiring, retention, and firing guidelines for VA physicians, which differ from those of GS physicians. A full explanation is outside of the scope of this article, however.

Final Thoughts

In summary, uniformed or federal service as a dermatologist offers a meaningful and impactful way to give back to those who have served our country. Opportunities exist throughout the United States for dermatologists interested in serving within the MHS or VA. The most transparent and up-to-date resource for identifying open positions in both large metropolitan areas and smaller communities is USAJOBS.gov. While financial compensation may not always match that of private practice, the intangible benefits are considerable—stable employment, comprehensive benefits, malpractice coverage, and secure retirement, among others. There is something deeply fulfilling about using one’s medical skills in service of a larger mission. The relationships built with service members, the sense of shared purpose, and the opportunity to contribute to the readiness and well-being of those who serve all make this career path profoundly rewarding. For dermatologists seeking a practice that combines professional growth with purpose and patriotism, military medicine offers a truly special calling.

Serving those who serve has been one of the most meaningful parts of my career. A career in military medicine offers dermatologists not only a chance to practice within a unique and diverse patient population but also an opportunity to contribute to something larger than themselves. Whether working with active-duty service members and their families within the Military Health System (MHS) or caring for veterans through the Department of Veterans Affairs (VA), the experience can be both enriching and rewarding. This article will explore the various pathways available to dermatologists to serve military communities, whether they are at the start of their careers or are looking for a change of pace within their established practice.

Care Pathways for Military and Veterans

To care for uniformed service members, their families, and retired personnel, dermatologists typically serve within the MHS—a global, integrated network of military hospitals and clinics dedicated to delivering health care to this population.¹ TRICARE is the health insurance program that covers those eligible for care within the system, including active-duty and retired service members.² In this context, it is important to clarify what the term retired actually means, as it differs from the term veteran when it comes to accessing health care options, and these terms frequently are conflated. A retired service member is an individual who completed at least 20 years of active-duty service or who has been medically retired because of a condition or injury incurred while on active duty.³ In contrast, a veteran may not have completed 20 years of service but has separated honorably after serving at least 24 continuous months.⁴ Veterans typically receive care through the VA system.⁵

Serving on Active Duty

In general, there are 2 main pathways to serve as a dermatologist within the MHS. The first is to commission in the military and serve on active duty. Most often, this pathway begins with a premedical student applying to medical school. Those considering military service typically explore scholarship programs such as the Health Professions Scholarship Program (HPSP)(https://www.medicineandthemilitary.com/applying-and-what-to-expect/medical-school-programs/hpsp) or the Health Services Collegiate Program (HSCP), or they apply to the Uniformed Services University of the Health Sciences (USU)(https://www.usuhs.edu/about). The HPSP and HSCP programs financially support medical students training at civilian medical schools, though in different ways—the HPSP covers tuition and fees, while the HSCP provides a salary during training but does not cover tuition.⁶ In contrast, students of USU attend the nation’s only military medical school, serving in uniform for 4 years while earning the pay and benefits of a junior officer in their respective service branch. Any premedical student considering the HPSP, HSCP or USU routes for service must meet the commissioning standards of their chosen branch—Army, Navy, or Air Force—and enter service as an officer before beginning medical school.

While direct commission prior to medical school is the most common route to active-duty service, board-certified dermatologists also can join a military branch later through what is called Direct Accession or Direct Commission; for example, the Navy offers a Residency to Direct Accession program, which commissions residents in their final year of training to join the Navy upon graduation. In some cases, commissioning at this stage includes a bonus of up to $600,000 in exchange for a 4-year active-duty commitment.⁷ The Army and Air Force offer similar direct commission programs, though specific incentives vary.⁸ Interested residents or practitioners can contact a local recruiting office within their branch of interest to learn more. Direct accession is open at many points in a dermatologist’s career—after residency, after fellowship, or even as an established civilian practitioner—and the initial commissioning rank and bonus generally reflect one’s level of experience.

Serving as a Civilian

Outside of uniformed service, dermatologists can find opportunities to provide care for active-duty service members, veterans, and military families through employment as General Schedule (GS) employees. The GS is a role classification and pay system that covers most federal employees in professional, administrative, and technical positions (eg, physicians). The GS system classifies most of these employees based on the complexity, responsibility, and qualifications required for their role.⁹ Such positions often are at the highest level of the GS pay scale, reflecting the expertise and years of education required to become a dermatologist, though pay varies by location and experience. In contrast, physicians employed through the VA system are classified as Title 38 federal employees, governed by a different pay structure and regulatory framework under the US Code of Federal Regulations.¹⁰ These regulations govern the hiring, retention, and firing guidelines for VA physicians, which differ from those of GS physicians. A full explanation is outside of the scope of this article, however.

Final Thoughts

In summary, uniformed or federal service as a dermatologist offers a meaningful and impactful way to give back to those who have served our country. Opportunities exist throughout the United States for dermatologists interested in serving within the MHS or VA. The most transparent and up-to-date resource for identifying open positions in both large metropolitan areas and smaller communities is USAJOBS.gov. While financial compensation may not always match that of private practice, the intangible benefits are considerable—stable employment, comprehensive benefits, malpractice coverage, and secure retirement, among others. There is something deeply fulfilling about using one’s medical skills in service of a larger mission. The relationships built with service members, the sense of shared purpose, and the opportunity to contribute to the readiness and well-being of those who serve all make this career path profoundly rewarding. For dermatologists seeking a practice that combines professional growth with purpose and patriotism, military medicine offers a truly special calling.

I was accepted into my fellowship almost 1 year ago: major milestones on my curriculum vitae are now met, fellowship application materials are complete, and the stress of the match is long gone. At the start of my fellowship, I had 2 priorities: (1) to learn as much as I could about dermatologic surgery and (2) to be the best dad possible to my newborn son, Jay. However, most nights I still find myself up late editing a manuscript draft or chasing down references, long after the “need” to publish has passed. Recently, my wife asked me why—what’s left to prove?

I’ll be the first to admit it: early on, publishing felt almost purely transactional. Each project was little more than a line on an application or a way to stand out or meet a new mentor. I have reflected before on how easily that mindset can slip into a kind of research arms race, in which productivity overshadows purpose.¹ This time, I wanted to explore the other side of that equation: the “why” behind it all.

I have learned that writing forces me to slow down and actually think about what I am seeing every day. It turns routine work into something I must understand well enough to explain. Even a small write-up can make me notice details I would otherwise skim past in clinic or surgery. These days, most of my projects start small: a case that taught me something, an observation that made me pause and think. Those seemingly small questions are what eventually grow into bigger ones. The clinical trial I am designing now did not begin as a grand plan—it started because I could not stop thinking about how we manage pain and analgesia after Mohs surgery. That curiosity, shaped by the experience of writing those earlier “smaller” papers, evolved into a study that might actually help improve patient care one day. Still, most of what I write will not revolutionize the field. It is not cutting-edge science or paradigm-shifting data; it is mostly modest analyses with a few interesting conclusions or surgical pearls that might cut down on a patient’s procedural time or save a dermatologist somewhere a few sutures. But it still feels worth doing.

While rotating with Dr. Anna Bar at Oregon Health & Science University, Portland, I noticed a poster hanging on the wall titled, “Top 10 Reasons Why Our Faculty Are Dedicated to Academics and Teaching,” based on the wisdom of Dr. Jane M. Grant-Kels.² My favorite line on the poster reads, “Residents make us better by asking questions.” I think this philosophy is the main reason why I still write. Even though I am not a resident anymore, I am still asking questions. But if I had to sum up my “why” into a neat list, here is what it might look like:

Because asking questions keeps your brain wired for curiosity. Even small projects train us to remain curious, and this curiosity can mean the difference between just doing your job and continuing to evolve within it. As Dr. Rodolfo Neirotti reminds us, “Questions are useful tools—they open communication, improve understanding, and drive scientific research. In medicine, doing things without knowing why is risky.”³

Because the small stuff builds the culture. Dermatology is a small world. Even short case series, pearls, or “how we do it” pieces can shape how we practice. They may not change paradigms, but they can refine them. Over time, those small practical contributions become part of the field’s collective muscle memory.

Because it preserves perspective. Residency, fellowship, and early practice can blur together. A tiny project can become a timestamp of what you were learning or caring about at that specific moment. Years later, you may remember the case through the paper.

Because the act of writing is the point. Writing forces clarity. You cannot hide behind saying, “That’s just how I do things,” when you have to explain it to others. The discipline of organizing your thoughts sharpens your clinical reasoning and keeps you honest about what you actually know.

Because sometimes it is simply about participating. Publishing, even small pieces, is a way of staying in touch with your field. It says, “I’m still here. I’m still paying attention.”

I think about how Dr. Frederic Mohs developed the technique that now bears his name while he was still a medical student.⁴ He could have said, “I already made it into medical school. That’s enough.” But he did not. I guess my point is not that we are all on the verge of inventing something revolutionary; it is that innovation happens only when curiosity keeps moving us forward. So no, I do not write to check boxes anymore. I write because it keeps me curious, and I have realized that curiosity is a habit I never want to outgrow.

Or maybe it’s because Jay keeps me up at night, and I have nothing better to do.

I was accepted into my fellowship almost 1 year ago: major milestones on my curriculum vitae are now met, fellowship application materials are complete, and the stress of the match is long gone. At the start of my fellowship, I had 2 priorities: (1) to learn as much as I could about dermatologic surgery and (2) to be the best dad possible to my newborn son, Jay. However, most nights I still find myself up late editing a manuscript draft or chasing down references, long after the “need” to publish has passed. Recently, my wife asked me why—what’s left to prove?

I’ll be the first to admit it: early on, publishing felt almost purely transactional. Each project was little more than a line on an application or a way to stand out or meet a new mentor. I have reflected before on how easily that mindset can slip into a kind of research arms race, in which productivity overshadows purpose.¹ This time, I wanted to explore the other side of that equation: the “why” behind it all.

I have learned that writing forces me to slow down and actually think about what I am seeing every day. It turns routine work into something I must understand well enough to explain. Even a small write-up can make me notice details I would otherwise skim past in clinic or surgery. These days, most of my projects start small: a case that taught me something, an observation that made me pause and think. Those seemingly small questions are what eventually grow into bigger ones. The clinical trial I am designing now did not begin as a grand plan—it started because I could not stop thinking about how we manage pain and analgesia after Mohs surgery. That curiosity, shaped by the experience of writing those earlier “smaller” papers, evolved into a study that might actually help improve patient care one day. Still, most of what I write will not revolutionize the field. It is not cutting-edge science or paradigm-shifting data; it is mostly modest analyses with a few interesting conclusions or surgical pearls that might cut down on a patient’s procedural time or save a dermatologist somewhere a few sutures. But it still feels worth doing.

While rotating with Dr. Anna Bar at Oregon Health & Science University, Portland, I noticed a poster hanging on the wall titled, “Top 10 Reasons Why Our Faculty Are Dedicated to Academics and Teaching,” based on the wisdom of Dr. Jane M. Grant-Kels.² My favorite line on the poster reads, “Residents make us better by asking questions.” I think this philosophy is the main reason why I still write. Even though I am not a resident anymore, I am still asking questions. But if I had to sum up my “why” into a neat list, here is what it might look like:

Because asking questions keeps your brain wired for curiosity. Even small projects train us to remain curious, and this curiosity can mean the difference between just doing your job and continuing to evolve within it. As Dr. Rodolfo Neirotti reminds us, “Questions are useful tools—they open communication, improve understanding, and drive scientific research. In medicine, doing things without knowing why is risky.”³

Because the small stuff builds the culture. Dermatology is a small world. Even short case series, pearls, or “how we do it” pieces can shape how we practice. They may not change paradigms, but they can refine them. Over time, those small practical contributions become part of the field’s collective muscle memory.

Because it preserves perspective. Residency, fellowship, and early practice can blur together. A tiny project can become a timestamp of what you were learning or caring about at that specific moment. Years later, you may remember the case through the paper.

Because the act of writing is the point. Writing forces clarity. You cannot hide behind saying, “That’s just how I do things,” when you have to explain it to others. The discipline of organizing your thoughts sharpens your clinical reasoning and keeps you honest about what you actually know.

Because sometimes it is simply about participating. Publishing, even small pieces, is a way of staying in touch with your field. It says, “I’m still here. I’m still paying attention.”

I think about how Dr. Frederic Mohs developed the technique that now bears his name while he was still a medical student.⁴ He could have said, “I already made it into medical school. That’s enough.” But he did not. I guess my point is not that we are all on the verge of inventing something revolutionary; it is that innovation happens only when curiosity keeps moving us forward. So no, I do not write to check boxes anymore. I write because it keeps me curious, and I have realized that curiosity is a habit I never want to outgrow.

Or maybe it’s because Jay keeps me up at night, and I have nothing better to do.

I was accepted into my fellowship almost 1 year ago: major milestones on my curriculum vitae are now met, fellowship application materials are complete, and the stress of the match is long gone. At the start of my fellowship, I had 2 priorities: (1) to learn as much as I could about dermatologic surgery and (2) to be the best dad possible to my newborn son, Jay. However, most nights I still find myself up late editing a manuscript draft or chasing down references, long after the “need” to publish has passed. Recently, my wife asked me why—what’s left to prove?

I’ll be the first to admit it: early on, publishing felt almost purely transactional. Each project was little more than a line on an application or a way to stand out or meet a new mentor. I have reflected before on how easily that mindset can slip into a kind of research arms race, in which productivity overshadows purpose.¹ This time, I wanted to explore the other side of that equation: the “why” behind it all.

I have learned that writing forces me to slow down and actually think about what I am seeing every day. It turns routine work into something I must understand well enough to explain. Even a small write-up can make me notice details I would otherwise skim past in clinic or surgery. These days, most of my projects start small: a case that taught me something, an observation that made me pause and think. Those seemingly small questions are what eventually grow into bigger ones. The clinical trial I am designing now did not begin as a grand plan—it started because I could not stop thinking about how we manage pain and analgesia after Mohs surgery. That curiosity, shaped by the experience of writing those earlier “smaller” papers, evolved into a study that might actually help improve patient care one day. Still, most of what I write will not revolutionize the field. It is not cutting-edge science or paradigm-shifting data; it is mostly modest analyses with a few interesting conclusions or surgical pearls that might cut down on a patient’s procedural time or save a dermatologist somewhere a few sutures. But it still feels worth doing.

While rotating with Dr. Anna Bar at Oregon Health & Science University, Portland, I noticed a poster hanging on the wall titled, “Top 10 Reasons Why Our Faculty Are Dedicated to Academics and Teaching,” based on the wisdom of Dr. Jane M. Grant-Kels.² My favorite line on the poster reads, “Residents make us better by asking questions.” I think this philosophy is the main reason why I still write. Even though I am not a resident anymore, I am still asking questions. But if I had to sum up my “why” into a neat list, here is what it might look like:

Because asking questions keeps your brain wired for curiosity. Even small projects train us to remain curious, and this curiosity can mean the difference between just doing your job and continuing to evolve within it. As Dr. Rodolfo Neirotti reminds us, “Questions are useful tools—they open communication, improve understanding, and drive scientific research. In medicine, doing things without knowing why is risky.”³

Because the small stuff builds the culture. Dermatology is a small world. Even short case series, pearls, or “how we do it” pieces can shape how we practice. They may not change paradigms, but they can refine them. Over time, those small practical contributions become part of the field’s collective muscle memory.

Because it preserves perspective. Residency, fellowship, and early practice can blur together. A tiny project can become a timestamp of what you were learning or caring about at that specific moment. Years later, you may remember the case through the paper.

Because the act of writing is the point. Writing forces clarity. You cannot hide behind saying, “That’s just how I do things,” when you have to explain it to others. The discipline of organizing your thoughts sharpens your clinical reasoning and keeps you honest about what you actually know.

Because sometimes it is simply about participating. Publishing, even small pieces, is a way of staying in touch with your field. It says, “I’m still here. I’m still paying attention.”

I think about how Dr. Frederic Mohs developed the technique that now bears his name while he was still a medical student.⁴ He could have said, “I already made it into medical school. That’s enough.” But he did not. I guess my point is not that we are all on the verge of inventing something revolutionary; it is that innovation happens only when curiosity keeps moving us forward. So no, I do not write to check boxes anymore. I write because it keeps me curious, and I have realized that curiosity is a habit I never want to outgrow.

Or maybe it’s because Jay keeps me up at night, and I have nothing better to do.

More than 50 million US adults report experiencing chronic pain, with nearly 7% experiencing high-impact chronic pain.^1-3 Chronic pain negatively affects daily function, results in lost productivity, is a leading cause of disability, and is more prevalent among veterans compared with the general population.^1,2,4-6 Estimates from 2021 suggest the prevalence of chronic pain among veterans exceeds 30%; > 11% experienced high-impact chronic pain.¹

Primary care practitioners (PCPs) have a prominent role in chronic pain management. Pharmacologic options for treating pain, once a mainstay of therapy, present several challenges for patients and PCPs, including drug-drug interactions and adverse effects.⁷ The US opioid epidemic and shift to a biopsychosocial model of chronic pain care have increased emphasis on nonpharmacologic treatment options.^8,9 These include integrative modalities, which incorporate conventional approaches with an array of complementary health approaches.^10-12

Integrative therapy is a prominent feature in whole person care, which may be best exemplified by the US Department of Veterans Affairs (VA) Whole Health System of care.^13-14 Whole health empowers an individual to take charge of their health and well-being so they can “live their life to the fullest.”¹⁴ As implemented in the Veterans Health Administration (VHA), whole health includes the use of evidence-based complementary and integrative therapies, encompassing a multimodal pain management approach. Expanding the use of these therapies requires a better understanding of PCP and patient knowledge, interest, and use of integrative modalities for chronic pain.

METHODS

Using a cross-sectional survey design, PCPs and patients with chronic back pain affiliated with the VA Ann Arbor Healthcare System were invited to participate in separate but similar surveys to assess knowledge, interest, and use of nonpharmacologic integrative modalities for the treatment of chronic pain. In May, June, and July 2023, 78 PCPs received 3 email invitations to participate in an electronic (Qualtrics) survey. Patients were identified based on having an International Statistical Classification of Diseases, Tenth Revision code for low back pain (M54.5, M54.40, 41, 42, M54.89) on ≥ 2 outpatient encounters within 18 months (April 1, 2021, to March 31, 2023). A random sample of 200 patients was selected and sent a packet in September 2023 that included an introductory letter and a paper survey, along with a website link and QR code to complete the survey electronically if preferred. The introductory letter stated that participation is voluntary, had no impact on the health care currently received at the VA, and names are not attached to the survey, allowing them to remain anonymous. The packet also included a $10 gift card to encourage survey completion.

Both survey instruments are available upon request, were developed by the study team, and included a mix of yes/no questions, “select all that apply” items, Likert scale response items, and open-ended questions. For one question about which modalities they would like available, the respondent was instructed to select up to 5 modalities. The instruments were extensively pretested by members of the study team, which included 2 PCPs and a nonveteran with chronic back pain.

The list of integrative modalities included in the survey was derived from the tier 1 and tier 2 complementary and integrative health modalities identified in a VHA Directive on complementary and integrative health.^15,16 Tier 1 approaches are considered to have sufficient evidence and must be made available to veterans either within a VA medical facility or in the community. Tier 2 approaches are generally considered safe and may be made available but do not have sufficient evidence to mandate their provision. For participant ease, the integrative modalities were divided into 5 subgroups: manual therapies, energy/biofield therapies, mental health therapies, nutrition counseling, and movement therapies. The clinician survey assessed clinicians’ training and interest, clinical and personal use, and perceived barriers to providing integrative modalities for chronic pain. Professional and personal demographic data were also collected. Similarly, the patient survey assessed use of integrative therapies, perceptions of and interest in integrative modalities, and potential barriers to use. Demographic and health-related information was also collected.

Data analysis included descriptive statistics (eg, frequency counts, means, medians) and visual graphic displays. Separate analyses were conducted for clinicians and patients in addition to a comparative analysis of the use and potential interest in integrative modalities. Analysis were conducted using R software. This study was deemed nonresearch quality improvement by the VA Ann Arbor Healthcare System facility research oversight board and institutional review board approval was not solicited.

RESULTS

Twenty-eight clinicians completed the survey, yielding a participation rate of 36%. Participating clinicians had a median (IQR) age of 48 years (9.5), 15 self-identified as White (54%), 8 as Asian (29%), 15 as female (54%), 26 as non-Hispanic (93%), and 25 were medical doctors or doctors of osteopathy (89%). Nineteen (68%) worked at the main hospital outpatient clinic, and 9 practiced at community-based outpatient clinics (CBOCs). Thirteen respondents (46%) reported having no formal education or training in integrative approaches. Among those with prior training, 8 clinicians had nutrition counseling (29%) and 7 had psychologic therapy training (25%). Thirteen respondents (46%) also reported using integrative modalities for personal health needs: 8 used psychological therapies, 8 used movement therapies, 10 used integrative modalities for stress management or relaxation, and 8 used them for physical symptoms (Table 1).

Overall, 85 of 200 patients (43%) responded to the study survey. Two patients indicated they did not have chronic back pain and were excluded. Patients had a median (IQR) age of 66 (20) years, with 66 self-identifying as White (80%), 69 as male (83%), and 66 as non-Hispanic (80%). Forty-four patients (53%) received care at CBOCs. Forty-seven patients reported excellent, very good, or good overall health (57%), while 53 reported excellent, very good, or good mental health (64%). Fifty-nine patients reported back pain duration > 5 years (71%), and 67 (81%) indicated experiencing back pain flare-ups at least once per week over the previous 12 months. Sixty patients (72%) indicated they were somewhat or very interested in using integrative therapies as a back pain treatment; however, 40 patients (48%) indicated they had not received information about these therapies. Among those who indicated they had received information, the most frequently reported source was their PCP (41%). Most patients (72%) also reported feeling somewhat to very comfortable discussing integrative medicine therapies with their PCP.

Integrative Therapy Recommendations and Use

PCPs reported recommending multiple integrative modalities: 23 (82%) recommended cognitive-behavioral therapy, 22 (79%) recommended acupuncture, 21 (75%) recommended chiropractic, 19 (68%) recommended battlefield acupuncture, recommended massage 18 (64%), 17 (61%) recommended meditation or mindfulness, and 15 (54%) recommended movement therapies such as yoga or tai chi/qigong (Figure 1). The only therapies used by at least half of the patients were chiropractic used by 59 patients (71%) and acupuncture by 42 patients (51%). Thirty-eight patients (46%) reported massage use and 21 patients (25%) used cognitive-behavioral therapy (Table 2).

Integrative Therapies Desired

A majority of PCPs identified acupuncture (n = 20, 71%), chiropractic (n = 19, 68%), and massage (n = 19, 68%) as therapies they would most like to have available for patients with chronic pain (Figure 2). Similarly, patients identified massage (n = 42, 51%), chiropractic (n = 34, 41%), and acupuncture (n = 27, 33%) as most desired. Seventeen patients (21%) expressed interest in movement therapies.

Barriers to Integrative Therapies Use

When asked about barriers to use, 26 PCPs (93%) identified access to services as a somewhat or extremely likely barrier, and 22 identified time constraints (79%) (Table 3). However, 17 PCPs (61%) noted lack of familiarity, and 18 (64%) noted a lack of scientific evidence as barriers to recommending integrative modalities. Among patients, 33 (40%) indicated not knowing what services were available at their facility as a barrier, 32 (39%) were not familiar with specific therapies, and 21 (25%) indicated a lack of clarity about the benefits of a specific therapy. Only 14 patients (17%) indicated that there were no obstacles to use.

DISCUSSION

Use of integrative therapies, including complementary treatments, is an increasingly important part of chronic pain management. This survey study suggests VA PCPs are willing to recommend integrative therapies and patients with chronic back pain both desire and use several therapies. Moreover, both groups expressed interest in greater availability of similar therapies. The results also highlight key barriers, such as knowledge gaps, that should be addressed to increase the uptake of integrative modalities for managing chronic pain.

An increasing number of US adults are using complementary health approaches, an important component of integrative therapy.¹² This trend includes an increase in use for pain management, from 42.3% in 2002 to 49.2% in 2022; chiropractic care, acupuncture, and massage were most frequently used.¹² Similarly, chiropractic, acupuncture and massage were most often used by this sample of veterans with chronic back pain and were identified by the highest percentages of PCPs and patients as the therapies they would most like available.

There were areas where the opinions of patients and clinicians differed. As has been seen previously reported, clinicians largely recommended cognitive-behavioral therapy while patients showed less interest.¹⁷ Additionally, while patients expressed interest in the availability of movement therapies, such as yoga, PCPs expressed more interest in other strategies, such as trigger point injections. These differences may reflect true preference or a tendency for clinicians and patients to select therapies with which they are more familiar. Additional research is needed to better understand the acceptability and potential use of integrative health treatments across a broad array of therapeutic options.

Despite VHA policy requiring facilities to provide certain complementary and integrative health modalities, almost all PCPs identified access to services as a major obstacle.¹⁵ Based on evidence and a rigorous vetting process, services currently required on-site, via telehealth, or through community partners include acupuncture and battlefield acupuncture (battlefield auricular acupuncture), biofeedback, clinical hypnosis, guided imagery, medical massage therapy, medication, tai chi/qigong, and yoga. Optional approaches, which may be made available to veterans, include chiropractic and healing touch. Outside the VHA, some states have introduced or enacted legislation mandating insurance coverage of nonpharmacological pain treatments.¹⁸ However, these requirements and mandates do not help address challenges such as the availability of trained/qualified practitioners.^19,20 Ensuring access to complementary and integrative health treatments requires a more concerted effort to ensure that supply meets demand. It is also important to acknowledge the budgetary and physical space constraints that further limit access to services. Although expansion and integration of integrative medicine services remain a priority within the VA Whole Health program, implementation is contingent on available financial and infrastructure resources.

Time was also identified by PCPs as a barrier to recommending integrative therapies to patients. Developing and implementing time-efficient communication strategies for patient education such as concise talking points and informational handouts could help address this barrier. Furthermore, leveraging existing programs and engaging the entire health care team in patient education and referral could help increase integrative and complementary therapy uptake and use.

Although access and time were identified as major barriers, these findings also suggest that PCP and patient knowledge are another target area for enhancing the use of complementary and integrative therapies. Like prior research, most clinicians identified a lack of familiarity with certain services and a lack of scientific evidence as extremely or somewhat likely to affect their ability to offer integrative services to patients with chronic pain.²¹ Likewise, about 40% of patients identified being unfamiliar with a specific therapy as one of the major obstacles to receiving integrative therapies, with a similar number identifying PCPs as a source of information. The lack of familiarity may be due in part to the evolving nomenclature, with terms such as alternative, complementary, and integrative used to describe approaches outside what is often considered conventional medicine.¹⁰ On the other hand, there has also been considerable expansion in the number of therapies within this domain, along with an expanding evidence base. This suggests a need for targeted educational strategies for clinicians and patients, which can be rapidly deployed and continuously adapted as new therapies and evidence emerge.

Limitations

There are some inherent limitations with a survey-based approach, including sampling, non-response, and social desirability biases. In addition, this study only included PCPs and patients affiliated with a single VA medical center. Steps to mitigate these limitations included maintaining survey anonymity and reporting information about respondent characteristics to enhance transparency about the representativeness of the study findings.

CONCLUSIONS

Expanding the use of nonpharmacological pain treatments, including integrative modalities, is essential for safe and effective chronic pain management and reducing opioid use. Our findings show that VA PCPs and patients with chronic back pain are interested in and have some experience with certain integrative therapies. However, even within the context of a health care system that supports the use of integrative therapies for chronic pain as part of whole person care, increasing uptake will require addressing access and time-related constraints as well as ongoing clinician and patient education.

More than 50 million US adults report experiencing chronic pain, with nearly 7% experiencing high-impact chronic pain.^1-3 Chronic pain negatively affects daily function, results in lost productivity, is a leading cause of disability, and is more prevalent among veterans compared with the general population.^1,2,4-6 Estimates from 2021 suggest the prevalence of chronic pain among veterans exceeds 30%; > 11% experienced high-impact chronic pain.¹

Primary care practitioners (PCPs) have a prominent role in chronic pain management. Pharmacologic options for treating pain, once a mainstay of therapy, present several challenges for patients and PCPs, including drug-drug interactions and adverse effects.⁷ The US opioid epidemic and shift to a biopsychosocial model of chronic pain care have increased emphasis on nonpharmacologic treatment options.^8,9 These include integrative modalities, which incorporate conventional approaches with an array of complementary health approaches.^10-12

Integrative therapy is a prominent feature in whole person care, which may be best exemplified by the US Department of Veterans Affairs (VA) Whole Health System of care.^13-14 Whole health empowers an individual to take charge of their health and well-being so they can “live their life to the fullest.”¹⁴ As implemented in the Veterans Health Administration (VHA), whole health includes the use of evidence-based complementary and integrative therapies, encompassing a multimodal pain management approach. Expanding the use of these therapies requires a better understanding of PCP and patient knowledge, interest, and use of integrative modalities for chronic pain.

METHODS

Using a cross-sectional survey design, PCPs and patients with chronic back pain affiliated with the VA Ann Arbor Healthcare System were invited to participate in separate but similar surveys to assess knowledge, interest, and use of nonpharmacologic integrative modalities for the treatment of chronic pain. In May, June, and July 2023, 78 PCPs received 3 email invitations to participate in an electronic (Qualtrics) survey. Patients were identified based on having an International Statistical Classification of Diseases, Tenth Revision code for low back pain (M54.5, M54.40, 41, 42, M54.89) on ≥ 2 outpatient encounters within 18 months (April 1, 2021, to March 31, 2023). A random sample of 200 patients was selected and sent a packet in September 2023 that included an introductory letter and a paper survey, along with a website link and QR code to complete the survey electronically if preferred. The introductory letter stated that participation is voluntary, had no impact on the health care currently received at the VA, and names are not attached to the survey, allowing them to remain anonymous. The packet also included a $10 gift card to encourage survey completion.

Both survey instruments are available upon request, were developed by the study team, and included a mix of yes/no questions, “select all that apply” items, Likert scale response items, and open-ended questions. For one question about which modalities they would like available, the respondent was instructed to select up to 5 modalities. The instruments were extensively pretested by members of the study team, which included 2 PCPs and a nonveteran with chronic back pain.

The list of integrative modalities included in the survey was derived from the tier 1 and tier 2 complementary and integrative health modalities identified in a VHA Directive on complementary and integrative health.^15,16 Tier 1 approaches are considered to have sufficient evidence and must be made available to veterans either within a VA medical facility or in the community. Tier 2 approaches are generally considered safe and may be made available but do not have sufficient evidence to mandate their provision. For participant ease, the integrative modalities were divided into 5 subgroups: manual therapies, energy/biofield therapies, mental health therapies, nutrition counseling, and movement therapies. The clinician survey assessed clinicians’ training and interest, clinical and personal use, and perceived barriers to providing integrative modalities for chronic pain. Professional and personal demographic data were also collected. Similarly, the patient survey assessed use of integrative therapies, perceptions of and interest in integrative modalities, and potential barriers to use. Demographic and health-related information was also collected.

Data analysis included descriptive statistics (eg, frequency counts, means, medians) and visual graphic displays. Separate analyses were conducted for clinicians and patients in addition to a comparative analysis of the use and potential interest in integrative modalities. Analysis were conducted using R software. This study was deemed nonresearch quality improvement by the VA Ann Arbor Healthcare System facility research oversight board and institutional review board approval was not solicited.

RESULTS

Twenty-eight clinicians completed the survey, yielding a participation rate of 36%. Participating clinicians had a median (IQR) age of 48 years (9.5), 15 self-identified as White (54%), 8 as Asian (29%), 15 as female (54%), 26 as non-Hispanic (93%), and 25 were medical doctors or doctors of osteopathy (89%). Nineteen (68%) worked at the main hospital outpatient clinic, and 9 practiced at community-based outpatient clinics (CBOCs). Thirteen respondents (46%) reported having no formal education or training in integrative approaches. Among those with prior training, 8 clinicians had nutrition counseling (29%) and 7 had psychologic therapy training (25%). Thirteen respondents (46%) also reported using integrative modalities for personal health needs: 8 used psychological therapies, 8 used movement therapies, 10 used integrative modalities for stress management or relaxation, and 8 used them for physical symptoms (Table 1).

Overall, 85 of 200 patients (43%) responded to the study survey. Two patients indicated they did not have chronic back pain and were excluded. Patients had a median (IQR) age of 66 (20) years, with 66 self-identifying as White (80%), 69 as male (83%), and 66 as non-Hispanic (80%). Forty-four patients (53%) received care at CBOCs. Forty-seven patients reported excellent, very good, or good overall health (57%), while 53 reported excellent, very good, or good mental health (64%). Fifty-nine patients reported back pain duration > 5 years (71%), and 67 (81%) indicated experiencing back pain flare-ups at least once per week over the previous 12 months. Sixty patients (72%) indicated they were somewhat or very interested in using integrative therapies as a back pain treatment; however, 40 patients (48%) indicated they had not received information about these therapies. Among those who indicated they had received information, the most frequently reported source was their PCP (41%). Most patients (72%) also reported feeling somewhat to very comfortable discussing integrative medicine therapies with their PCP.

Integrative Therapy Recommendations and Use

PCPs reported recommending multiple integrative modalities: 23 (82%) recommended cognitive-behavioral therapy, 22 (79%) recommended acupuncture, 21 (75%) recommended chiropractic, 19 (68%) recommended battlefield acupuncture, recommended massage 18 (64%), 17 (61%) recommended meditation or mindfulness, and 15 (54%) recommended movement therapies such as yoga or tai chi/qigong (Figure 1). The only therapies used by at least half of the patients were chiropractic used by 59 patients (71%) and acupuncture by 42 patients (51%). Thirty-eight patients (46%) reported massage use and 21 patients (25%) used cognitive-behavioral therapy (Table 2).

Integrative Therapies Desired

A majority of PCPs identified acupuncture (n = 20, 71%), chiropractic (n = 19, 68%), and massage (n = 19, 68%) as therapies they would most like to have available for patients with chronic pain (Figure 2). Similarly, patients identified massage (n = 42, 51%), chiropractic (n = 34, 41%), and acupuncture (n = 27, 33%) as most desired. Seventeen patients (21%) expressed interest in movement therapies.

Barriers to Integrative Therapies Use

When asked about barriers to use, 26 PCPs (93%) identified access to services as a somewhat or extremely likely barrier, and 22 identified time constraints (79%) (Table 3). However, 17 PCPs (61%) noted lack of familiarity, and 18 (64%) noted a lack of scientific evidence as barriers to recommending integrative modalities. Among patients, 33 (40%) indicated not knowing what services were available at their facility as a barrier, 32 (39%) were not familiar with specific therapies, and 21 (25%) indicated a lack of clarity about the benefits of a specific therapy. Only 14 patients (17%) indicated that there were no obstacles to use.

DISCUSSION

Use of integrative therapies, including complementary treatments, is an increasingly important part of chronic pain management. This survey study suggests VA PCPs are willing to recommend integrative therapies and patients with chronic back pain both desire and use several therapies. Moreover, both groups expressed interest in greater availability of similar therapies. The results also highlight key barriers, such as knowledge gaps, that should be addressed to increase the uptake of integrative modalities for managing chronic pain.

An increasing number of US adults are using complementary health approaches, an important component of integrative therapy.¹² This trend includes an increase in use for pain management, from 42.3% in 2002 to 49.2% in 2022; chiropractic care, acupuncture, and massage were most frequently used.¹² Similarly, chiropractic, acupuncture and massage were most often used by this sample of veterans with chronic back pain and were identified by the highest percentages of PCPs and patients as the therapies they would most like available.

There were areas where the opinions of patients and clinicians differed. As has been seen previously reported, clinicians largely recommended cognitive-behavioral therapy while patients showed less interest.¹⁷ Additionally, while patients expressed interest in the availability of movement therapies, such as yoga, PCPs expressed more interest in other strategies, such as trigger point injections. These differences may reflect true preference or a tendency for clinicians and patients to select therapies with which they are more familiar. Additional research is needed to better understand the acceptability and potential use of integrative health treatments across a broad array of therapeutic options.

Despite VHA policy requiring facilities to provide certain complementary and integrative health modalities, almost all PCPs identified access to services as a major obstacle.¹⁵ Based on evidence and a rigorous vetting process, services currently required on-site, via telehealth, or through community partners include acupuncture and battlefield acupuncture (battlefield auricular acupuncture), biofeedback, clinical hypnosis, guided imagery, medical massage therapy, medication, tai chi/qigong, and yoga. Optional approaches, which may be made available to veterans, include chiropractic and healing touch. Outside the VHA, some states have introduced or enacted legislation mandating insurance coverage of nonpharmacological pain treatments.¹⁸ However, these requirements and mandates do not help address challenges such as the availability of trained/qualified practitioners.^19,20 Ensuring access to complementary and integrative health treatments requires a more concerted effort to ensure that supply meets demand. It is also important to acknowledge the budgetary and physical space constraints that further limit access to services. Although expansion and integration of integrative medicine services remain a priority within the VA Whole Health program, implementation is contingent on available financial and infrastructure resources.

Time was also identified by PCPs as a barrier to recommending integrative therapies to patients. Developing and implementing time-efficient communication strategies for patient education such as concise talking points and informational handouts could help address this barrier. Furthermore, leveraging existing programs and engaging the entire health care team in patient education and referral could help increase integrative and complementary therapy uptake and use.

Although access and time were identified as major barriers, these findings also suggest that PCP and patient knowledge are another target area for enhancing the use of complementary and integrative therapies. Like prior research, most clinicians identified a lack of familiarity with certain services and a lack of scientific evidence as extremely or somewhat likely to affect their ability to offer integrative services to patients with chronic pain.²¹ Likewise, about 40% of patients identified being unfamiliar with a specific therapy as one of the major obstacles to receiving integrative therapies, with a similar number identifying PCPs as a source of information. The lack of familiarity may be due in part to the evolving nomenclature, with terms such as alternative, complementary, and integrative used to describe approaches outside what is often considered conventional medicine.¹⁰ On the other hand, there has also been considerable expansion in the number of therapies within this domain, along with an expanding evidence base. This suggests a need for targeted educational strategies for clinicians and patients, which can be rapidly deployed and continuously adapted as new therapies and evidence emerge.

Limitations

There are some inherent limitations with a survey-based approach, including sampling, non-response, and social desirability biases. In addition, this study only included PCPs and patients affiliated with a single VA medical center. Steps to mitigate these limitations included maintaining survey anonymity and reporting information about respondent characteristics to enhance transparency about the representativeness of the study findings.

CONCLUSIONS

Expanding the use of nonpharmacological pain treatments, including integrative modalities, is essential for safe and effective chronic pain management and reducing opioid use. Our findings show that VA PCPs and patients with chronic back pain are interested in and have some experience with certain integrative therapies. However, even within the context of a health care system that supports the use of integrative therapies for chronic pain as part of whole person care, increasing uptake will require addressing access and time-related constraints as well as ongoing clinician and patient education.

More than 50 million US adults report experiencing chronic pain, with nearly 7% experiencing high-impact chronic pain.^1-3 Chronic pain negatively affects daily function, results in lost productivity, is a leading cause of disability, and is more prevalent among veterans compared with the general population.^1,2,4-6 Estimates from 2021 suggest the prevalence of chronic pain among veterans exceeds 30%; > 11% experienced high-impact chronic pain.¹

Primary care practitioners (PCPs) have a prominent role in chronic pain management. Pharmacologic options for treating pain, once a mainstay of therapy, present several challenges for patients and PCPs, including drug-drug interactions and adverse effects.⁷ The US opioid epidemic and shift to a biopsychosocial model of chronic pain care have increased emphasis on nonpharmacologic treatment options.^8,9 These include integrative modalities, which incorporate conventional approaches with an array of complementary health approaches.^10-12

Integrative therapy is a prominent feature in whole person care, which may be best exemplified by the US Department of Veterans Affairs (VA) Whole Health System of care.^13-14 Whole health empowers an individual to take charge of their health and well-being so they can “live their life to the fullest.”¹⁴ As implemented in the Veterans Health Administration (VHA), whole health includes the use of evidence-based complementary and integrative therapies, encompassing a multimodal pain management approach. Expanding the use of these therapies requires a better understanding of PCP and patient knowledge, interest, and use of integrative modalities for chronic pain.

METHODS

Using a cross-sectional survey design, PCPs and patients with chronic back pain affiliated with the VA Ann Arbor Healthcare System were invited to participate in separate but similar surveys to assess knowledge, interest, and use of nonpharmacologic integrative modalities for the treatment of chronic pain. In May, June, and July 2023, 78 PCPs received 3 email invitations to participate in an electronic (Qualtrics) survey. Patients were identified based on having an International Statistical Classification of Diseases, Tenth Revision code for low back pain (M54.5, M54.40, 41, 42, M54.89) on ≥ 2 outpatient encounters within 18 months (April 1, 2021, to March 31, 2023). A random sample of 200 patients was selected and sent a packet in September 2023 that included an introductory letter and a paper survey, along with a website link and QR code to complete the survey electronically if preferred. The introductory letter stated that participation is voluntary, had no impact on the health care currently received at the VA, and names are not attached to the survey, allowing them to remain anonymous. The packet also included a $10 gift card to encourage survey completion.

Both survey instruments are available upon request, were developed by the study team, and included a mix of yes/no questions, “select all that apply” items, Likert scale response items, and open-ended questions. For one question about which modalities they would like available, the respondent was instructed to select up to 5 modalities. The instruments were extensively pretested by members of the study team, which included 2 PCPs and a nonveteran with chronic back pain.

The list of integrative modalities included in the survey was derived from the tier 1 and tier 2 complementary and integrative health modalities identified in a VHA Directive on complementary and integrative health.^15,16 Tier 1 approaches are considered to have sufficient evidence and must be made available to veterans either within a VA medical facility or in the community. Tier 2 approaches are generally considered safe and may be made available but do not have sufficient evidence to mandate their provision. For participant ease, the integrative modalities were divided into 5 subgroups: manual therapies, energy/biofield therapies, mental health therapies, nutrition counseling, and movement therapies. The clinician survey assessed clinicians’ training and interest, clinical and personal use, and perceived barriers to providing integrative modalities for chronic pain. Professional and personal demographic data were also collected. Similarly, the patient survey assessed use of integrative therapies, perceptions of and interest in integrative modalities, and potential barriers to use. Demographic and health-related information was also collected.

Data analysis included descriptive statistics (eg, frequency counts, means, medians) and visual graphic displays. Separate analyses were conducted for clinicians and patients in addition to a comparative analysis of the use and potential interest in integrative modalities. Analysis were conducted using R software. This study was deemed nonresearch quality improvement by the VA Ann Arbor Healthcare System facility research oversight board and institutional review board approval was not solicited.

RESULTS

Twenty-eight clinicians completed the survey, yielding a participation rate of 36%. Participating clinicians had a median (IQR) age of 48 years (9.5), 15 self-identified as White (54%), 8 as Asian (29%), 15 as female (54%), 26 as non-Hispanic (93%), and 25 were medical doctors or doctors of osteopathy (89%). Nineteen (68%) worked at the main hospital outpatient clinic, and 9 practiced at community-based outpatient clinics (CBOCs). Thirteen respondents (46%) reported having no formal education or training in integrative approaches. Among those with prior training, 8 clinicians had nutrition counseling (29%) and 7 had psychologic therapy training (25%). Thirteen respondents (46%) also reported using integrative modalities for personal health needs: 8 used psychological therapies, 8 used movement therapies, 10 used integrative modalities for stress management or relaxation, and 8 used them for physical symptoms (Table 1).

Overall, 85 of 200 patients (43%) responded to the study survey. Two patients indicated they did not have chronic back pain and were excluded. Patients had a median (IQR) age of 66 (20) years, with 66 self-identifying as White (80%), 69 as male (83%), and 66 as non-Hispanic (80%). Forty-four patients (53%) received care at CBOCs. Forty-seven patients reported excellent, very good, or good overall health (57%), while 53 reported excellent, very good, or good mental health (64%). Fifty-nine patients reported back pain duration > 5 years (71%), and 67 (81%) indicated experiencing back pain flare-ups at least once per week over the previous 12 months. Sixty patients (72%) indicated they were somewhat or very interested in using integrative therapies as a back pain treatment; however, 40 patients (48%) indicated they had not received information about these therapies. Among those who indicated they had received information, the most frequently reported source was their PCP (41%). Most patients (72%) also reported feeling somewhat to very comfortable discussing integrative medicine therapies with their PCP.

Integrative Therapy Recommendations and Use

PCPs reported recommending multiple integrative modalities: 23 (82%) recommended cognitive-behavioral therapy, 22 (79%) recommended acupuncture, 21 (75%) recommended chiropractic, 19 (68%) recommended battlefield acupuncture, recommended massage 18 (64%), 17 (61%) recommended meditation or mindfulness, and 15 (54%) recommended movement therapies such as yoga or tai chi/qigong (Figure 1). The only therapies used by at least half of the patients were chiropractic used by 59 patients (71%) and acupuncture by 42 patients (51%). Thirty-eight patients (46%) reported massage use and 21 patients (25%) used cognitive-behavioral therapy (Table 2).

Integrative Therapies Desired

A majority of PCPs identified acupuncture (n = 20, 71%), chiropractic (n = 19, 68%), and massage (n = 19, 68%) as therapies they would most like to have available for patients with chronic pain (Figure 2). Similarly, patients identified massage (n = 42, 51%), chiropractic (n = 34, 41%), and acupuncture (n = 27, 33%) as most desired. Seventeen patients (21%) expressed interest in movement therapies.

Barriers to Integrative Therapies Use

When asked about barriers to use, 26 PCPs (93%) identified access to services as a somewhat or extremely likely barrier, and 22 identified time constraints (79%) (Table 3). However, 17 PCPs (61%) noted lack of familiarity, and 18 (64%) noted a lack of scientific evidence as barriers to recommending integrative modalities. Among patients, 33 (40%) indicated not knowing what services were available at their facility as a barrier, 32 (39%) were not familiar with specific therapies, and 21 (25%) indicated a lack of clarity about the benefits of a specific therapy. Only 14 patients (17%) indicated that there were no obstacles to use.

DISCUSSION

Use of integrative therapies, including complementary treatments, is an increasingly important part of chronic pain management. This survey study suggests VA PCPs are willing to recommend integrative therapies and patients with chronic back pain both desire and use several therapies. Moreover, both groups expressed interest in greater availability of similar therapies. The results also highlight key barriers, such as knowledge gaps, that should be addressed to increase the uptake of integrative modalities for managing chronic pain.

An increasing number of US adults are using complementary health approaches, an important component of integrative therapy.¹² This trend includes an increase in use for pain management, from 42.3% in 2002 to 49.2% in 2022; chiropractic care, acupuncture, and massage were most frequently used.¹² Similarly, chiropractic, acupuncture and massage were most often used by this sample of veterans with chronic back pain and were identified by the highest percentages of PCPs and patients as the therapies they would most like available.

There were areas where the opinions of patients and clinicians differed. As has been seen previously reported, clinicians largely recommended cognitive-behavioral therapy while patients showed less interest.¹⁷ Additionally, while patients expressed interest in the availability of movement therapies, such as yoga, PCPs expressed more interest in other strategies, such as trigger point injections. These differences may reflect true preference or a tendency for clinicians and patients to select therapies with which they are more familiar. Additional research is needed to better understand the acceptability and potential use of integrative health treatments across a broad array of therapeutic options.

Despite VHA policy requiring facilities to provide certain complementary and integrative health modalities, almost all PCPs identified access to services as a major obstacle.¹⁵ Based on evidence and a rigorous vetting process, services currently required on-site, via telehealth, or through community partners include acupuncture and battlefield acupuncture (battlefield auricular acupuncture), biofeedback, clinical hypnosis, guided imagery, medical massage therapy, medication, tai chi/qigong, and yoga. Optional approaches, which may be made available to veterans, include chiropractic and healing touch. Outside the VHA, some states have introduced or enacted legislation mandating insurance coverage of nonpharmacological pain treatments.¹⁸ However, these requirements and mandates do not help address challenges such as the availability of trained/qualified practitioners.^19,20 Ensuring access to complementary and integrative health treatments requires a more concerted effort to ensure that supply meets demand. It is also important to acknowledge the budgetary and physical space constraints that further limit access to services. Although expansion and integration of integrative medicine services remain a priority within the VA Whole Health program, implementation is contingent on available financial and infrastructure resources.

Time was also identified by PCPs as a barrier to recommending integrative therapies to patients. Developing and implementing time-efficient communication strategies for patient education such as concise talking points and informational handouts could help address this barrier. Furthermore, leveraging existing programs and engaging the entire health care team in patient education and referral could help increase integrative and complementary therapy uptake and use.

Although access and time were identified as major barriers, these findings also suggest that PCP and patient knowledge are another target area for enhancing the use of complementary and integrative therapies. Like prior research, most clinicians identified a lack of familiarity with certain services and a lack of scientific evidence as extremely or somewhat likely to affect their ability to offer integrative services to patients with chronic pain.²¹ Likewise, about 40% of patients identified being unfamiliar with a specific therapy as one of the major obstacles to receiving integrative therapies, with a similar number identifying PCPs as a source of information. The lack of familiarity may be due in part to the evolving nomenclature, with terms such as alternative, complementary, and integrative used to describe approaches outside what is often considered conventional medicine.¹⁰ On the other hand, there has also been considerable expansion in the number of therapies within this domain, along with an expanding evidence base. This suggests a need for targeted educational strategies for clinicians and patients, which can be rapidly deployed and continuously adapted as new therapies and evidence emerge.

Limitations

There are some inherent limitations with a survey-based approach, including sampling, non-response, and social desirability biases. In addition, this study only included PCPs and patients affiliated with a single VA medical center. Steps to mitigate these limitations included maintaining survey anonymity and reporting information about respondent characteristics to enhance transparency about the representativeness of the study findings.

CONCLUSIONS

Expanding the use of nonpharmacological pain treatments, including integrative modalities, is essential for safe and effective chronic pain management and reducing opioid use. Our findings show that VA PCPs and patients with chronic back pain are interested in and have some experience with certain integrative therapies. However, even within the context of a health care system that supports the use of integrative therapies for chronic pain as part of whole person care, increasing uptake will require addressing access and time-related constraints as well as ongoing clinician and patient education.

The US Coast Guard (USCG) operates within the US Department of Homeland Security and represents a force of > 50,000 servicemembers.¹ The missions of the service include maritime law enforcement (drug interdiction), search and rescue, and defense readiness.²

The USCG operates 42 clinics and numerous smaller sick bays of varying sizes and medical capabilities throughout the country to provide acute and routine medical services. Health services technicians (HSs) are the most common staffing component and provide much of the support services in each USCG health care setting. The HS rating, colloquially referred to as corpsmen, is achieved through a 22-week course known as “A” school that trains servicemembers in outpatient and acute care, including emergency medical technician training.³ There are about 750 USCG HSs.

Within USCG clinics, HSs conduct ambulatory intakes for outpatient appointments, administer immunizations and blood draws, requisition medical equipment and supplies, serve as a pharmacy technician, complete physical examinations, and manage referrals, among other duties. Their familiarity with different aspects of clinic operations and medical practice must be broad. To that end, corpsmen develop and reinforce their medical knowledge through various trainings, including additional courses to specialize in certain medical skills, such as pharmacy technician “C” school or dental assistant “C” school.

The USCG employs < 15 field pharmacists, most of whom serve in an ambulatory care environment.⁴ Responsibilities of USCG pharmacists include the routine reinforcement of pharmacy knowledge with HSs. For the corpsmen who are not pharmacy technicians or who have not attended pharmacy technician “C” school, the extent of their pharmacy instruction primarily came from the “A” school curriculum, of which only 1 class is specific to pharmacy. Providing routine pharmacy-related training to the HSs further cultivates their pharmacy knowledge and confidence so that they can practice more holistically. These trainings do not need to follow any specific format.

In this study, 3 pharmacists at 3 separate USCG clinics conducted a training inspired by the Jeopardy! game show with the corpsmen at their respective clinics. This study examined the effectiveness of game-based learning on the pharmacy knowledge retention of HSs at 3 USCG clinics. A secondary objective was to evaluate the baseline pharmacy knowledge of corpsmen based on specific corpsmen demographics.

Methods

As part of a USCG quality improvement study in 2024, 28 HSs at the 3 USCG clinics were provided a preintervention assessment, completed game-based educational program (intervention), and then were assessed again following the intervention.

The HSs were presented with a 25-question assessment that included 10 knowledge questions (3 on over-the-counter medications, 2 on use of medications in pregnancy, 2 on precautions and contraindications, 2 on indications, and 1 on immunizations) and 15 brand-generic matching questions. These questions were developed and reviewed by the 3 participating pharmacists to ensure that their scope was commensurate with the overall pharmacy knowledge that could be reasonably expected of corpsmen spanning various points of their HS career.

One to 7 days after the preintervention assessment, the pharmacists hosted the game-based learning modeled after Jeopardy!. The Jeopardy! categories mirrored the assessment knowledge question categories, and brand-generic nomenclature was freely discussed throughout. About 2 weeks later, the same HSs who completed the preintervention assessment and participated in the game were presented with the same assessment.

In addition to capturing the difference in scores between the 2 assessments, additional demographic data were gathered, including service time as an HS and whether they received formalized pharmacy technician training and if so, how long they have served in that capacity. Demographic data were collected to identify potential correlations between demographic characteristics and results.

Results

Twenty-eight HSs at the 3 clinics completed the game-based training and both assessments. The mean score increased from 15.1 preintervention to 17.4 postintervention (Table). Preintervention scores ranged from 1 to 24 and postintervention scores ranged from 6 to 25.

There were 19 HSs (68%) whose score increased from preintervention to postintervention and 5 (18%) had decreased scores. The largest score decrease was 4 (from 18 to 14), and the largest score increase was 11 (from 13 to 24). The mean improvement was 3.9 among the 19 HSs with increased scores

Twenty-one HSs reported no formal pharmacy technician training, 3 completed pharmacy technician “C” school, and 4 received informal on-the-job training. The mean score for the “C” school trained HSs was 23.0 preintervention and 23.7 postintervention. The mean score for HSs trained on the job was 16.0 preintervention and 18.5 postintervention. The mean score for HSs with no training was 13.9 preintervention and 16.3 postintervention.

As HSs advance in their careers, they typically assume roles with increasing technical knowledge, responsibility, and oversight, thus aligning with advancement from E-4 (third class petty officer) to E-6 (first class petty officer) and beyond. In this study, there was 1 E-3, 12 E-4s (mean time as an HS, 1.3 years), 8 E-5s (mean time as an HS, 4.8 years), and 7 E-6s (mean time as an HS, 8.6 years). The E-3 had a preintervention score of 1.0 and a postintervention score of 6.0. The E-4s had a mean change in score from pre- to postintervention of 2.4. The E-5s had a mean change in score from pre- to postintervention of 1.6. The E-6s had a mean change in score from pre- to postintervention of 2.3.

Discussion

This study is novel in its examination of the impact of game-based learning on the retention of the pharmacy knowledge of USCG corpsmen. A PubMed literature search of the phrase “((Corpsman) OR (Corpsmen)) AND (Coast Guard)” yields 135 results, though none were relevant to the USCG population described in this study. A PubMed literature search of the phrase “(Jeopardy!) AND (pharmacy)” yields 28 results, only 1 of which discusses using the game-based approach as an instructional tool.⁵ A PubMed literature search of the phrase “(game) AND (Coast Guard)” yields 55 results, none of which were specifically relevant to game-based learning in the USCG. This study appears to be among the first to discuss results and trends in game-based learning with USCG corpsmen.

The preponderance of literature for game-based learning strategies exists in children; more research in adults is needed.^6,7 With studies showing that game-based learning may impact motivation to learn and learning gains, it is unsurprising that there is some research in professional health care education. Games modeled after everything from simulated clinical scenarios to Family Feud and Chutes and Ladders-style games have been compared with traditional learning strategies. However, the results of whether game-based learning strategies improve knowledge, clinical decision-making, and motivation to learn vary, suggesting the need for more research in this field.⁸

The results of this study suggest that Jeopardy! is likely an effective instructional method for USCG corpsmen on pharmacy topics. While there were some HSs whose postintervention scores decreased, 19 (68%) had increased scores. Because the second assessment was administered about 2 weeks after the game-based learning, the results suggest some level of knowledge retention. Between these results and the informally perceived level of engagement, game-based learning could be a more stimulating alternative training method to a standard slide-based presentation.

Stratifying the data by demographics revealed additional trends, although they should be interpreted with caution due to the small sample size. The baseline results strongly illustrate the value of formalized training. It is generally expected that HSs who have completed the “C” school pharmacy technician training program should have more pharmacy knowledge than those with on-the-job or less training. The results indicate that “C” school trained and on-the-job trained HSs scored higher on the preintervention assessment (mean, 23.0 and 16.0, respectively), than those with no such experiences (mean, 13.9). Such results underscore the value of formalized training—whether as a pharmacy technician or in any other “C” school—in enhancing the medical knowledge of HSs that may allow them to hold roles of increased responsibility and medical scope.

In addition to stratification by pharmacy technician training, stratification by years of HS experience (roughly correlated to rank) yields a similar result. It would be expected that as HSs advance in their careers, they gain more exposure to various medical topics, including pharmacy. That is not always the case, however, as it is possible an HS never rotated through a pharmacy technician position or has not been recently exposed to pharmacy knowledge. Nevertheless, the results suggest that increased HS experience was likely associated with an increased baseline pharmacy knowledge, with mean preintervention scores increasing from 11.9 to 18.1 to 19.3 for E-4, E-5, and E-6, respectively.

While there are many explanations for these results, the authors hypothesize that when HSs are E-4s, they might not yet have exposure to all aspects of the clinic and are perhaps not as well-versed in pharmacy practice. An E-5—now a few years into their career—would have completed pharmacy technician “C” school or on-the-job training (if applicable), which could account for the significant jump in pharmacy knowledge scores. An E-6 can still engage in direct patient care activities but take on leadership and supervisory roles within the clinic, perhaps explaining the smaller increase in score.

In terms of increasing responsibility, many USCG corpsmen complete another schooling opportunity—Independent Duty Health Services Technician (IDHS)—so they can serve in independent duty roles, many of which are on USCG cutters. While cutters are deployed, that IDHS could be the sole medical personnel on the cutter and function in a midlevel practitioner extender role. Formalized training in pharmacy—the benefits of which are suggested through these results—or another field of medical practice would strengthen the skillset and confidence of IDHSs.

Though not formally assessed, the 3 pharmacists noted that the game-based learning was met with overwhelmingly positive feedback in terms of excitement, energy, and overall engagement.

Limitations

This cohort of individuals represents a small proportion of the total number of USCG corpsmen, and it is not fully representative of all practice settings. HSs can be assigned to USCG cutters as IDHSs, which would not be captured in this cohort. Even within a single clinic, the knowledge of HSs varies, as not all HS duties consist solely of clinical skills. Additionally, while the overall game framework was consistent among the 3 sites, there may have been unquantifiable differences in overall teaching style by the 3 pharmacists that may have resulted in different levels of content retention. Given the lack of similar studies in this population, this study can best be described as a quantitative descriptor of results rather than a statistical comparison of what instructional method works best.

Conclusions

The USCG greatly benefits from having trained and experienced HSs fulfilling mission support roles in the organization. In addition to traditional slide-based trainings, game-based learning can be considered to create engaging learning environments to support the knowledge retention of pharmacy and other medical topics for USCG corpsmen.

The US Coast Guard (USCG) operates within the US Department of Homeland Security and represents a force of > 50,000 servicemembers.¹ The missions of the service include maritime law enforcement (drug interdiction), search and rescue, and defense readiness.²

The USCG operates 42 clinics and numerous smaller sick bays of varying sizes and medical capabilities throughout the country to provide acute and routine medical services. Health services technicians (HSs) are the most common staffing component and provide much of the support services in each USCG health care setting. The HS rating, colloquially referred to as corpsmen, is achieved through a 22-week course known as “A” school that trains servicemembers in outpatient and acute care, including emergency medical technician training.³ There are about 750 USCG HSs.

Within USCG clinics, HSs conduct ambulatory intakes for outpatient appointments, administer immunizations and blood draws, requisition medical equipment and supplies, serve as a pharmacy technician, complete physical examinations, and manage referrals, among other duties. Their familiarity with different aspects of clinic operations and medical practice must be broad. To that end, corpsmen develop and reinforce their medical knowledge through various trainings, including additional courses to specialize in certain medical skills, such as pharmacy technician “C” school or dental assistant “C” school.

The USCG employs < 15 field pharmacists, most of whom serve in an ambulatory care environment.⁴ Responsibilities of USCG pharmacists include the routine reinforcement of pharmacy knowledge with HSs. For the corpsmen who are not pharmacy technicians or who have not attended pharmacy technician “C” school, the extent of their pharmacy instruction primarily came from the “A” school curriculum, of which only 1 class is specific to pharmacy. Providing routine pharmacy-related training to the HSs further cultivates their pharmacy knowledge and confidence so that they can practice more holistically. These trainings do not need to follow any specific format.

In this study, 3 pharmacists at 3 separate USCG clinics conducted a training inspired by the Jeopardy! game show with the corpsmen at their respective clinics. This study examined the effectiveness of game-based learning on the pharmacy knowledge retention of HSs at 3 USCG clinics. A secondary objective was to evaluate the baseline pharmacy knowledge of corpsmen based on specific corpsmen demographics.

Methods

As part of a USCG quality improvement study in 2024, 28 HSs at the 3 USCG clinics were provided a preintervention assessment, completed game-based educational program (intervention), and then were assessed again following the intervention.

The HSs were presented with a 25-question assessment that included 10 knowledge questions (3 on over-the-counter medications, 2 on use of medications in pregnancy, 2 on precautions and contraindications, 2 on indications, and 1 on immunizations) and 15 brand-generic matching questions. These questions were developed and reviewed by the 3 participating pharmacists to ensure that their scope was commensurate with the overall pharmacy knowledge that could be reasonably expected of corpsmen spanning various points of their HS career.

One to 7 days after the preintervention assessment, the pharmacists hosted the game-based learning modeled after Jeopardy!. The Jeopardy! categories mirrored the assessment knowledge question categories, and brand-generic nomenclature was freely discussed throughout. About 2 weeks later, the same HSs who completed the preintervention assessment and participated in the game were presented with the same assessment.

In addition to capturing the difference in scores between the 2 assessments, additional demographic data were gathered, including service time as an HS and whether they received formalized pharmacy technician training and if so, how long they have served in that capacity. Demographic data were collected to identify potential correlations between demographic characteristics and results.

Results

Twenty-eight HSs at the 3 clinics completed the game-based training and both assessments. The mean score increased from 15.1 preintervention to 17.4 postintervention (Table). Preintervention scores ranged from 1 to 24 and postintervention scores ranged from 6 to 25.

There were 19 HSs (68%) whose score increased from preintervention to postintervention and 5 (18%) had decreased scores. The largest score decrease was 4 (from 18 to 14), and the largest score increase was 11 (from 13 to 24). The mean improvement was 3.9 among the 19 HSs with increased scores

Twenty-one HSs reported no formal pharmacy technician training, 3 completed pharmacy technician “C” school, and 4 received informal on-the-job training. The mean score for the “C” school trained HSs was 23.0 preintervention and 23.7 postintervention. The mean score for HSs trained on the job was 16.0 preintervention and 18.5 postintervention. The mean score for HSs with no training was 13.9 preintervention and 16.3 postintervention.

As HSs advance in their careers, they typically assume roles with increasing technical knowledge, responsibility, and oversight, thus aligning with advancement from E-4 (third class petty officer) to E-6 (first class petty officer) and beyond. In this study, there was 1 E-3, 12 E-4s (mean time as an HS, 1.3 years), 8 E-5s (mean time as an HS, 4.8 years), and 7 E-6s (mean time as an HS, 8.6 years). The E-3 had a preintervention score of 1.0 and a postintervention score of 6.0. The E-4s had a mean change in score from pre- to postintervention of 2.4. The E-5s had a mean change in score from pre- to postintervention of 1.6. The E-6s had a mean change in score from pre- to postintervention of 2.3.

Discussion

This study is novel in its examination of the impact of game-based learning on the retention of the pharmacy knowledge of USCG corpsmen. A PubMed literature search of the phrase “((Corpsman) OR (Corpsmen)) AND (Coast Guard)” yields 135 results, though none were relevant to the USCG population described in this study. A PubMed literature search of the phrase “(Jeopardy!) AND (pharmacy)” yields 28 results, only 1 of which discusses using the game-based approach as an instructional tool.⁵ A PubMed literature search of the phrase “(game) AND (Coast Guard)” yields 55 results, none of which were specifically relevant to game-based learning in the USCG. This study appears to be among the first to discuss results and trends in game-based learning with USCG corpsmen.

The preponderance of literature for game-based learning strategies exists in children; more research in adults is needed.^6,7 With studies showing that game-based learning may impact motivation to learn and learning gains, it is unsurprising that there is some research in professional health care education. Games modeled after everything from simulated clinical scenarios to Family Feud and Chutes and Ladders-style games have been compared with traditional learning strategies. However, the results of whether game-based learning strategies improve knowledge, clinical decision-making, and motivation to learn vary, suggesting the need for more research in this field.⁸

The results of this study suggest that Jeopardy! is likely an effective instructional method for USCG corpsmen on pharmacy topics. While there were some HSs whose postintervention scores decreased, 19 (68%) had increased scores. Because the second assessment was administered about 2 weeks after the game-based learning, the results suggest some level of knowledge retention. Between these results and the informally perceived level of engagement, game-based learning could be a more stimulating alternative training method to a standard slide-based presentation.

Stratifying the data by demographics revealed additional trends, although they should be interpreted with caution due to the small sample size. The baseline results strongly illustrate the value of formalized training. It is generally expected that HSs who have completed the “C” school pharmacy technician training program should have more pharmacy knowledge than those with on-the-job or less training. The results indicate that “C” school trained and on-the-job trained HSs scored higher on the preintervention assessment (mean, 23.0 and 16.0, respectively), than those with no such experiences (mean, 13.9). Such results underscore the value of formalized training—whether as a pharmacy technician or in any other “C” school—in enhancing the medical knowledge of HSs that may allow them to hold roles of increased responsibility and medical scope.

In addition to stratification by pharmacy technician training, stratification by years of HS experience (roughly correlated to rank) yields a similar result. It would be expected that as HSs advance in their careers, they gain more exposure to various medical topics, including pharmacy. That is not always the case, however, as it is possible an HS never rotated through a pharmacy technician position or has not been recently exposed to pharmacy knowledge. Nevertheless, the results suggest that increased HS experience was likely associated with an increased baseline pharmacy knowledge, with mean preintervention scores increasing from 11.9 to 18.1 to 19.3 for E-4, E-5, and E-6, respectively.

While there are many explanations for these results, the authors hypothesize that when HSs are E-4s, they might not yet have exposure to all aspects of the clinic and are perhaps not as well-versed in pharmacy practice. An E-5—now a few years into their career—would have completed pharmacy technician “C” school or on-the-job training (if applicable), which could account for the significant jump in pharmacy knowledge scores. An E-6 can still engage in direct patient care activities but take on leadership and supervisory roles within the clinic, perhaps explaining the smaller increase in score.

In terms of increasing responsibility, many USCG corpsmen complete another schooling opportunity—Independent Duty Health Services Technician (IDHS)—so they can serve in independent duty roles, many of which are on USCG cutters. While cutters are deployed, that IDHS could be the sole medical personnel on the cutter and function in a midlevel practitioner extender role. Formalized training in pharmacy—the benefits of which are suggested through these results—or another field of medical practice would strengthen the skillset and confidence of IDHSs.

Though not formally assessed, the 3 pharmacists noted that the game-based learning was met with overwhelmingly positive feedback in terms of excitement, energy, and overall engagement.

Limitations

This cohort of individuals represents a small proportion of the total number of USCG corpsmen, and it is not fully representative of all practice settings. HSs can be assigned to USCG cutters as IDHSs, which would not be captured in this cohort. Even within a single clinic, the knowledge of HSs varies, as not all HS duties consist solely of clinical skills. Additionally, while the overall game framework was consistent among the 3 sites, there may have been unquantifiable differences in overall teaching style by the 3 pharmacists that may have resulted in different levels of content retention. Given the lack of similar studies in this population, this study can best be described as a quantitative descriptor of results rather than a statistical comparison of what instructional method works best.

Conclusions

The USCG greatly benefits from having trained and experienced HSs fulfilling mission support roles in the organization. In addition to traditional slide-based trainings, game-based learning can be considered to create engaging learning environments to support the knowledge retention of pharmacy and other medical topics for USCG corpsmen.

The US Coast Guard (USCG) operates within the US Department of Homeland Security and represents a force of > 50,000 servicemembers.¹ The missions of the service include maritime law enforcement (drug interdiction), search and rescue, and defense readiness.²

The USCG operates 42 clinics and numerous smaller sick bays of varying sizes and medical capabilities throughout the country to provide acute and routine medical services. Health services technicians (HSs) are the most common staffing component and provide much of the support services in each USCG health care setting. The HS rating, colloquially referred to as corpsmen, is achieved through a 22-week course known as “A” school that trains servicemembers in outpatient and acute care, including emergency medical technician training.³ There are about 750 USCG HSs.

Within USCG clinics, HSs conduct ambulatory intakes for outpatient appointments, administer immunizations and blood draws, requisition medical equipment and supplies, serve as a pharmacy technician, complete physical examinations, and manage referrals, among other duties. Their familiarity with different aspects of clinic operations and medical practice must be broad. To that end, corpsmen develop and reinforce their medical knowledge through various trainings, including additional courses to specialize in certain medical skills, such as pharmacy technician “C” school or dental assistant “C” school.

The USCG employs < 15 field pharmacists, most of whom serve in an ambulatory care environment.⁴ Responsibilities of USCG pharmacists include the routine reinforcement of pharmacy knowledge with HSs. For the corpsmen who are not pharmacy technicians or who have not attended pharmacy technician “C” school, the extent of their pharmacy instruction primarily came from the “A” school curriculum, of which only 1 class is specific to pharmacy. Providing routine pharmacy-related training to the HSs further cultivates their pharmacy knowledge and confidence so that they can practice more holistically. These trainings do not need to follow any specific format.

In this study, 3 pharmacists at 3 separate USCG clinics conducted a training inspired by the Jeopardy! game show with the corpsmen at their respective clinics. This study examined the effectiveness of game-based learning on the pharmacy knowledge retention of HSs at 3 USCG clinics. A secondary objective was to evaluate the baseline pharmacy knowledge of corpsmen based on specific corpsmen demographics.

Methods

As part of a USCG quality improvement study in 2024, 28 HSs at the 3 USCG clinics were provided a preintervention assessment, completed game-based educational program (intervention), and then were assessed again following the intervention.

The HSs were presented with a 25-question assessment that included 10 knowledge questions (3 on over-the-counter medications, 2 on use of medications in pregnancy, 2 on precautions and contraindications, 2 on indications, and 1 on immunizations) and 15 brand-generic matching questions. These questions were developed and reviewed by the 3 participating pharmacists to ensure that their scope was commensurate with the overall pharmacy knowledge that could be reasonably expected of corpsmen spanning various points of their HS career.

One to 7 days after the preintervention assessment, the pharmacists hosted the game-based learning modeled after Jeopardy!. The Jeopardy! categories mirrored the assessment knowledge question categories, and brand-generic nomenclature was freely discussed throughout. About 2 weeks later, the same HSs who completed the preintervention assessment and participated in the game were presented with the same assessment.

In addition to capturing the difference in scores between the 2 assessments, additional demographic data were gathered, including service time as an HS and whether they received formalized pharmacy technician training and if so, how long they have served in that capacity. Demographic data were collected to identify potential correlations between demographic characteristics and results.

Results

Twenty-eight HSs at the 3 clinics completed the game-based training and both assessments. The mean score increased from 15.1 preintervention to 17.4 postintervention (Table). Preintervention scores ranged from 1 to 24 and postintervention scores ranged from 6 to 25.

There were 19 HSs (68%) whose score increased from preintervention to postintervention and 5 (18%) had decreased scores. The largest score decrease was 4 (from 18 to 14), and the largest score increase was 11 (from 13 to 24). The mean improvement was 3.9 among the 19 HSs with increased scores

Twenty-one HSs reported no formal pharmacy technician training, 3 completed pharmacy technician “C” school, and 4 received informal on-the-job training. The mean score for the “C” school trained HSs was 23.0 preintervention and 23.7 postintervention. The mean score for HSs trained on the job was 16.0 preintervention and 18.5 postintervention. The mean score for HSs with no training was 13.9 preintervention and 16.3 postintervention.

As HSs advance in their careers, they typically assume roles with increasing technical knowledge, responsibility, and oversight, thus aligning with advancement from E-4 (third class petty officer) to E-6 (first class petty officer) and beyond. In this study, there was 1 E-3, 12 E-4s (mean time as an HS, 1.3 years), 8 E-5s (mean time as an HS, 4.8 years), and 7 E-6s (mean time as an HS, 8.6 years). The E-3 had a preintervention score of 1.0 and a postintervention score of 6.0. The E-4s had a mean change in score from pre- to postintervention of 2.4. The E-5s had a mean change in score from pre- to postintervention of 1.6. The E-6s had a mean change in score from pre- to postintervention of 2.3.

Discussion

This study is novel in its examination of the impact of game-based learning on the retention of the pharmacy knowledge of USCG corpsmen. A PubMed literature search of the phrase “((Corpsman) OR (Corpsmen)) AND (Coast Guard)” yields 135 results, though none were relevant to the USCG population described in this study. A PubMed literature search of the phrase “(Jeopardy!) AND (pharmacy)” yields 28 results, only 1 of which discusses using the game-based approach as an instructional tool.⁵ A PubMed literature search of the phrase “(game) AND (Coast Guard)” yields 55 results, none of which were specifically relevant to game-based learning in the USCG. This study appears to be among the first to discuss results and trends in game-based learning with USCG corpsmen.

The preponderance of literature for game-based learning strategies exists in children; more research in adults is needed.^6,7 With studies showing that game-based learning may impact motivation to learn and learning gains, it is unsurprising that there is some research in professional health care education. Games modeled after everything from simulated clinical scenarios to Family Feud and Chutes and Ladders-style games have been compared with traditional learning strategies. However, the results of whether game-based learning strategies improve knowledge, clinical decision-making, and motivation to learn vary, suggesting the need for more research in this field.⁸

The results of this study suggest that Jeopardy! is likely an effective instructional method for USCG corpsmen on pharmacy topics. While there were some HSs whose postintervention scores decreased, 19 (68%) had increased scores. Because the second assessment was administered about 2 weeks after the game-based learning, the results suggest some level of knowledge retention. Between these results and the informally perceived level of engagement, game-based learning could be a more stimulating alternative training method to a standard slide-based presentation.

Stratifying the data by demographics revealed additional trends, although they should be interpreted with caution due to the small sample size. The baseline results strongly illustrate the value of formalized training. It is generally expected that HSs who have completed the “C” school pharmacy technician training program should have more pharmacy knowledge than those with on-the-job or less training. The results indicate that “C” school trained and on-the-job trained HSs scored higher on the preintervention assessment (mean, 23.0 and 16.0, respectively), than those with no such experiences (mean, 13.9). Such results underscore the value of formalized training—whether as a pharmacy technician or in any other “C” school—in enhancing the medical knowledge of HSs that may allow them to hold roles of increased responsibility and medical scope.

In addition to stratification by pharmacy technician training, stratification by years of HS experience (roughly correlated to rank) yields a similar result. It would be expected that as HSs advance in their careers, they gain more exposure to various medical topics, including pharmacy. That is not always the case, however, as it is possible an HS never rotated through a pharmacy technician position or has not been recently exposed to pharmacy knowledge. Nevertheless, the results suggest that increased HS experience was likely associated with an increased baseline pharmacy knowledge, with mean preintervention scores increasing from 11.9 to 18.1 to 19.3 for E-4, E-5, and E-6, respectively.

While there are many explanations for these results, the authors hypothesize that when HSs are E-4s, they might not yet have exposure to all aspects of the clinic and are perhaps not as well-versed in pharmacy practice. An E-5—now a few years into their career—would have completed pharmacy technician “C” school or on-the-job training (if applicable), which could account for the significant jump in pharmacy knowledge scores. An E-6 can still engage in direct patient care activities but take on leadership and supervisory roles within the clinic, perhaps explaining the smaller increase in score.

In terms of increasing responsibility, many USCG corpsmen complete another schooling opportunity—Independent Duty Health Services Technician (IDHS)—so they can serve in independent duty roles, many of which are on USCG cutters. While cutters are deployed, that IDHS could be the sole medical personnel on the cutter and function in a midlevel practitioner extender role. Formalized training in pharmacy—the benefits of which are suggested through these results—or another field of medical practice would strengthen the skillset and confidence of IDHSs.

Though not formally assessed, the 3 pharmacists noted that the game-based learning was met with overwhelmingly positive feedback in terms of excitement, energy, and overall engagement.

Limitations

This cohort of individuals represents a small proportion of the total number of USCG corpsmen, and it is not fully representative of all practice settings. HSs can be assigned to USCG cutters as IDHSs, which would not be captured in this cohort. Even within a single clinic, the knowledge of HSs varies, as not all HS duties consist solely of clinical skills. Additionally, while the overall game framework was consistent among the 3 sites, there may have been unquantifiable differences in overall teaching style by the 3 pharmacists that may have resulted in different levels of content retention. Given the lack of similar studies in this population, this study can best be described as a quantitative descriptor of results rather than a statistical comparison of what instructional method works best.

Conclusions

The USCG greatly benefits from having trained and experienced HSs fulfilling mission support roles in the organization. In addition to traditional slide-based trainings, game-based learning can be considered to create engaging learning environments to support the knowledge retention of pharmacy and other medical topics for USCG corpsmen.