Matthew Keller, MD

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

Case Report

A 28-year-old man presented to the dermatology department with cone-shaped, oyster shell–like skin lesions on the scalp, trunk, arms, and legs of 1 month’s duration. He denied any fever, pruritus, pain, joint stiffness, or arthralgia. His family history was remarkable for psoriasis in his paternal grandfather and uncle.

A few years prior to the eruption, the patient developed a rash in the bilateral inguinal area but did not seek medical attention. One month prior to presentation, the rash began to spread to the scalp, trunk, arms, and legs. He was treated in the emergency department with a 5-day course of oral prednisone without any noticeable improvement. At the time of presentation to the dermatology clinic, he was found to have multiple well-demarcated erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crusts (Figure 1). Rapid plasma reagin testing was negative. A 4-mm punch biopsy specimen from the right upper arm demonstrated thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (Figure 2). In the stratum corneum, there was seroexudate with numerous red blood cells between the parakeratosis.

Figure 1. Multiple well-demarcated erythematous plaques with hyperkeratotic crust on the back (A). Closer view of erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crust (B).

Figure 2. Thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (H&E, original magnification ×100).

The patient was diagnosed with rupioid psoriasis. The lesions dramatically improved with methotrexate 10 mg weekly and topical steroids. Two months following diagnosis the patient presented with persistent hyperkeratotic lesions on the back, as he had difficulty reaching the lesions to apply topical medications; intralesional steroid injections were added. This regimen resulted in near-complete resolution maintained at his most recent follow-up 2 years following diagnosis in our clinic.

Comment

Rupia is based on the Greek word rhupos, which means dirt or filth. The term rupioid has been used to describe well-demarcated, cone-shaped plaques with thick, dark, lamellate, and adherent crusts on the skin somewhat resembling oyster or limpet shells. Histologically, a serosanguineous exudate along with thick skin helps to impart a “dirty” appearance to rupioid lesions. Rupioid manifestations have been clinically observed in a variety of diseases, including rupioid psoriasis,^1-3 reactive arthritis,⁴ disseminated histoplasmosis,⁵ keratotic scabies,⁶ secondary syphilis,⁷ and photosensitive skin lesions in association with aminoaciduria.⁸ To diagnose the underlying infectious or inflammatory diseases beneath the thick crusts, skin biopsy and a blood test for syphilis may be necessary.

Rupioid psoriasis is a morphologic subtype of plaque psoriasis with hyperkeratotic lesions that resemble an oyster or limpet shell. Patients with thick plaque psoriasis are more likely to be male with a higher incidence of nail disease and psoriatic arthritis as well as a greater body surface area affected than patients with thin plaque psoriasis.¹ Although most cases of rupioid psoriasis were associated with psoriatic arthritis,³ our patient showed no evidence of psoriatic arthritis or nail changes.

Reactive arthritis may have a similar appearance to rupioid psoriasis but may be distinguished by a geographic relief map configuration with coalescing, keratotic and desquamating lesions, as well as associated urethritis, arthritis, and conjunctivitis.⁴ A rupioid eruption was reported as a manifestation of disseminated histoplasmosis with dirty-appearing, heaped-up, crusted lesions present on the cheeks, nose, and forehead on clinical examination and several intracellular and extracellular oval structures on histologic examination with periodic acid–Schiff and Gomori methenamine-silver stain.⁵ Malignant or rupioid syphilis refers to the stage in which papulopustules of pustular syphilis undergo central necrosis due to endarteritis obliterans and intravascular thrombosis.⁷

In our case, the patient’s psoriasis could have flared after discontinuation of the prednisone that was administered by the emergency department physician. Most cases have been treated with combined systemic and topical therapy.⁹ For systemic treatment, cyclosporine, intramuscular or oral methotrexate, adalimumab, and ustekinumab³ have been used with remarkable improvement. Hyperkeratotic types of psoriasis are generally thought to be resistant to topical therapy because of poor penetration of applied agents; however, a case of rupioid psoriasis without arthritis was successfully treated with topical steroids without concomitant systemic medications.²

Conclusion

Rupioid psoriasis is a morphological subtype of plaque psoriasis with hyperkeratotic lesions that resemble a limpet shell. Rupioid skin manifestations may be seen in a variety of diseases including rupioid psoriasis, reactive arthritis, disseminated histoplasmosis, keratotic scabies, secondary syphilis, and photosensitive skin lesions associated with aminoaciduria. Diagnosis of rupioid psoriasis often requires additional testing such as skin biopsy, skin scraping, and blood tests, and it typically requires systemic therapy for treatment.

Case Report

A 28-year-old man presented to the dermatology department with cone-shaped, oyster shell–like skin lesions on the scalp, trunk, arms, and legs of 1 month’s duration. He denied any fever, pruritus, pain, joint stiffness, or arthralgia. His family history was remarkable for psoriasis in his paternal grandfather and uncle.

A few years prior to the eruption, the patient developed a rash in the bilateral inguinal area but did not seek medical attention. One month prior to presentation, the rash began to spread to the scalp, trunk, arms, and legs. He was treated in the emergency department with a 5-day course of oral prednisone without any noticeable improvement. At the time of presentation to the dermatology clinic, he was found to have multiple well-demarcated erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crusts (Figure 1). Rapid plasma reagin testing was negative. A 4-mm punch biopsy specimen from the right upper arm demonstrated thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (Figure 2). In the stratum corneum, there was seroexudate with numerous red blood cells between the parakeratosis.

Figure 1. Multiple well-demarcated erythematous plaques with hyperkeratotic crust on the back (A). Closer view of erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crust (B).

Figure 2. Thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (H&E, original magnification ×100).

The patient was diagnosed with rupioid psoriasis. The lesions dramatically improved with methotrexate 10 mg weekly and topical steroids. Two months following diagnosis the patient presented with persistent hyperkeratotic lesions on the back, as he had difficulty reaching the lesions to apply topical medications; intralesional steroid injections were added. This regimen resulted in near-complete resolution maintained at his most recent follow-up 2 years following diagnosis in our clinic.

Comment

Rupia is based on the Greek word rhupos, which means dirt or filth. The term rupioid has been used to describe well-demarcated, cone-shaped plaques with thick, dark, lamellate, and adherent crusts on the skin somewhat resembling oyster or limpet shells. Histologically, a serosanguineous exudate along with thick skin helps to impart a “dirty” appearance to rupioid lesions. Rupioid manifestations have been clinically observed in a variety of diseases, including rupioid psoriasis,^1-3 reactive arthritis,⁴ disseminated histoplasmosis,⁵ keratotic scabies,⁶ secondary syphilis,⁷ and photosensitive skin lesions in association with aminoaciduria.⁸ To diagnose the underlying infectious or inflammatory diseases beneath the thick crusts, skin biopsy and a blood test for syphilis may be necessary.

Rupioid psoriasis is a morphologic subtype of plaque psoriasis with hyperkeratotic lesions that resemble an oyster or limpet shell. Patients with thick plaque psoriasis are more likely to be male with a higher incidence of nail disease and psoriatic arthritis as well as a greater body surface area affected than patients with thin plaque psoriasis.¹ Although most cases of rupioid psoriasis were associated with psoriatic arthritis,³ our patient showed no evidence of psoriatic arthritis or nail changes.

Reactive arthritis may have a similar appearance to rupioid psoriasis but may be distinguished by a geographic relief map configuration with coalescing, keratotic and desquamating lesions, as well as associated urethritis, arthritis, and conjunctivitis.⁴ A rupioid eruption was reported as a manifestation of disseminated histoplasmosis with dirty-appearing, heaped-up, crusted lesions present on the cheeks, nose, and forehead on clinical examination and several intracellular and extracellular oval structures on histologic examination with periodic acid–Schiff and Gomori methenamine-silver stain.⁵ Malignant or rupioid syphilis refers to the stage in which papulopustules of pustular syphilis undergo central necrosis due to endarteritis obliterans and intravascular thrombosis.⁷

In our case, the patient’s psoriasis could have flared after discontinuation of the prednisone that was administered by the emergency department physician. Most cases have been treated with combined systemic and topical therapy.⁹ For systemic treatment, cyclosporine, intramuscular or oral methotrexate, adalimumab, and ustekinumab³ have been used with remarkable improvement. Hyperkeratotic types of psoriasis are generally thought to be resistant to topical therapy because of poor penetration of applied agents; however, a case of rupioid psoriasis without arthritis was successfully treated with topical steroids without concomitant systemic medications.²

Conclusion

Rupioid psoriasis is a morphological subtype of plaque psoriasis with hyperkeratotic lesions that resemble a limpet shell. Rupioid skin manifestations may be seen in a variety of diseases including rupioid psoriasis, reactive arthritis, disseminated histoplasmosis, keratotic scabies, secondary syphilis, and photosensitive skin lesions associated with aminoaciduria. Diagnosis of rupioid psoriasis often requires additional testing such as skin biopsy, skin scraping, and blood tests, and it typically requires systemic therapy for treatment.

Case Report

A 28-year-old man presented to the dermatology department with cone-shaped, oyster shell–like skin lesions on the scalp, trunk, arms, and legs of 1 month’s duration. He denied any fever, pruritus, pain, joint stiffness, or arthralgia. His family history was remarkable for psoriasis in his paternal grandfather and uncle.

A few years prior to the eruption, the patient developed a rash in the bilateral inguinal area but did not seek medical attention. One month prior to presentation, the rash began to spread to the scalp, trunk, arms, and legs. He was treated in the emergency department with a 5-day course of oral prednisone without any noticeable improvement. At the time of presentation to the dermatology clinic, he was found to have multiple well-demarcated erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crusts (Figure 1). Rapid plasma reagin testing was negative. A 4-mm punch biopsy specimen from the right upper arm demonstrated thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (Figure 2). In the stratum corneum, there was seroexudate with numerous red blood cells between the parakeratosis.

Figure 1. Multiple well-demarcated erythematous plaques with hyperkeratotic crust on the back (A). Closer view of erythematous plaques with conical, oyster shell–like, dirty-appearing, hyperkeratotic crust (B).

Figure 2. Thick parakeratosis with a remarkable Munro microabscess, regular psoriasiform acanthosis with thin suprapapillary epidermal plates, absent granular layer, and prominent papillary dermal edema (H&E, original magnification ×100).

The patient was diagnosed with rupioid psoriasis. The lesions dramatically improved with methotrexate 10 mg weekly and topical steroids. Two months following diagnosis the patient presented with persistent hyperkeratotic lesions on the back, as he had difficulty reaching the lesions to apply topical medications; intralesional steroid injections were added. This regimen resulted in near-complete resolution maintained at his most recent follow-up 2 years following diagnosis in our clinic.

Comment

Rupia is based on the Greek word rhupos, which means dirt or filth. The term rupioid has been used to describe well-demarcated, cone-shaped plaques with thick, dark, lamellate, and adherent crusts on the skin somewhat resembling oyster or limpet shells. Histologically, a serosanguineous exudate along with thick skin helps to impart a “dirty” appearance to rupioid lesions. Rupioid manifestations have been clinically observed in a variety of diseases, including rupioid psoriasis,^1-3 reactive arthritis,⁴ disseminated histoplasmosis,⁵ keratotic scabies,⁶ secondary syphilis,⁷ and photosensitive skin lesions in association with aminoaciduria.⁸ To diagnose the underlying infectious or inflammatory diseases beneath the thick crusts, skin biopsy and a blood test for syphilis may be necessary.

Rupioid psoriasis is a morphologic subtype of plaque psoriasis with hyperkeratotic lesions that resemble an oyster or limpet shell. Patients with thick plaque psoriasis are more likely to be male with a higher incidence of nail disease and psoriatic arthritis as well as a greater body surface area affected than patients with thin plaque psoriasis.¹ Although most cases of rupioid psoriasis were associated with psoriatic arthritis,³ our patient showed no evidence of psoriatic arthritis or nail changes.

Reactive arthritis may have a similar appearance to rupioid psoriasis but may be distinguished by a geographic relief map configuration with coalescing, keratotic and desquamating lesions, as well as associated urethritis, arthritis, and conjunctivitis.⁴ A rupioid eruption was reported as a manifestation of disseminated histoplasmosis with dirty-appearing, heaped-up, crusted lesions present on the cheeks, nose, and forehead on clinical examination and several intracellular and extracellular oval structures on histologic examination with periodic acid–Schiff and Gomori methenamine-silver stain.⁵ Malignant or rupioid syphilis refers to the stage in which papulopustules of pustular syphilis undergo central necrosis due to endarteritis obliterans and intravascular thrombosis.⁷

In our case, the patient’s psoriasis could have flared after discontinuation of the prednisone that was administered by the emergency department physician. Most cases have been treated with combined systemic and topical therapy.⁹ For systemic treatment, cyclosporine, intramuscular or oral methotrexate, adalimumab, and ustekinumab³ have been used with remarkable improvement. Hyperkeratotic types of psoriasis are generally thought to be resistant to topical therapy because of poor penetration of applied agents; however, a case of rupioid psoriasis without arthritis was successfully treated with topical steroids without concomitant systemic medications.²

Conclusion

Rupioid psoriasis is a morphological subtype of plaque psoriasis with hyperkeratotic lesions that resemble a limpet shell. Rupioid skin manifestations may be seen in a variety of diseases including rupioid psoriasis, reactive arthritis, disseminated histoplasmosis, keratotic scabies, secondary syphilis, and photosensitive skin lesions associated with aminoaciduria. Diagnosis of rupioid psoriasis often requires additional testing such as skin biopsy, skin scraping, and blood tests, and it typically requires systemic therapy for treatment.