For Residents

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

Patient surveys reveal communication to be one of the most important competencies a physician should possess.¹ However, communication is not only what is spoken. A physician’s nonverbal communication or “body language” sets the trajectory for treatment from the moment the patient first sees the physician. Body language includes all forms of communication other than words,² such as vocal tone, posture, and facial and body movements. Being mindful of such behaviors can provide physicians with greater access to their patients. Effective nonverbal communication can have significant effects on patient engagement, compliance, and outcome.

First impressions

The physician’s nonverbal behavior is crucial to the patient’s impression of his (her) physician.³ Appropriate eye gaze, proper distance or forward lean, direct body orientation, uncrossed legs and arms, and arm symmetry also have been associated with patient reports of satisfaction.^3,4 A physician who displays these affiliative non­verbal behaviors is more likely to engage with the patient and be rated higher for patient satisfaction.^5,6 Once a patient has developed rapport and an alliance with the physician and is satisfied with care, you likely will see improvements in patient adherence.

Adherence to treatment

The physician’s ability to verbally and nonverbally communicate a safe, encouraging, and efficient relationship is crucial for patient adherence to treatment. Patients report greater alliance with their physicians when they perceive genuine engagement and concern.⁷ The physician showing interest impacts the patient’s rating of the relationship⁶ and provides confidence that the physician is sensitive and understanding.⁸ As a result, the patient is more trusting and communicative, which allows for greater progress in the patient’s care because it often leads to attending appointments as well as medication adherence.⁹

Medication nonadherence is a complex issue that is influenced by several factors,¹⁰ but it is widely accepted that lack of communication and patient education are important factors.¹¹ Nonverbal communication can help the clinician to distinguish patients who are unwilling to take medication from those who are willing but unable to do so.¹¹

Overall adherence with care also can be affected by nonverbal behaviors. Positive perception of the physician’s tone of voice has been associated with greater attendance at appointments,¹² greater referral rates to alcohol abuse treatment clinics,¹³ and lower rates of malpractice among surgeons.¹⁴ Such trends demonstrate the influence that effective nonverbal communication could have on health care costs by reducing doctor shopping and malpractice rates and increasing effective care.

Outcomes

Physician’s positive nonverbal communication has been linked to positive patient outcomes. Physical therapists who smile, nod, and maintain eye contact compared with those who do not smile or look away from the patient, have been shown to achieve greater short- and long-term improvements in functioning of their patients.¹⁵ Perceptions of physicians as distant or detached are associated with poorer patient outcomes.^5,6,16 Pain patients with high nonverbal support from their physicians show increased pain tolerance and reduction in the amount of pain expressed, compared with those interacting with low nonverbal support physicians.¹⁷ Patients respond more to care if they feel their physician is engaged and sensitive to their needs.

There is much to gain if a physician is mindful of his body language. As Henry A. Nasrallah, MD, Editor-in-Chief of Current Psychiatry wrote in one of his editorials, physicians can exert a far more positive placebo effect through their behavior and relatedness to a patient than the classic placebo.¹⁸

Orf, also known as ecthyma contagiosum, is a common viral zoonotic infection caused by a parapoxvirus. It is widespread among small ruminants such as sheep and goats, and it can be transmitted to humans by close contact with infected animals or contaminated fomites. It usually manifests as vesiculoulcerative lesions or nodules on the inoculation sites, mostly on the hands, but other sites such as the head and scalp occasionally may be involved.¹ We report the case of an orf that proliferated dramatically and became giant after total excision. It was successfully treated with systemic interferon alfa-2a injections and imiquimod cream.

Case Report

A 68-year-old man presented with a rapidly enlarging mass on the left hand that developed 4 weeks prior after close contact with a freshly slaughtered sheep during an Islamic holiday in Turkey. His medical history was remarkable for chronic lymphocytic leukemia (CLL), which was diagnosed one year prior. The patient had been treated with systemic prednisolone and cyclophosphamide therapies, but his disease was in remission at the current presentation and he currently was not receiving any treatment. On physical examination, a 2-cm, exophytic, pinkish gray, weeping nodule was observed on the proximal aspect of the right thumb. Based on the clinical findings and typical anamnesis, a diagnosis of an orf was concluded. It was decided to monitor the patient without any intervention; however, because the lesion did not resolve and remained stable, he was referred to a plastic surgeon for surgical removal after 6 weeks of follow-up.

Histopathologic examination of the excision specimen revealed pseudoepitheliomatous hyperplasia, massive capillary proliferation, and viral cytopathic changes in keratinocytes characterized by ballooning degeneration and eosinophilic cytoplasmic inclusions, which was consistent with the clinical diagnosis of an orf. Unfortunately, the lesion relapsed rapidly following excision (Figure, A). Treatment with oral valacyclovir (1 g 3 times daily) and imiquimod cream 5% (3 times weekly) was initiated. However, this treatment was unsuccessful and was discontinued after 6 weeks, as the lesion kept growing, reaching a diameter of approximately 5 cm and becoming lobulated on the surface (Figure, B). Combination therapy was started with imiquimod cream 5% (3 times weekly) and intralesional interferon alfa-2a injections (3 million IU twice weekly). The injections were so painful that the patient refused further therapy after only 2 injections. The therapy was switched from intralesional to systemic subcutaneous injections of interferon alfa-2a (3 million IU twice weekly) with concomitant imiquimod cream 5% 3 times weekly. This treatment was well tolerated by our patient with no notable side effects, except for mild fever on the night of each injection. Three weeks after the commencement of systemic injections, remarkable healing of the lesions with reduced size and exudation was noted. The frequency of injections was decreased to once weekly, which was then discontinued after 6 weeks when the lesion totally resolved (Figure, C). At 12 months’ follow-up, there were no signs of relapse.

Comment

Orf is an occupational disease that usually develops in farmers, butchers, and veterinarians; however, epidemic outbreaks of human orf are commonly observed in Turkey after the feast of sacrifice, as many individuals have close contact with the animals during sacrification.² In Turkey, orf is well recognized by dermatologists, and clinical diagnosis usually is not difficult.

Human orf has a self-limited course in which lesions spontaneously resolve in 4 to 8 weeks; however, in immunocompromised patients, such as our patient with CLL, orf lesions may be persistent, atypical, and giant, requiring early and effective treatment. Treatment options for giant orf tumors in immunocompromised individuals include surgical excision,³ cryotherapy, topical imiquimod,^4,5 topical or intralesional cidofovir,⁶ and intralesional interferon alfa injections.⁷ According to our clinical observations, surgical interventions for treatment of orfs usually cause a delay in the natural healing process; however, because surgical excision is a recommended treatment option for exophytic and recalcitrant orfs, we decided to treat our patient with surgical excision, which resulted in rapid recurrence and massive proliferation. A similar case of giant orf that was aggravated after surgery has been reported.⁸ In light of these cases, it is our opinion that treatment options other than surgery may be reasonable.

Chronic lymphocytic leukemia may show features of both humoral and cell-mediated deficiency. Patients are known to be prone to viral infections such as varicella-zoster virus, herpes simplex virus, cytomegalovirus, and human papillomavirus. A giant orf infection on the background of CLL also has been described.⁹

Interferons were first discovered in 1957 and named after their ability to interfere with viral replication. They represent a family of cytokines that has an essential role in the innate immune response to virus infections. Because of their antiviral properties, recombinant forms of interferon alfa are widely used with success in the treatment of chronic hepatitis B and hepatitis C virus infections. A few other antiviral clinical applications of interferon alfa include infections caused by human herpesvirus 8 (the etiological agent in Kaposi sarcoma) and human papillomatosis virus (the etiological agent in juvenile laryngeal papillomatosis and condyloma acuminatum).¹⁰

In a report by Ran et al,⁷ intralesional interferon alfa injections were successfully used for treatment of giant orf lesions in an immunocompromised patient. As a result, we started treating the patient with intralesional interferon alfa-2a, but it was not well tolerated by our patient, as it was quite painful. We then decided to continue the therapy with systemic interferon alfa-2a injections, as we believed that it was a good option due to its antiviral, antiproliferative, and antiangiogenic properties. With the experimental combined therapy of systemic interferon alfa-2a and topical imiquimod, our patient achieved a complete response in 9 weeks (3 weeks of twice weekly injections and then 6 weeks of once weekly injections) and had no relapses during 12 months of follow-up.

Conclusion

We present a rare case of a giant orf treated with systemic interferon alfa-2a injections. Because intralesional injections are quite painful, systemic subcutaneous injections of interferon might be a good and safe alternative for recalcitrant orf lesions in immunocompromised patients. However, more studies and reports are needed to confirm its effectiveness and safety.

The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

Orf, also known as ecthyma contagiosum, is a common viral zoonotic infection caused by a parapoxvirus. It is widespread among small ruminants such as sheep and goats, and it can be transmitted to humans by close contact with infected animals or contaminated fomites. It usually manifests as vesiculoulcerative lesions or nodules on the inoculation sites, mostly on the hands, but other sites such as the head and scalp occasionally may be involved.¹ We report the case of an orf that proliferated dramatically and became giant after total excision. It was successfully treated with systemic interferon alfa-2a injections and imiquimod cream.

Case Report

A 68-year-old man presented with a rapidly enlarging mass on the left hand that developed 4 weeks prior after close contact with a freshly slaughtered sheep during an Islamic holiday in Turkey. His medical history was remarkable for chronic lymphocytic leukemia (CLL), which was diagnosed one year prior. The patient had been treated with systemic prednisolone and cyclophosphamide therapies, but his disease was in remission at the current presentation and he currently was not receiving any treatment. On physical examination, a 2-cm, exophytic, pinkish gray, weeping nodule was observed on the proximal aspect of the right thumb. Based on the clinical findings and typical anamnesis, a diagnosis of an orf was concluded. It was decided to monitor the patient without any intervention; however, because the lesion did not resolve and remained stable, he was referred to a plastic surgeon for surgical removal after 6 weeks of follow-up.

Histopathologic examination of the excision specimen revealed pseudoepitheliomatous hyperplasia, massive capillary proliferation, and viral cytopathic changes in keratinocytes characterized by ballooning degeneration and eosinophilic cytoplasmic inclusions, which was consistent with the clinical diagnosis of an orf. Unfortunately, the lesion relapsed rapidly following excision (Figure, A). Treatment with oral valacyclovir (1 g 3 times daily) and imiquimod cream 5% (3 times weekly) was initiated. However, this treatment was unsuccessful and was discontinued after 6 weeks, as the lesion kept growing, reaching a diameter of approximately 5 cm and becoming lobulated on the surface (Figure, B). Combination therapy was started with imiquimod cream 5% (3 times weekly) and intralesional interferon alfa-2a injections (3 million IU twice weekly). The injections were so painful that the patient refused further therapy after only 2 injections. The therapy was switched from intralesional to systemic subcutaneous injections of interferon alfa-2a (3 million IU twice weekly) with concomitant imiquimod cream 5% 3 times weekly. This treatment was well tolerated by our patient with no notable side effects, except for mild fever on the night of each injection. Three weeks after the commencement of systemic injections, remarkable healing of the lesions with reduced size and exudation was noted. The frequency of injections was decreased to once weekly, which was then discontinued after 6 weeks when the lesion totally resolved (Figure, C). At 12 months’ follow-up, there were no signs of relapse.

Comment

Orf is an occupational disease that usually develops in farmers, butchers, and veterinarians; however, epidemic outbreaks of human orf are commonly observed in Turkey after the feast of sacrifice, as many individuals have close contact with the animals during sacrification.² In Turkey, orf is well recognized by dermatologists, and clinical diagnosis usually is not difficult.

Human orf has a self-limited course in which lesions spontaneously resolve in 4 to 8 weeks; however, in immunocompromised patients, such as our patient with CLL, orf lesions may be persistent, atypical, and giant, requiring early and effective treatment. Treatment options for giant orf tumors in immunocompromised individuals include surgical excision,³ cryotherapy, topical imiquimod,^4,5 topical or intralesional cidofovir,⁶ and intralesional interferon alfa injections.⁷ According to our clinical observations, surgical interventions for treatment of orfs usually cause a delay in the natural healing process; however, because surgical excision is a recommended treatment option for exophytic and recalcitrant orfs, we decided to treat our patient with surgical excision, which resulted in rapid recurrence and massive proliferation. A similar case of giant orf that was aggravated after surgery has been reported.⁸ In light of these cases, it is our opinion that treatment options other than surgery may be reasonable.

Chronic lymphocytic leukemia may show features of both humoral and cell-mediated deficiency. Patients are known to be prone to viral infections such as varicella-zoster virus, herpes simplex virus, cytomegalovirus, and human papillomavirus. A giant orf infection on the background of CLL also has been described.⁹

Interferons were first discovered in 1957 and named after their ability to interfere with viral replication. They represent a family of cytokines that has an essential role in the innate immune response to virus infections. Because of their antiviral properties, recombinant forms of interferon alfa are widely used with success in the treatment of chronic hepatitis B and hepatitis C virus infections. A few other antiviral clinical applications of interferon alfa include infections caused by human herpesvirus 8 (the etiological agent in Kaposi sarcoma) and human papillomatosis virus (the etiological agent in juvenile laryngeal papillomatosis and condyloma acuminatum).¹⁰

In a report by Ran et al,⁷ intralesional interferon alfa injections were successfully used for treatment of giant orf lesions in an immunocompromised patient. As a result, we started treating the patient with intralesional interferon alfa-2a, but it was not well tolerated by our patient, as it was quite painful. We then decided to continue the therapy with systemic interferon alfa-2a injections, as we believed that it was a good option due to its antiviral, antiproliferative, and antiangiogenic properties. With the experimental combined therapy of systemic interferon alfa-2a and topical imiquimod, our patient achieved a complete response in 9 weeks (3 weeks of twice weekly injections and then 6 weeks of once weekly injections) and had no relapses during 12 months of follow-up.

Conclusion

We present a rare case of a giant orf treated with systemic interferon alfa-2a injections. Because intralesional injections are quite painful, systemic subcutaneous injections of interferon might be a good and safe alternative for recalcitrant orf lesions in immunocompromised patients. However, more studies and reports are needed to confirm its effectiveness and safety.

The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

Orf, also known as ecthyma contagiosum, is a common viral zoonotic infection caused by a parapoxvirus. It is widespread among small ruminants such as sheep and goats, and it can be transmitted to humans by close contact with infected animals or contaminated fomites. It usually manifests as vesiculoulcerative lesions or nodules on the inoculation sites, mostly on the hands, but other sites such as the head and scalp occasionally may be involved.¹ We report the case of an orf that proliferated dramatically and became giant after total excision. It was successfully treated with systemic interferon alfa-2a injections and imiquimod cream.

Case Report

A 68-year-old man presented with a rapidly enlarging mass on the left hand that developed 4 weeks prior after close contact with a freshly slaughtered sheep during an Islamic holiday in Turkey. His medical history was remarkable for chronic lymphocytic leukemia (CLL), which was diagnosed one year prior. The patient had been treated with systemic prednisolone and cyclophosphamide therapies, but his disease was in remission at the current presentation and he currently was not receiving any treatment. On physical examination, a 2-cm, exophytic, pinkish gray, weeping nodule was observed on the proximal aspect of the right thumb. Based on the clinical findings and typical anamnesis, a diagnosis of an orf was concluded. It was decided to monitor the patient without any intervention; however, because the lesion did not resolve and remained stable, he was referred to a plastic surgeon for surgical removal after 6 weeks of follow-up.

Histopathologic examination of the excision specimen revealed pseudoepitheliomatous hyperplasia, massive capillary proliferation, and viral cytopathic changes in keratinocytes characterized by ballooning degeneration and eosinophilic cytoplasmic inclusions, which was consistent with the clinical diagnosis of an orf. Unfortunately, the lesion relapsed rapidly following excision (Figure, A). Treatment with oral valacyclovir (1 g 3 times daily) and imiquimod cream 5% (3 times weekly) was initiated. However, this treatment was unsuccessful and was discontinued after 6 weeks, as the lesion kept growing, reaching a diameter of approximately 5 cm and becoming lobulated on the surface (Figure, B). Combination therapy was started with imiquimod cream 5% (3 times weekly) and intralesional interferon alfa-2a injections (3 million IU twice weekly). The injections were so painful that the patient refused further therapy after only 2 injections. The therapy was switched from intralesional to systemic subcutaneous injections of interferon alfa-2a (3 million IU twice weekly) with concomitant imiquimod cream 5% 3 times weekly. This treatment was well tolerated by our patient with no notable side effects, except for mild fever on the night of each injection. Three weeks after the commencement of systemic injections, remarkable healing of the lesions with reduced size and exudation was noted. The frequency of injections was decreased to once weekly, which was then discontinued after 6 weeks when the lesion totally resolved (Figure, C). At 12 months’ follow-up, there were no signs of relapse.

Comment

Orf is an occupational disease that usually develops in farmers, butchers, and veterinarians; however, epidemic outbreaks of human orf are commonly observed in Turkey after the feast of sacrifice, as many individuals have close contact with the animals during sacrification.² In Turkey, orf is well recognized by dermatologists, and clinical diagnosis usually is not difficult.

Human orf has a self-limited course in which lesions spontaneously resolve in 4 to 8 weeks; however, in immunocompromised patients, such as our patient with CLL, orf lesions may be persistent, atypical, and giant, requiring early and effective treatment. Treatment options for giant orf tumors in immunocompromised individuals include surgical excision,³ cryotherapy, topical imiquimod,^4,5 topical or intralesional cidofovir,⁶ and intralesional interferon alfa injections.⁷ According to our clinical observations, surgical interventions for treatment of orfs usually cause a delay in the natural healing process; however, because surgical excision is a recommended treatment option for exophytic and recalcitrant orfs, we decided to treat our patient with surgical excision, which resulted in rapid recurrence and massive proliferation. A similar case of giant orf that was aggravated after surgery has been reported.⁸ In light of these cases, it is our opinion that treatment options other than surgery may be reasonable.

Chronic lymphocytic leukemia may show features of both humoral and cell-mediated deficiency. Patients are known to be prone to viral infections such as varicella-zoster virus, herpes simplex virus, cytomegalovirus, and human papillomavirus. A giant orf infection on the background of CLL also has been described.⁹

Interferons were first discovered in 1957 and named after their ability to interfere with viral replication. They represent a family of cytokines that has an essential role in the innate immune response to virus infections. Because of their antiviral properties, recombinant forms of interferon alfa are widely used with success in the treatment of chronic hepatitis B and hepatitis C virus infections. A few other antiviral clinical applications of interferon alfa include infections caused by human herpesvirus 8 (the etiological agent in Kaposi sarcoma) and human papillomatosis virus (the etiological agent in juvenile laryngeal papillomatosis and condyloma acuminatum).¹⁰

In a report by Ran et al,⁷ intralesional interferon alfa injections were successfully used for treatment of giant orf lesions in an immunocompromised patient. As a result, we started treating the patient with intralesional interferon alfa-2a, but it was not well tolerated by our patient, as it was quite painful. We then decided to continue the therapy with systemic interferon alfa-2a injections, as we believed that it was a good option due to its antiviral, antiproliferative, and antiangiogenic properties. With the experimental combined therapy of systemic interferon alfa-2a and topical imiquimod, our patient achieved a complete response in 9 weeks (3 weeks of twice weekly injections and then 6 weeks of once weekly injections) and had no relapses during 12 months of follow-up.

Conclusion

We present a rare case of a giant orf treated with systemic interferon alfa-2a injections. Because intralesional injections are quite painful, systemic subcutaneous injections of interferon might be a good and safe alternative for recalcitrant orf lesions in immunocompromised patients. However, more studies and reports are needed to confirm its effectiveness and safety.

The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

Since the serendipitous discovery of expedited involution of infantile hemangiomas (IHs) with propranolol in 2008,¹ current research has proliferated to discern the mechanism of action of beta-blockers in the care of IHs. Propranolol is a nonselective beta-blocker with a structure similar to catecholamines and thus competes for β-adrenergic receptors. Blocking β₁-receptors is cardioselective, leading to decreased heart rate and myocardial contractility, while blocking β₂-receptors leads to inhibition of smooth muscle relaxation and decreased glycogenolysis. The endothelial cells of IH express β₂-adrenergic receptors; the mechanistic role of propranolol in these lesions is surmised to be due to vasoconstriction, decreased angiogenesis through inhibition of vascular endothelial growth factor, and subsequent endothelial cell apoptosis.²

After this breakthrough finding, a subsequent novel development was made when an ophthalmologist demonstrated that timolol, a topical beta-blocker, could be utilized to expedite IH involution and prevent ocular complications such as amblyopia secondary to the mass effect of the lesion. Guo and Ni³ prescribed the commercially available ophthalmologic solution of timolol maleate 0.5% for twice-daily use for 5 weeks. Remarkable reduction in the periorbital IH without rebound phenomenon was observed.³ A recent multicenter retrospective cohort of more than 700 patients with IH were treated with topical timolol with a 70% success rate, corresponding to 10% improvement from baseline; this study highlights the efficacy of timolol while confirming the safety of the medication.⁴

Systemic beta-blockers for IH have been used predominately for critical sites such as the nasal tip, lip, ear, perineum, and periocular area; ulcerated lesions or those that may be prone to leave a fibrofatty tissue residue after involution also have been targeted. Contraindications for use include premature infants younger than 5 weeks, infants weighing less than 2 kg, history of asthma or bronchospasm, heart rate less than 80 beats per minute, blood pressure less than 50/30 mm Hg, or hypersensitivity to the medication.⁵ Current guidelines for propranolol initiation vary; some dermatologists consult cardiology prior to initiation, while others perform routine vitals and an indication-driven electrocardiogram as needed based on family history of cardiac disease, maternal history of connective tissue disease, congenital heart block, or abnormal vital signs.

Given the demonstrated long-term safety of propranolol and the acceptable side-effect profile, the use of beta-blockers for IH has become increasingly mainstream. Three randomized controlled trials (RCTs) have evaluated the efficacy and minimal adverse effects of propranolol for IH. The first RCT evaluated 40 patients who received either placebo or propranolol 2 mg/kg daily (divided into 3 doses) for 6 months; IH growth stopped by week 4 in the treatment group and the largest volume difference in IH was seen at week 12.⁶ Léauté-Labrèze et al⁷ demonstrated that propranolol could be given earlier to patients and at higher doses; the treatment group included 7 patients at 3 mg/kg daily of propranolol for 15 days, followed by 15 additional days of 4 mg/kg daily of propranolol. A statistically significant (P=.004) decrease in IH volume, quantified by use of ultrasonography, was exhibited by the propranolol group.⁷ Lastly, the largest RCT (N=456) established the efficacy of propranolol 3 mg/kg daily for 6 months with a 60% successful treatment rate compared to 4% for patients receiving placebo.⁸

Given the efficacy of propranolol for IH, other investigators have experimented with nonselective beta-blockers for other dermatologic conditions. In addition to second-line use for flushing, hyperhidrosis, and adrenergic urticaria, the future of propranolol is expanding for vascular lesions in particular.⁹ Chow et al¹⁰ highlighted a case of progressive angiosarcoma of the scalp that responded to propranolol hydrochloride therapy at 40 mg 3 times daily with extensive regression; propranolol was given in addition to chemotherapy and radiation. The tumor was biopsied before and after propranolol therapy and exhibited a 34% decrease in the proliferative index (Ki-67).¹⁰ Interestingly, Chisholm et al¹¹ evaluated the expression of β-adrenergic expression in 141 vascular lesions; endothelial cell expression of β₂-adrenergic receptors was found positive in 100% of IHs, 67% of kaposiform hemangioendotheliomas, 41% of angiosarcomas, 50% of pyogenic granulomas, and 75% of Kaposi sarcomas, to name merely a few studied lesions.

These data have spurred physicians to further seek beta-blocker dermatologic use in specific patient populations. For example, Meseguer-Yebra et al¹² employed timolol solution 0.5% twice daily for 12 weeks for 2 human immunodeficiency virus–negative patients with limited Kaposi sarcoma of the right thigh and foot; no clinical evidence of recurrence was seen at 20 months, and one of the patients had a subsequent biopsy performed with negative human herpesvirus 8 staining after therapy. In the pediatric arena, topical timolol has been used for both port-wine stains and pyogenic granulomas.^13-15 Two lesions of pyogenic granulomas on the scalp of a child were treated with timolol ophthalmic solution 0.5% under occlusion for 4 weeks with resolution.¹⁵ Propranolol also has been utilized as adjunctive therapy for aggressive pediatric vascular lesions such as kaposiform hemangioendothelioma with promising results and additionally reducing the duration of therapy needed with vincristine.²

In summary, propranolol and timolol have made an indelible impression on the field of pediatric dermatology and have demonstrated a burgeoning role in the dermatologic arena. The use of nonselective beta-blockers for the management of vascular lesions can serve as adjunctive or monotherapy for certain patient populations. The relatively low adverse risk profile of propranolol makes it a versatile tool to use both systemically and topically. Although the authors of the study assessing the β₂-adrenergic expression in vascular lesions admittedly stated that the positivity of the receptors does not necessarily correlate with therapeutic management, it is an interesting subject area with much potential in the future.¹¹ This review serves to illuminate the expanding role of beta-blockers in dermatology.

Since the serendipitous discovery of expedited involution of infantile hemangiomas (IHs) with propranolol in 2008,¹ current research has proliferated to discern the mechanism of action of beta-blockers in the care of IHs. Propranolol is a nonselective beta-blocker with a structure similar to catecholamines and thus competes for β-adrenergic receptors. Blocking β₁-receptors is cardioselective, leading to decreased heart rate and myocardial contractility, while blocking β₂-receptors leads to inhibition of smooth muscle relaxation and decreased glycogenolysis. The endothelial cells of IH express β₂-adrenergic receptors; the mechanistic role of propranolol in these lesions is surmised to be due to vasoconstriction, decreased angiogenesis through inhibition of vascular endothelial growth factor, and subsequent endothelial cell apoptosis.²

After this breakthrough finding, a subsequent novel development was made when an ophthalmologist demonstrated that timolol, a topical beta-blocker, could be utilized to expedite IH involution and prevent ocular complications such as amblyopia secondary to the mass effect of the lesion. Guo and Ni³ prescribed the commercially available ophthalmologic solution of timolol maleate 0.5% for twice-daily use for 5 weeks. Remarkable reduction in the periorbital IH without rebound phenomenon was observed.³ A recent multicenter retrospective cohort of more than 700 patients with IH were treated with topical timolol with a 70% success rate, corresponding to 10% improvement from baseline; this study highlights the efficacy of timolol while confirming the safety of the medication.⁴

Systemic beta-blockers for IH have been used predominately for critical sites such as the nasal tip, lip, ear, perineum, and periocular area; ulcerated lesions or those that may be prone to leave a fibrofatty tissue residue after involution also have been targeted. Contraindications for use include premature infants younger than 5 weeks, infants weighing less than 2 kg, history of asthma or bronchospasm, heart rate less than 80 beats per minute, blood pressure less than 50/30 mm Hg, or hypersensitivity to the medication.⁵ Current guidelines for propranolol initiation vary; some dermatologists consult cardiology prior to initiation, while others perform routine vitals and an indication-driven electrocardiogram as needed based on family history of cardiac disease, maternal history of connective tissue disease, congenital heart block, or abnormal vital signs.

Given the demonstrated long-term safety of propranolol and the acceptable side-effect profile, the use of beta-blockers for IH has become increasingly mainstream. Three randomized controlled trials (RCTs) have evaluated the efficacy and minimal adverse effects of propranolol for IH. The first RCT evaluated 40 patients who received either placebo or propranolol 2 mg/kg daily (divided into 3 doses) for 6 months; IH growth stopped by week 4 in the treatment group and the largest volume difference in IH was seen at week 12.⁶ Léauté-Labrèze et al⁷ demonstrated that propranolol could be given earlier to patients and at higher doses; the treatment group included 7 patients at 3 mg/kg daily of propranolol for 15 days, followed by 15 additional days of 4 mg/kg daily of propranolol. A statistically significant (P=.004) decrease in IH volume, quantified by use of ultrasonography, was exhibited by the propranolol group.⁷ Lastly, the largest RCT (N=456) established the efficacy of propranolol 3 mg/kg daily for 6 months with a 60% successful treatment rate compared to 4% for patients receiving placebo.⁸

Given the efficacy of propranolol for IH, other investigators have experimented with nonselective beta-blockers for other dermatologic conditions. In addition to second-line use for flushing, hyperhidrosis, and adrenergic urticaria, the future of propranolol is expanding for vascular lesions in particular.⁹ Chow et al¹⁰ highlighted a case of progressive angiosarcoma of the scalp that responded to propranolol hydrochloride therapy at 40 mg 3 times daily with extensive regression; propranolol was given in addition to chemotherapy and radiation. The tumor was biopsied before and after propranolol therapy and exhibited a 34% decrease in the proliferative index (Ki-67).¹⁰ Interestingly, Chisholm et al¹¹ evaluated the expression of β-adrenergic expression in 141 vascular lesions; endothelial cell expression of β₂-adrenergic receptors was found positive in 100% of IHs, 67% of kaposiform hemangioendotheliomas, 41% of angiosarcomas, 50% of pyogenic granulomas, and 75% of Kaposi sarcomas, to name merely a few studied lesions.

These data have spurred physicians to further seek beta-blocker dermatologic use in specific patient populations. For example, Meseguer-Yebra et al¹² employed timolol solution 0.5% twice daily for 12 weeks for 2 human immunodeficiency virus–negative patients with limited Kaposi sarcoma of the right thigh and foot; no clinical evidence of recurrence was seen at 20 months, and one of the patients had a subsequent biopsy performed with negative human herpesvirus 8 staining after therapy. In the pediatric arena, topical timolol has been used for both port-wine stains and pyogenic granulomas.^13-15 Two lesions of pyogenic granulomas on the scalp of a child were treated with timolol ophthalmic solution 0.5% under occlusion for 4 weeks with resolution.¹⁵ Propranolol also has been utilized as adjunctive therapy for aggressive pediatric vascular lesions such as kaposiform hemangioendothelioma with promising results and additionally reducing the duration of therapy needed with vincristine.²

In summary, propranolol and timolol have made an indelible impression on the field of pediatric dermatology and have demonstrated a burgeoning role in the dermatologic arena. The use of nonselective beta-blockers for the management of vascular lesions can serve as adjunctive or monotherapy for certain patient populations. The relatively low adverse risk profile of propranolol makes it a versatile tool to use both systemically and topically. Although the authors of the study assessing the β₂-adrenergic expression in vascular lesions admittedly stated that the positivity of the receptors does not necessarily correlate with therapeutic management, it is an interesting subject area with much potential in the future.¹¹ This review serves to illuminate the expanding role of beta-blockers in dermatology.

Since the serendipitous discovery of expedited involution of infantile hemangiomas (IHs) with propranolol in 2008,¹ current research has proliferated to discern the mechanism of action of beta-blockers in the care of IHs. Propranolol is a nonselective beta-blocker with a structure similar to catecholamines and thus competes for β-adrenergic receptors. Blocking β₁-receptors is cardioselective, leading to decreased heart rate and myocardial contractility, while blocking β₂-receptors leads to inhibition of smooth muscle relaxation and decreased glycogenolysis. The endothelial cells of IH express β₂-adrenergic receptors; the mechanistic role of propranolol in these lesions is surmised to be due to vasoconstriction, decreased angiogenesis through inhibition of vascular endothelial growth factor, and subsequent endothelial cell apoptosis.²

After this breakthrough finding, a subsequent novel development was made when an ophthalmologist demonstrated that timolol, a topical beta-blocker, could be utilized to expedite IH involution and prevent ocular complications such as amblyopia secondary to the mass effect of the lesion. Guo and Ni³ prescribed the commercially available ophthalmologic solution of timolol maleate 0.5% for twice-daily use for 5 weeks. Remarkable reduction in the periorbital IH without rebound phenomenon was observed.³ A recent multicenter retrospective cohort of more than 700 patients with IH were treated with topical timolol with a 70% success rate, corresponding to 10% improvement from baseline; this study highlights the efficacy of timolol while confirming the safety of the medication.⁴

Systemic beta-blockers for IH have been used predominately for critical sites such as the nasal tip, lip, ear, perineum, and periocular area; ulcerated lesions or those that may be prone to leave a fibrofatty tissue residue after involution also have been targeted. Contraindications for use include premature infants younger than 5 weeks, infants weighing less than 2 kg, history of asthma or bronchospasm, heart rate less than 80 beats per minute, blood pressure less than 50/30 mm Hg, or hypersensitivity to the medication.⁵ Current guidelines for propranolol initiation vary; some dermatologists consult cardiology prior to initiation, while others perform routine vitals and an indication-driven electrocardiogram as needed based on family history of cardiac disease, maternal history of connective tissue disease, congenital heart block, or abnormal vital signs.

Given the demonstrated long-term safety of propranolol and the acceptable side-effect profile, the use of beta-blockers for IH has become increasingly mainstream. Three randomized controlled trials (RCTs) have evaluated the efficacy and minimal adverse effects of propranolol for IH. The first RCT evaluated 40 patients who received either placebo or propranolol 2 mg/kg daily (divided into 3 doses) for 6 months; IH growth stopped by week 4 in the treatment group and the largest volume difference in IH was seen at week 12.⁶ Léauté-Labrèze et al⁷ demonstrated that propranolol could be given earlier to patients and at higher doses; the treatment group included 7 patients at 3 mg/kg daily of propranolol for 15 days, followed by 15 additional days of 4 mg/kg daily of propranolol. A statistically significant (P=.004) decrease in IH volume, quantified by use of ultrasonography, was exhibited by the propranolol group.⁷ Lastly, the largest RCT (N=456) established the efficacy of propranolol 3 mg/kg daily for 6 months with a 60% successful treatment rate compared to 4% for patients receiving placebo.⁸

Given the efficacy of propranolol for IH, other investigators have experimented with nonselective beta-blockers for other dermatologic conditions. In addition to second-line use for flushing, hyperhidrosis, and adrenergic urticaria, the future of propranolol is expanding for vascular lesions in particular.⁹ Chow et al¹⁰ highlighted a case of progressive angiosarcoma of the scalp that responded to propranolol hydrochloride therapy at 40 mg 3 times daily with extensive regression; propranolol was given in addition to chemotherapy and radiation. The tumor was biopsied before and after propranolol therapy and exhibited a 34% decrease in the proliferative index (Ki-67).¹⁰ Interestingly, Chisholm et al¹¹ evaluated the expression of β-adrenergic expression in 141 vascular lesions; endothelial cell expression of β₂-adrenergic receptors was found positive in 100% of IHs, 67% of kaposiform hemangioendotheliomas, 41% of angiosarcomas, 50% of pyogenic granulomas, and 75% of Kaposi sarcomas, to name merely a few studied lesions.

These data have spurred physicians to further seek beta-blocker dermatologic use in specific patient populations. For example, Meseguer-Yebra et al¹² employed timolol solution 0.5% twice daily for 12 weeks for 2 human immunodeficiency virus–negative patients with limited Kaposi sarcoma of the right thigh and foot; no clinical evidence of recurrence was seen at 20 months, and one of the patients had a subsequent biopsy performed with negative human herpesvirus 8 staining after therapy. In the pediatric arena, topical timolol has been used for both port-wine stains and pyogenic granulomas.^13-15 Two lesions of pyogenic granulomas on the scalp of a child were treated with timolol ophthalmic solution 0.5% under occlusion for 4 weeks with resolution.¹⁵ Propranolol also has been utilized as adjunctive therapy for aggressive pediatric vascular lesions such as kaposiform hemangioendothelioma with promising results and additionally reducing the duration of therapy needed with vincristine.²

In summary, propranolol and timolol have made an indelible impression on the field of pediatric dermatology and have demonstrated a burgeoning role in the dermatologic arena. The use of nonselective beta-blockers for the management of vascular lesions can serve as adjunctive or monotherapy for certain patient populations. The relatively low adverse risk profile of propranolol makes it a versatile tool to use both systemically and topically. Although the authors of the study assessing the β₂-adrenergic expression in vascular lesions admittedly stated that the positivity of the receptors does not necessarily correlate with therapeutic management, it is an interesting subject area with much potential in the future.¹¹ This review serves to illuminate the expanding role of beta-blockers in dermatology.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

Darla Conrad (left), Senior Director, North America Education Solutions, Johnson & Johnson Medical Devices, presents Kalpit N. Shah, MD (right) with his plaque for the second-place Resident Writer’s Award, and Christopher Rice, MD (center) with his plaque for the third-place Resident Writer’s Award at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
 

Winners of the 2016 Resident Writer’s Award

First-Place Award

An Original Study

Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population

Dr. Kusnezov is a senior resident, completing his orthopedic surgery residency training, at the Texas Tech University Health Sciences Center/William Beaumont Army Medical Center joint military-civilian program in El Paso, Texas. Prior to residency, he completed both his undergraduate education and medical school at the University of California, Los Angeles, graduating Summa Cum Laude and AOA, respectively. Dr. Kusnezov is currently engaged in a multitude of ongoing projects with over 50 peer-reviewed publications to date. His research interests include trauma and limb salvage, complex total joint reconstruction, and interdisciplinary system improvement.

Second-Place Award

An Original Study

Patient-Reported Outcome Measures: How Do Digital Tablets Stack Up to Paper Forms? A Randomized, Controlled Study

Dr. Shah is currently in his third year of orthopedic surgery residency training at Brown University in Providence, Rhode Island. Prior to residency, he completed undergraduate education at the University of California, Berkeley, and medical school at the University of California, Irvine. He hopes to pursue a hand and upper extremity fellowship after residency. His research interests include upper extremity trauma and surgical complications, as well as technology and its implications on orthopedic surgery.

Third-Place Award

An Original Study

Treating Tibia Fractures With Far Cortical Locking Implants

Dr. Rice is an orthopedic surgery resident at the University of Wisconsin, Madison. He received his medical degree from the University of Utah and attended Brigham Young University for his undergraduate studies. He has a special interest in disorders of the hand and upper extremity trauma.

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

The importance of establishing a bond with a patient early in treatment is instilled in psychiatry trainees during their first year of residency. It is well-known that a strong therapeutic connection is correlated with successful treatment and favorable outcomes.¹ But what if social and cultural factors that could provide an almost immediate familiarity threatened the therapeutic alliance?

We present a case in which sharing my cultural background with a patient was detrimental to the therapeutic relationship and forced me to look beyond superficial similarities to forge a meaningful connection.

A shared language, a shared connection?

When I, a psychiatry intern who emigrated from Honduras 11 years ago, met Ms. M, a middle-age, Spanish-speaking Honduran immigrant with schizoaffective disorder, I was curious to hear the story of how her immigration intermingled with her mental illness. As a budding psychiatrist, I was certain our common culture would intensify our interactions. It did, although in ways I did not expect.

Despite my enthusiasm and best intentions, our first meeting was less than ideal. Ms. M believed she not only was God’s wife and my attending physician’s wife, but that I was her rival for my attending’s affections. “I heard you are from Honduras. I am from Honduras, too. What part are you from?” I asked her. She became angry. “I am not from there. I am from Israel,” she said. For many days, we had the same hostile and disappointing conversations, during which I would try to tease out the basis for her delusions and understand our lack of connection. I felt hurt and puzzled. If I could not connect with someone with whom I shared a common background, then to whom could I connect with? I had to re-evaluate my approach. Should I alter my attire to seem less feminine? Should I tell her I am happily married? Should I not speak Spanish? Would these changes make our interactions feel less threatening to her?

“You are focused too much on you and not enough on her,” my attending retorted. I came to realize that, in my crusade to have Ms. M perceive me a certain way, I had lost sight of who she was and what lay at the core of her delusions. I stepped back and considered Ms. M: a patient, yes, but also a woman who was unable to communicate freely with others because she did not speak English. Because of her perpetual paranoia and psychosis, she was emotionally isolated, lacked necessary social support from her family, and had no sense of community. However, in her delusions she was a prophet, a herald for God’s news, with a vital role in His plans. In her mind, she was a mother and had the support of a life-long partner.

As I considered her struggles, I thought about myself. When I first came to the United States, it was difficult to develop relationships with my peers because I worried about my accent and idioms. In Honduras, my friends and family knew me as a gregarious, quick-witted individual. In acculturating to my new home, I became reclusive and insecure. It took years to regain a semblance of identity.

In my attending’s office, I found that it was not our shared heritage that was the path to engaging Ms. M, but rather our shared isolation, which I had not been validating. This helped me reframe the way I viewed the therapeutic relationship and changed the focus of my attempts to engage her. I stopped taking her rejection personally and focused on providing her support and solace. By tapping into her isolation, she opened up and eventually agreed to medication changes, which slowly reduced—but did not eliminate—her delusions, hallucinations, and hostility toward others. Because of her intractable psychotic symptoms, she required a long-term structured care setting and was transferred to the state hospital.

Culture is only ‘skin deep’

I assumed our shared background would have effortlessly led to a trustworthy relationship, but her resistance challenged that notion. My own desires to have a deep connection with a fellow immigrant contributed to my internalization of her rejection. Our physical and cultural similarities acted as a hindrance because she subconsciously projected her idealized image of a woman onto me. Nevertheless, she helped me recognize the importance of unexamined projective identification and countertransference, evidenced by wanting to change my appearance and behavior and my increased willingness for self-disclosure.

As I start my second year of residency and reflect on my experiences as an intern, Ms. M always comes to mind. She taught me that culture may be only “skin deep” and similarities between therapist and patient do not guarantee a successful bond. Searching for deeper, fundamental connections and validating these bonds can open the doors to connecting with those from all walks of life, from whichever road they come.

Blepharoplasty, or surgical manipulation of the upper and/or lower eyelids, is a commonly performed cosmetic procedure to improve the appearance and function of the eyelids by repositioning and/or removing excess skin and soft tissue from the eyelids, most often through external incisions that minimize scarring and maximize the aesthetic outcomes of the surgery. Therefore, the placement of the incisions is an important determinant of the surgical outcome, and the preoperative marking of the eyelids to indicate where the incisions should be placed is a crucial part of preparation for the surgery.

Preoperative marking has unique challenges due to the dynamicity of the eyelids and the delicate nature of the surgery. The mark must be narrow to minimize the risk of placing the incision higher or lower than intended. The mark also must dry quickly because the patient may blink and create multiple impressions of the marking on skinfolds in contact with the wet ink. Fast drying of the ink used to create the marks improves the efficiency and clarity of the presurgical planning.

We present data on the performance of the various blepharoplasty markers regarding drying time and ink spread width based on an evaluation of 13 surgical markers.

Methods

Eleven unique fine tip (FT) markers and 2 standard tip (ST) markers were obtained based on their accessibility at the researchers’ home institution and availability for direct purchase in small quantities from the distributors (Figure 1). Four markers were double tipped with one FT end and one ST end; for these markers, only the FT end was studied. The experiments were conducted on the bilateral upper eyelids and on hairless patches of skin of a single patient in a minor procedure room with surgical lighting and minimal draft of air. The sole experimenter (J.M.K.) conducting the study was not blinded.

The drying time of each marker was measured by marking 1-in lines on a patch of hairless skin that was first cleaned with an alcohol pad, then dried. Drying time for each marking was measured in increments of 5 seconds; at each time point, the markings were wiped with a single-ply, light-duty tissue under the weight of 10 US quarters to ensure that the same weight/pressure was applied when wiping the skin. Smudges observed with the naked eye on either the wipe or the patients’ skin were interpreted as nondry status of the marking. The first time point at which a marking was found to have no visible smudges either on the skin or the wipe was recorded as the drying time of the respective marker.

Ink spread was measured on clean eyelid skin by drawing curved lines along the natural crease as would be done for actual blepharoplasty planning. Each line was allowed to dry for 2 minutes. The greatest perpendicular spread width along the line observed with the naked eye was measured using a digital Vernier caliper with 0.01-mm graduations. Three measurements were obtained per marker and the values averaged to arrive at the final spread width.

Results

Drying time among the 13 total markers (11 FT and 2 ST) ranged from 5 to 70 seconds, with a mean of 20.8 seconds and median of 5 seconds (Table). The drying time for the DERMarker E-Z Removable Ink Mini Skin Marker (Delasco, LLC) with an ST was 5 seconds, while the drying time for the other ST marker, WriteSite Plus Surgical Skin Marker (Aspen Surgical, Inc), was 70 seconds. The FT markers spanned the entire range of drying times. The ink spread width among the markers ranged from 0.53 to 2.27 mm with a median of 0.9 mm and mean of 1.13 mm (Table). The 2 ST markers were found to make some of the widest marks measured, including the WriteSite Plus Surgical Skin Marker, a nonsterile ST marker that created the widest ink marks. The second widest mark was made by an FT marker (Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker [Viscot Medical, LLC]).

To prioritize short drying time coupled with minimal ink spread width, the values associated with each marker were averaged to arrive at the overall score for each marker. The smaller the overall score, the higher we ranked the marker. The Devon Surgical Skin Marker, Dual Tip (Medtronic) ranked the highest among the 13 markers with a final score of 2.78. Runner-up markers included the Sterile Devon Surgical Skin marker, Fine Tip (Medtronic)(final score, 2.86); the Sterile Dual Tip Skin/Utility Marker (Medline Industries, Inc)(final score, 2.86); and the Skin Marker, Fine Tip (Cardinal Health)(final score, 2.89). The 2 lowest-ranking markers were the WriteSite Plus Surgical Skin Marker, an ST marker (final score, 36.13), followed by the Sterile BlephMarker (Viscot Medical, LLC)(final score, 35.27).

Figure 2 shows the drying time and ink spread width for all 13 markers.

Comment

Blepharoplasty surgeons generally agree that meticulous presurgical planning with marking of the eyelids is critical for successful surgical outcomes.^1,2 Fine tip markers have been recommended for this purpose due to the relative precision of the marks, but the prerequisite of these markers is that the marks must have minimal ink spread through skinfolds to allow for precision as well as short drying time to avoid unintentional duplication of the ink on overlapping skin, especially with the likely chance of reflexive blinking by the patient. The associated assumption is that FT markers automatically leave precise marks with minimal drying time. This study systemically compared these 2 qualities for 13 markers, and the results are notable for the unexpected wide range of performance. Although most of the FT markers had ink spread width of less than 1 mm, the Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker was an outlier among FT markers, with ink spread greater than 2 mm, making it too broad and imprecise for practical use. This result indicates that not every FT marker actually makes fine marks. The 2 ST markers in the study—DERMarker E-Z Removable Ink Mini Skin Marker and WriteSite Plus Surgical Skin Marker—left broad marks as anticipated.

The drying time of the markers also ranged from 5 to 70 seconds among both FT and ST markers. Indeed, most of the FT markers were dry at or before 5 seconds of marking, but 2 FT markers—Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker and Sterile BlephMarker—dried at 65 and 70 seconds, respectively. Such a long drying time would be considered impractical for use in blepharoplasty marking and also unexpected of FT markers, which usually are marketed for their precision and efficiency. Notable in the discussion of drying time is that one of the 2 ST markers in the study, the DERMarker E-Z Removable Ink Mini Skin Marker, had the shortest possible drying time of 5 seconds, while the other ST marker, WriteSite Plus Surgical Skin Marker, dried at 70 seconds. This observation coupled with the unexpected results of broad marks and long drying time for some of the FT markers indicates that a surgeon cannot simply assume that a FT marker would provide marks with precision and fast drying time, or that an ST marker would be the opposite.

Future directions for study include the addition of other markers and the extent of resistance to antiseptic routines that can fade the markings.

Conclusion

Among the 13 markers studied, FT markers typically had the shortest drying time and least ink spread on skin. Markers with these qualities rather than those with longer drying times or greater ink spread may be preferred by blepharoplasty surgeons. The dual- and fine-tipped Devon Surgical Skin Markers and the Sterile Dual Tip Skin/Utility Marker had the most favorable scores among the markers included in the study.

Acknowledgement

The authors would like to thank Laura B. Hall, MD (New Haven, Connecticut), for her participation as the volunteer in this study.

Blepharoplasty, or surgical manipulation of the upper and/or lower eyelids, is a commonly performed cosmetic procedure to improve the appearance and function of the eyelids by repositioning and/or removing excess skin and soft tissue from the eyelids, most often through external incisions that minimize scarring and maximize the aesthetic outcomes of the surgery. Therefore, the placement of the incisions is an important determinant of the surgical outcome, and the preoperative marking of the eyelids to indicate where the incisions should be placed is a crucial part of preparation for the surgery.

Preoperative marking has unique challenges due to the dynamicity of the eyelids and the delicate nature of the surgery. The mark must be narrow to minimize the risk of placing the incision higher or lower than intended. The mark also must dry quickly because the patient may blink and create multiple impressions of the marking on skinfolds in contact with the wet ink. Fast drying of the ink used to create the marks improves the efficiency and clarity of the presurgical planning.

We present data on the performance of the various blepharoplasty markers regarding drying time and ink spread width based on an evaluation of 13 surgical markers.

Methods

Eleven unique fine tip (FT) markers and 2 standard tip (ST) markers were obtained based on their accessibility at the researchers’ home institution and availability for direct purchase in small quantities from the distributors (Figure 1). Four markers were double tipped with one FT end and one ST end; for these markers, only the FT end was studied. The experiments were conducted on the bilateral upper eyelids and on hairless patches of skin of a single patient in a minor procedure room with surgical lighting and minimal draft of air. The sole experimenter (J.M.K.) conducting the study was not blinded.

The drying time of each marker was measured by marking 1-in lines on a patch of hairless skin that was first cleaned with an alcohol pad, then dried. Drying time for each marking was measured in increments of 5 seconds; at each time point, the markings were wiped with a single-ply, light-duty tissue under the weight of 10 US quarters to ensure that the same weight/pressure was applied when wiping the skin. Smudges observed with the naked eye on either the wipe or the patients’ skin were interpreted as nondry status of the marking. The first time point at which a marking was found to have no visible smudges either on the skin or the wipe was recorded as the drying time of the respective marker.

Ink spread was measured on clean eyelid skin by drawing curved lines along the natural crease as would be done for actual blepharoplasty planning. Each line was allowed to dry for 2 minutes. The greatest perpendicular spread width along the line observed with the naked eye was measured using a digital Vernier caliper with 0.01-mm graduations. Three measurements were obtained per marker and the values averaged to arrive at the final spread width.

Results

Drying time among the 13 total markers (11 FT and 2 ST) ranged from 5 to 70 seconds, with a mean of 20.8 seconds and median of 5 seconds (Table). The drying time for the DERMarker E-Z Removable Ink Mini Skin Marker (Delasco, LLC) with an ST was 5 seconds, while the drying time for the other ST marker, WriteSite Plus Surgical Skin Marker (Aspen Surgical, Inc), was 70 seconds. The FT markers spanned the entire range of drying times. The ink spread width among the markers ranged from 0.53 to 2.27 mm with a median of 0.9 mm and mean of 1.13 mm (Table). The 2 ST markers were found to make some of the widest marks measured, including the WriteSite Plus Surgical Skin Marker, a nonsterile ST marker that created the widest ink marks. The second widest mark was made by an FT marker (Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker [Viscot Medical, LLC]).

To prioritize short drying time coupled with minimal ink spread width, the values associated with each marker were averaged to arrive at the overall score for each marker. The smaller the overall score, the higher we ranked the marker. The Devon Surgical Skin Marker, Dual Tip (Medtronic) ranked the highest among the 13 markers with a final score of 2.78. Runner-up markers included the Sterile Devon Surgical Skin marker, Fine Tip (Medtronic)(final score, 2.86); the Sterile Dual Tip Skin/Utility Marker (Medline Industries, Inc)(final score, 2.86); and the Skin Marker, Fine Tip (Cardinal Health)(final score, 2.89). The 2 lowest-ranking markers were the WriteSite Plus Surgical Skin Marker, an ST marker (final score, 36.13), followed by the Sterile BlephMarker (Viscot Medical, LLC)(final score, 35.27).

Figure 2 shows the drying time and ink spread width for all 13 markers.

Comment

Blepharoplasty surgeons generally agree that meticulous presurgical planning with marking of the eyelids is critical for successful surgical outcomes.^1,2 Fine tip markers have been recommended for this purpose due to the relative precision of the marks, but the prerequisite of these markers is that the marks must have minimal ink spread through skinfolds to allow for precision as well as short drying time to avoid unintentional duplication of the ink on overlapping skin, especially with the likely chance of reflexive blinking by the patient. The associated assumption is that FT markers automatically leave precise marks with minimal drying time. This study systemically compared these 2 qualities for 13 markers, and the results are notable for the unexpected wide range of performance. Although most of the FT markers had ink spread width of less than 1 mm, the Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker was an outlier among FT markers, with ink spread greater than 2 mm, making it too broad and imprecise for practical use. This result indicates that not every FT marker actually makes fine marks. The 2 ST markers in the study—DERMarker E-Z Removable Ink Mini Skin Marker and WriteSite Plus Surgical Skin Marker—left broad marks as anticipated.

The drying time of the markers also ranged from 5 to 70 seconds among both FT and ST markers. Indeed, most of the FT markers were dry at or before 5 seconds of marking, but 2 FT markers—Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker and Sterile BlephMarker—dried at 65 and 70 seconds, respectively. Such a long drying time would be considered impractical for use in blepharoplasty marking and also unexpected of FT markers, which usually are marketed for their precision and efficiency. Notable in the discussion of drying time is that one of the 2 ST markers in the study, the DERMarker E-Z Removable Ink Mini Skin Marker, had the shortest possible drying time of 5 seconds, while the other ST marker, WriteSite Plus Surgical Skin Marker, dried at 70 seconds. This observation coupled with the unexpected results of broad marks and long drying time for some of the FT markers indicates that a surgeon cannot simply assume that a FT marker would provide marks with precision and fast drying time, or that an ST marker would be the opposite.

Future directions for study include the addition of other markers and the extent of resistance to antiseptic routines that can fade the markings.

Conclusion

Among the 13 markers studied, FT markers typically had the shortest drying time and least ink spread on skin. Markers with these qualities rather than those with longer drying times or greater ink spread may be preferred by blepharoplasty surgeons. The dual- and fine-tipped Devon Surgical Skin Markers and the Sterile Dual Tip Skin/Utility Marker had the most favorable scores among the markers included in the study.

Acknowledgement

The authors would like to thank Laura B. Hall, MD (New Haven, Connecticut), for her participation as the volunteer in this study.

Blepharoplasty, or surgical manipulation of the upper and/or lower eyelids, is a commonly performed cosmetic procedure to improve the appearance and function of the eyelids by repositioning and/or removing excess skin and soft tissue from the eyelids, most often through external incisions that minimize scarring and maximize the aesthetic outcomes of the surgery. Therefore, the placement of the incisions is an important determinant of the surgical outcome, and the preoperative marking of the eyelids to indicate where the incisions should be placed is a crucial part of preparation for the surgery.

Preoperative marking has unique challenges due to the dynamicity of the eyelids and the delicate nature of the surgery. The mark must be narrow to minimize the risk of placing the incision higher or lower than intended. The mark also must dry quickly because the patient may blink and create multiple impressions of the marking on skinfolds in contact with the wet ink. Fast drying of the ink used to create the marks improves the efficiency and clarity of the presurgical planning.

We present data on the performance of the various blepharoplasty markers regarding drying time and ink spread width based on an evaluation of 13 surgical markers.

Methods

Eleven unique fine tip (FT) markers and 2 standard tip (ST) markers were obtained based on their accessibility at the researchers’ home institution and availability for direct purchase in small quantities from the distributors (Figure 1). Four markers were double tipped with one FT end and one ST end; for these markers, only the FT end was studied. The experiments were conducted on the bilateral upper eyelids and on hairless patches of skin of a single patient in a minor procedure room with surgical lighting and minimal draft of air. The sole experimenter (J.M.K.) conducting the study was not blinded.

The drying time of each marker was measured by marking 1-in lines on a patch of hairless skin that was first cleaned with an alcohol pad, then dried. Drying time for each marking was measured in increments of 5 seconds; at each time point, the markings were wiped with a single-ply, light-duty tissue under the weight of 10 US quarters to ensure that the same weight/pressure was applied when wiping the skin. Smudges observed with the naked eye on either the wipe or the patients’ skin were interpreted as nondry status of the marking. The first time point at which a marking was found to have no visible smudges either on the skin or the wipe was recorded as the drying time of the respective marker.

Ink spread was measured on clean eyelid skin by drawing curved lines along the natural crease as would be done for actual blepharoplasty planning. Each line was allowed to dry for 2 minutes. The greatest perpendicular spread width along the line observed with the naked eye was measured using a digital Vernier caliper with 0.01-mm graduations. Three measurements were obtained per marker and the values averaged to arrive at the final spread width.

Results

Drying time among the 13 total markers (11 FT and 2 ST) ranged from 5 to 70 seconds, with a mean of 20.8 seconds and median of 5 seconds (Table). The drying time for the DERMarker E-Z Removable Ink Mini Skin Marker (Delasco, LLC) with an ST was 5 seconds, while the drying time for the other ST marker, WriteSite Plus Surgical Skin Marker (Aspen Surgical, Inc), was 70 seconds. The FT markers spanned the entire range of drying times. The ink spread width among the markers ranged from 0.53 to 2.27 mm with a median of 0.9 mm and mean of 1.13 mm (Table). The 2 ST markers were found to make some of the widest marks measured, including the WriteSite Plus Surgical Skin Marker, a nonsterile ST marker that created the widest ink marks. The second widest mark was made by an FT marker (Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker [Viscot Medical, LLC]).

To prioritize short drying time coupled with minimal ink spread width, the values associated with each marker were averaged to arrive at the overall score for each marker. The smaller the overall score, the higher we ranked the marker. The Devon Surgical Skin Marker, Dual Tip (Medtronic) ranked the highest among the 13 markers with a final score of 2.78. Runner-up markers included the Sterile Devon Surgical Skin marker, Fine Tip (Medtronic)(final score, 2.86); the Sterile Dual Tip Skin/Utility Marker (Medline Industries, Inc)(final score, 2.86); and the Skin Marker, Fine Tip (Cardinal Health)(final score, 2.89). The 2 lowest-ranking markers were the WriteSite Plus Surgical Skin Marker, an ST marker (final score, 36.13), followed by the Sterile BlephMarker (Viscot Medical, LLC)(final score, 35.27).

Figure 2 shows the drying time and ink spread width for all 13 markers.

Comment

Blepharoplasty surgeons generally agree that meticulous presurgical planning with marking of the eyelids is critical for successful surgical outcomes.^1,2 Fine tip markers have been recommended for this purpose due to the relative precision of the marks, but the prerequisite of these markers is that the marks must have minimal ink spread through skinfolds to allow for precision as well as short drying time to avoid unintentional duplication of the ink on overlapping skin, especially with the likely chance of reflexive blinking by the patient. The associated assumption is that FT markers automatically leave precise marks with minimal drying time. This study systemically compared these 2 qualities for 13 markers, and the results are notable for the unexpected wide range of performance. Although most of the FT markers had ink spread width of less than 1 mm, the Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker was an outlier among FT markers, with ink spread greater than 2 mm, making it too broad and imprecise for practical use. This result indicates that not every FT marker actually makes fine marks. The 2 ST markers in the study—DERMarker E-Z Removable Ink Mini Skin Marker and WriteSite Plus Surgical Skin Marker—left broad marks as anticipated.

The drying time of the markers also ranged from 5 to 70 seconds among both FT and ST markers. Indeed, most of the FT markers were dry at or before 5 seconds of marking, but 2 FT markers—Sterile Mini Ultrafine Tip XL Prep Resistant Ink Marker and Sterile BlephMarker—dried at 65 and 70 seconds, respectively. Such a long drying time would be considered impractical for use in blepharoplasty marking and also unexpected of FT markers, which usually are marketed for their precision and efficiency. Notable in the discussion of drying time is that one of the 2 ST markers in the study, the DERMarker E-Z Removable Ink Mini Skin Marker, had the shortest possible drying time of 5 seconds, while the other ST marker, WriteSite Plus Surgical Skin Marker, dried at 70 seconds. This observation coupled with the unexpected results of broad marks and long drying time for some of the FT markers indicates that a surgeon cannot simply assume that a FT marker would provide marks with precision and fast drying time, or that an ST marker would be the opposite.

Future directions for study include the addition of other markers and the extent of resistance to antiseptic routines that can fade the markings.

Conclusion

Among the 13 markers studied, FT markers typically had the shortest drying time and least ink spread on skin. Markers with these qualities rather than those with longer drying times or greater ink spread may be preferred by blepharoplasty surgeons. The dual- and fine-tipped Devon Surgical Skin Markers and the Sterile Dual Tip Skin/Utility Marker had the most favorable scores among the markers included in the study.

Acknowledgement

The authors would like to thank Laura B. Hall, MD (New Haven, Connecticut), for her participation as the volunteer in this study.

More than 1.8 billion individuals utilize social media, a number that continues to grow as the social media market expands.¹ Social media enables individuals, groups, and organizations to efficiently disperse and access information^2-4 and also provides a structure that encourages collaboration between patients, staff, and physicians that cannot be achieved by other communication modalities.^4-6 Expert opinions and related educational materials can be shared globally, improving collaboration between dermatologists.⁶ A structured social networking site for sharing training materials, research, and ideas can help bring the national dermatology community together in a new way.

Other professions have employed social networking tools to accomplish similar goals of organizing training resources; radiology has an electronic database that allows sharing of training materials and incorporates social networking capabilities.⁷ Their Web software provides functionality for individual file uploading and supports collaboration and sharing, all while maintaining the security of uploaded information. General surgery has already addressed similar concerns via a task force that incorporates all the essential organizations in surgical education.⁸ Increased satisfaction and academic abilities have been demonstrated with their collaborative curriculum.⁹ Gastroenterologists also utilize electronic resources; one study showed that using videos to educate patients prior to colonoscopies was superior to face-to-face education.¹⁰ In addition, video education may free up time for office staff to accomplish other tasks.

As a specialty, dermatology has not been a leader in the implementation of social networking for collaboration and training purposes. Every dermatologist is an educator. To maintain a successful practice, dermatologists must keep up-to-date on their own clinical knowledge, provide training to their staff, and educate their patients. Although there are numerous educational resources available to dermatologists, an informal survey of 30 dermatology faculty members revealed a practice gap in awareness and utilization of these expanding electronic resources.¹¹

To better understand the needs of the specialty as a whole, we chose to focus on one aspect of dermatology education: resident training. The goal of our study was to survey dermatology residents and faculty to gain a better understanding of how they currently provide education and what online resources and social networking sites they currently use or would be willing to use. The study included 3 central hypotheses: First, residents would be less satisfied with their current curriculum and residents would report greater contributions to the curriculum relative to faculty. Second, both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Lastly, residents would be more willing than faculty to participate in social networking for educational purposes.

Methods

This study was granted institutional review board exemption. Two surveys were developed by the authors to assess the current structure and satisfaction of dermatology residency curriculum and the willingness to participate in social networking to use and share educational materials. The surveys were evaluated for relevance by the survey evaluation team of the Association of Professors of Dermatology (APD). The instrument was not pilot tested.

The surveys were electronically distributed using an online service to dermatology faculty via the APD listserve, which comprised the entirety of the APD membership in 2014. The resident survey was distributed to the dermatology residents via the American Society for Dermatologic Surgery listserve, which included all residents in training (2013-2014 academic year). Second and third invitations to complete the surveys were distributed 3 and 5 weeks later, respectively.

Resident and faculty responses were compared. Additionally, responses were stratified for large (>9 residents) and small programs (≤9 residents) for comparison. Descriptive statistics including means and medians for continuous variables and frequency tables for categorical variables were generated using research and spreadsheet software.

Results

There were 137 survey respondents; 52 of 426 (12.2%) dermatology faculty and 85 of 1539 (5.5%) dermatology residents responded to the survey. Small programs accounted for 24% of total survey responses and 76% were from large programs.

Current Curriculum

The majority of dermatology faculty (44%) and residents (35%) identified 1 to 2 faculty members as contributing to the creation and organization of their respective curricula; however, a notable percentage of residents (9%) reported that no faculty contributed to the organization of the curriculum. Residents noted that senior residents carry twice the responsibility for structuring the curriculum compared to faculty (61% vs 32% of the workload), but faculty described an even split between senior residents and faculty (47% vs 49% of the workload). Faculty believed their residents spend a similar amount of time in resident- and faculty-led instruction (38% vs 35% of their time); however, the majority of residents reported spending too little time in faculty-led instruction (53%). When residents ranked their preference for learning modes, faculty-led and self-study learning were ranked first and second by 48% and 45% of residents, respectively. Resident-led instruction was ranked last by 66% of residents. Likewise, a majority of residents (53%) described their amount of time in faculty-led instruction as too little.

When asked what subjects in dermatology were lacking at their programs, residents reported clinical trials (47%), skin of color (46%), cosmetic dermatology (34%), and aggressive skin cancer/multidisciplinary tumor board (32%). Although 11% of residents reported lacking inpatient dermatology in their curriculum, 0% of faculty reported the same. A notable percentage of faculty reported nothing was lacking compared to residents (25% vs 7%). Despite these different views between residents and faculty on their contributions to and structure of their curriculums, both faculty and residents claimed overall satisfaction (satisfied or very satisfied) with their program’s ability to optimally cover the field of dermatology in 3 years (100% and 91%, respectively).

Large Versus Small Residency Programs

When stratifying the resident responses for small versus large programs, both program sizes reported more time in resident-led instruction than faculty-led instruction. Likewise, residents in both program sizes equally preferred self-study or faculty-led instruction to resident-led instruction. Residents at small programs more often reported lacking instruction in rheumatology, immunobullous diseases, and basic science/skin biology compared to large-program residents. Compared to large-program faculty, small-program faculty reported lacking instruction in cosmetic dermatology.

Faculty at small programs reported spending too little time preparing for their faculty-led instruction compared to faculty at large programs (44% vs 12%). All (100%) of the faculty at small programs were likely to seek out study materials shared by top educators, while 77% of faculty at large programs were likely to do the same. When asked if faculty would translate what their program does well into an electronic format for sharing, 30% of large-program faculty were likely to do so compared to 11% of small-program faculty (Figure 1).

Use of Online Educational Materials and Interest in Collaboration

A majority of faculty and residents stated that they use online educational materials as supplements to traditional classroom lecture and print materials (81% vs 86%); however, almost twice as many residents stated that online educational materials were essential to their current study routines compared to faculty (39% vs 21%).

The majority of faculty (92%) and residents (84%) were either interested or very interested in a collaborative online curriculum. Both residents (85%) and faculty (81%) stated they would be likely to seek out online educational materials shared by top educators. Although both residents and faculty reported many aspects of their curriculums they thought could be beneficial to other dermatology programs (Table 1), only 27% of faculty and 19% of residents were likely to translate those strengths into a shareable electronic format. Several reasons were reported for not contributing to an online curriculum, with lack of time being the most common reason (Table 2).

Eighty percent of residents and 88% of faculty reported they were either interested or very interested in being more connected/interactive with their dermatology peers nationally (Figure 2). Likewise, 94% of residents and 87% of faculty agreed that the dermatology community could benefit from a social networking site for educational collaboration. Four times as many residents versus faculty currently use social networking sites (eg, Facebook, LinkedIn, Google Groups) as a primary mode of communication with distant professional peers. The majority of residents (52%) reported they would be likely to participate in a professional social networking site, while the majority of faculty (50%) stated they were neutral on their likelihood of participating. Both residents and faculty reported lack of time as a common reason for being unlikely to utilize a professional social networking site. Other barriers to participation are listed in Table 3.

Comment

This study showed how dermatology faculty and residents currently provide training and what online resources and social networking sites they currently use or would be willing to use. The generalizability of the conclusions is limited by the low response rate for the surveys. The results demonstrated the different views between faculty and residents and between large and small residency programs on various topics. This microcosm of dermatology training can likely be applied to other training scenarios in dermatology, including patient education; training of nurses, physician extenders, and office staff; continuing medical education for physicians; and peer-to-peer collaboration.

Hypothesis 1: Partially Proven

We hypothesized that residents would report less satisfaction with their current curriculum and would report greater resident contributions to the curriculum relative to faculty. Overall, residents and faculty reported satisfaction with their curriculums to provide up-to-date information and breadth in the field of dermatology. Despite their overall satisfaction, more residents reported lacking instruction in several dermatology subtopics compared to faculty. Additionally, residents believed they spend twice as much time structuring their curriculum compared to faculty, with some residents reporting no faculty involvement. Although residents preferred faculty-led instruction, a majority of residents reported they do not have enough faculty-led didactics. The preference for faculty-led training is likely due to the expertise of faculty compared to residents.

Hypothesis 2: Partially Proven

We also hypothesized that both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Although there was no difference in interest between residents at small versus large programs, there was a difference between faculty at small versus large programs. Small-program faculty were more interested in using shared materials than larger programs, while large-program faculty were more likely to share their educational materials. Small-program faculty reported spending too little time preparing their lectures, which is possibly due to a lack of time for preparation. Additionally, residents and faculty at smaller programs report their curriculum was lacking specific dermatology topics compared to large programs. These disparities between program sizes indicate a need for a social networking site for training collaboration in dermatology. Large programs have the ability to share what they do well, which small programs are eager to utilize.

Hypothesis 3: Not Proven

We hypothesized that residents would be more willing than faculty to participate in social networking for educational purposes. The majority of faculty and residents were interested in participating in a collaborative online curriculum and using the shared materials from top educators; however, even though such large majorities favored collaboration and sharing, only 27% of faculty and 19% of residents were likely to translate their own materials into a shareable format. Although lack of time was the most common reason for not sharing materials, electronic methods may have the potential to ultimately save time and remove the burden of content creation. The time it would take to translate selected personal training materials into a shareable form would be made up for by the time saved using another educators’ materials. Updating and customizing shared online educational materials can be much quicker and easier than educators creating materials on their own. Dermatologists would be more efficient facilitators of training via high-quality shared materials while decreasing the time burden associated with resident education.⁵ Another concern for not sharing or participating in a social networking site was skepticism of information security on such a network. The poor organization and information overload of online resources can compound the already existing time constraints on dermatologists, which may limit their ability to utilize such valuable resources. In addition, quality of online resources is not always guaranteed, and determining the sources that are high quality is sometimes a difficult task.⁶ For online materials to remain useful, there should be a peer-review process to evaluate quality and assess satisfaction.⁵

Solution: Create a Dermatology Task Force

A dermatology task force could facilitate the resolution of these challenges of online materials. In addition, a task force could cover the administrative support needed to ensure security and provide maintenance on social networks.

The main limitation to implementing a social network is the presence of the administrative infrastructure to jumpstart its creation. A task force incorporating the essential stakeholders in dermatology training is the first step. With inclusive representation from all of the smaller professional dermatology societies, the American Academy of Dermatology is optimally positioned to create this task force. With existing information technologies, a task force could address the concerns revealed in our survey as well as any future concerns that may arise.

The goal is a single social network for dermatologists that has the capability of improving communication and collaboration between professional peers regardless of their practice setting. Such a network is ideal for the practicing dermatologist for the purposes of staff training, patient education, and obtaining continuing medical education credit. Additionally, peer group collaboration would facilitate the understanding and completion of the evolving requirements for Maintenance of Certification from the American Board of Dermatology. The availability of quality shared materials would save time and increase efficiency of an entire dermatology practice. Materials that aid in patient education would allow office staff to dedicate their time to other tasks, thereby increasing productivity. Shared training materials would decrease the burden of staff education, providing more time for advanced hands-on training. This method of collaborative effort is capable of advancing the field of dermatology as a whole. It can overcome geographical and institutional barriers to connect dermatologists with similar interests worldwide; disseminate advances in diagnosis and treatment; and improve the quality of dermatology training of dermatologists, staff, and patients.

More than 1.8 billion individuals utilize social media, a number that continues to grow as the social media market expands.¹ Social media enables individuals, groups, and organizations to efficiently disperse and access information^2-4 and also provides a structure that encourages collaboration between patients, staff, and physicians that cannot be achieved by other communication modalities.^4-6 Expert opinions and related educational materials can be shared globally, improving collaboration between dermatologists.⁶ A structured social networking site for sharing training materials, research, and ideas can help bring the national dermatology community together in a new way.

Other professions have employed social networking tools to accomplish similar goals of organizing training resources; radiology has an electronic database that allows sharing of training materials and incorporates social networking capabilities.⁷ Their Web software provides functionality for individual file uploading and supports collaboration and sharing, all while maintaining the security of uploaded information. General surgery has already addressed similar concerns via a task force that incorporates all the essential organizations in surgical education.⁸ Increased satisfaction and academic abilities have been demonstrated with their collaborative curriculum.⁹ Gastroenterologists also utilize electronic resources; one study showed that using videos to educate patients prior to colonoscopies was superior to face-to-face education.¹⁰ In addition, video education may free up time for office staff to accomplish other tasks.

As a specialty, dermatology has not been a leader in the implementation of social networking for collaboration and training purposes. Every dermatologist is an educator. To maintain a successful practice, dermatologists must keep up-to-date on their own clinical knowledge, provide training to their staff, and educate their patients. Although there are numerous educational resources available to dermatologists, an informal survey of 30 dermatology faculty members revealed a practice gap in awareness and utilization of these expanding electronic resources.¹¹

To better understand the needs of the specialty as a whole, we chose to focus on one aspect of dermatology education: resident training. The goal of our study was to survey dermatology residents and faculty to gain a better understanding of how they currently provide education and what online resources and social networking sites they currently use or would be willing to use. The study included 3 central hypotheses: First, residents would be less satisfied with their current curriculum and residents would report greater contributions to the curriculum relative to faculty. Second, both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Lastly, residents would be more willing than faculty to participate in social networking for educational purposes.

Methods

This study was granted institutional review board exemption. Two surveys were developed by the authors to assess the current structure and satisfaction of dermatology residency curriculum and the willingness to participate in social networking to use and share educational materials. The surveys were evaluated for relevance by the survey evaluation team of the Association of Professors of Dermatology (APD). The instrument was not pilot tested.

The surveys were electronically distributed using an online service to dermatology faculty via the APD listserve, which comprised the entirety of the APD membership in 2014. The resident survey was distributed to the dermatology residents via the American Society for Dermatologic Surgery listserve, which included all residents in training (2013-2014 academic year). Second and third invitations to complete the surveys were distributed 3 and 5 weeks later, respectively.

Resident and faculty responses were compared. Additionally, responses were stratified for large (>9 residents) and small programs (≤9 residents) for comparison. Descriptive statistics including means and medians for continuous variables and frequency tables for categorical variables were generated using research and spreadsheet software.

Results

There were 137 survey respondents; 52 of 426 (12.2%) dermatology faculty and 85 of 1539 (5.5%) dermatology residents responded to the survey. Small programs accounted for 24% of total survey responses and 76% were from large programs.

Current Curriculum

The majority of dermatology faculty (44%) and residents (35%) identified 1 to 2 faculty members as contributing to the creation and organization of their respective curricula; however, a notable percentage of residents (9%) reported that no faculty contributed to the organization of the curriculum. Residents noted that senior residents carry twice the responsibility for structuring the curriculum compared to faculty (61% vs 32% of the workload), but faculty described an even split between senior residents and faculty (47% vs 49% of the workload). Faculty believed their residents spend a similar amount of time in resident- and faculty-led instruction (38% vs 35% of their time); however, the majority of residents reported spending too little time in faculty-led instruction (53%). When residents ranked their preference for learning modes, faculty-led and self-study learning were ranked first and second by 48% and 45% of residents, respectively. Resident-led instruction was ranked last by 66% of residents. Likewise, a majority of residents (53%) described their amount of time in faculty-led instruction as too little.

When asked what subjects in dermatology were lacking at their programs, residents reported clinical trials (47%), skin of color (46%), cosmetic dermatology (34%), and aggressive skin cancer/multidisciplinary tumor board (32%). Although 11% of residents reported lacking inpatient dermatology in their curriculum, 0% of faculty reported the same. A notable percentage of faculty reported nothing was lacking compared to residents (25% vs 7%). Despite these different views between residents and faculty on their contributions to and structure of their curriculums, both faculty and residents claimed overall satisfaction (satisfied or very satisfied) with their program’s ability to optimally cover the field of dermatology in 3 years (100% and 91%, respectively).

Large Versus Small Residency Programs

When stratifying the resident responses for small versus large programs, both program sizes reported more time in resident-led instruction than faculty-led instruction. Likewise, residents in both program sizes equally preferred self-study or faculty-led instruction to resident-led instruction. Residents at small programs more often reported lacking instruction in rheumatology, immunobullous diseases, and basic science/skin biology compared to large-program residents. Compared to large-program faculty, small-program faculty reported lacking instruction in cosmetic dermatology.

Faculty at small programs reported spending too little time preparing for their faculty-led instruction compared to faculty at large programs (44% vs 12%). All (100%) of the faculty at small programs were likely to seek out study materials shared by top educators, while 77% of faculty at large programs were likely to do the same. When asked if faculty would translate what their program does well into an electronic format for sharing, 30% of large-program faculty were likely to do so compared to 11% of small-program faculty (Figure 1).

Use of Online Educational Materials and Interest in Collaboration

A majority of faculty and residents stated that they use online educational materials as supplements to traditional classroom lecture and print materials (81% vs 86%); however, almost twice as many residents stated that online educational materials were essential to their current study routines compared to faculty (39% vs 21%).

The majority of faculty (92%) and residents (84%) were either interested or very interested in a collaborative online curriculum. Both residents (85%) and faculty (81%) stated they would be likely to seek out online educational materials shared by top educators. Although both residents and faculty reported many aspects of their curriculums they thought could be beneficial to other dermatology programs (Table 1), only 27% of faculty and 19% of residents were likely to translate those strengths into a shareable electronic format. Several reasons were reported for not contributing to an online curriculum, with lack of time being the most common reason (Table 2).

Eighty percent of residents and 88% of faculty reported they were either interested or very interested in being more connected/interactive with their dermatology peers nationally (Figure 2). Likewise, 94% of residents and 87% of faculty agreed that the dermatology community could benefit from a social networking site for educational collaboration. Four times as many residents versus faculty currently use social networking sites (eg, Facebook, LinkedIn, Google Groups) as a primary mode of communication with distant professional peers. The majority of residents (52%) reported they would be likely to participate in a professional social networking site, while the majority of faculty (50%) stated they were neutral on their likelihood of participating. Both residents and faculty reported lack of time as a common reason for being unlikely to utilize a professional social networking site. Other barriers to participation are listed in Table 3.

Comment

This study showed how dermatology faculty and residents currently provide training and what online resources and social networking sites they currently use or would be willing to use. The generalizability of the conclusions is limited by the low response rate for the surveys. The results demonstrated the different views between faculty and residents and between large and small residency programs on various topics. This microcosm of dermatology training can likely be applied to other training scenarios in dermatology, including patient education; training of nurses, physician extenders, and office staff; continuing medical education for physicians; and peer-to-peer collaboration.

Hypothesis 1: Partially Proven

We hypothesized that residents would report less satisfaction with their current curriculum and would report greater resident contributions to the curriculum relative to faculty. Overall, residents and faculty reported satisfaction with their curriculums to provide up-to-date information and breadth in the field of dermatology. Despite their overall satisfaction, more residents reported lacking instruction in several dermatology subtopics compared to faculty. Additionally, residents believed they spend twice as much time structuring their curriculum compared to faculty, with some residents reporting no faculty involvement. Although residents preferred faculty-led instruction, a majority of residents reported they do not have enough faculty-led didactics. The preference for faculty-led training is likely due to the expertise of faculty compared to residents.

Hypothesis 2: Partially Proven

We also hypothesized that both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Although there was no difference in interest between residents at small versus large programs, there was a difference between faculty at small versus large programs. Small-program faculty were more interested in using shared materials than larger programs, while large-program faculty were more likely to share their educational materials. Small-program faculty reported spending too little time preparing their lectures, which is possibly due to a lack of time for preparation. Additionally, residents and faculty at smaller programs report their curriculum was lacking specific dermatology topics compared to large programs. These disparities between program sizes indicate a need for a social networking site for training collaboration in dermatology. Large programs have the ability to share what they do well, which small programs are eager to utilize.

Hypothesis 3: Not Proven

We hypothesized that residents would be more willing than faculty to participate in social networking for educational purposes. The majority of faculty and residents were interested in participating in a collaborative online curriculum and using the shared materials from top educators; however, even though such large majorities favored collaboration and sharing, only 27% of faculty and 19% of residents were likely to translate their own materials into a shareable format. Although lack of time was the most common reason for not sharing materials, electronic methods may have the potential to ultimately save time and remove the burden of content creation. The time it would take to translate selected personal training materials into a shareable form would be made up for by the time saved using another educators’ materials. Updating and customizing shared online educational materials can be much quicker and easier than educators creating materials on their own. Dermatologists would be more efficient facilitators of training via high-quality shared materials while decreasing the time burden associated with resident education.⁵ Another concern for not sharing or participating in a social networking site was skepticism of information security on such a network. The poor organization and information overload of online resources can compound the already existing time constraints on dermatologists, which may limit their ability to utilize such valuable resources. In addition, quality of online resources is not always guaranteed, and determining the sources that are high quality is sometimes a difficult task.⁶ For online materials to remain useful, there should be a peer-review process to evaluate quality and assess satisfaction.⁵

Solution: Create a Dermatology Task Force

A dermatology task force could facilitate the resolution of these challenges of online materials. In addition, a task force could cover the administrative support needed to ensure security and provide maintenance on social networks.

The main limitation to implementing a social network is the presence of the administrative infrastructure to jumpstart its creation. A task force incorporating the essential stakeholders in dermatology training is the first step. With inclusive representation from all of the smaller professional dermatology societies, the American Academy of Dermatology is optimally positioned to create this task force. With existing information technologies, a task force could address the concerns revealed in our survey as well as any future concerns that may arise.

The goal is a single social network for dermatologists that has the capability of improving communication and collaboration between professional peers regardless of their practice setting. Such a network is ideal for the practicing dermatologist for the purposes of staff training, patient education, and obtaining continuing medical education credit. Additionally, peer group collaboration would facilitate the understanding and completion of the evolving requirements for Maintenance of Certification from the American Board of Dermatology. The availability of quality shared materials would save time and increase efficiency of an entire dermatology practice. Materials that aid in patient education would allow office staff to dedicate their time to other tasks, thereby increasing productivity. Shared training materials would decrease the burden of staff education, providing more time for advanced hands-on training. This method of collaborative effort is capable of advancing the field of dermatology as a whole. It can overcome geographical and institutional barriers to connect dermatologists with similar interests worldwide; disseminate advances in diagnosis and treatment; and improve the quality of dermatology training of dermatologists, staff, and patients.

More than 1.8 billion individuals utilize social media, a number that continues to grow as the social media market expands.¹ Social media enables individuals, groups, and organizations to efficiently disperse and access information^2-4 and also provides a structure that encourages collaboration between patients, staff, and physicians that cannot be achieved by other communication modalities.^4-6 Expert opinions and related educational materials can be shared globally, improving collaboration between dermatologists.⁶ A structured social networking site for sharing training materials, research, and ideas can help bring the national dermatology community together in a new way.

Other professions have employed social networking tools to accomplish similar goals of organizing training resources; radiology has an electronic database that allows sharing of training materials and incorporates social networking capabilities.⁷ Their Web software provides functionality for individual file uploading and supports collaboration and sharing, all while maintaining the security of uploaded information. General surgery has already addressed similar concerns via a task force that incorporates all the essential organizations in surgical education.⁸ Increased satisfaction and academic abilities have been demonstrated with their collaborative curriculum.⁹ Gastroenterologists also utilize electronic resources; one study showed that using videos to educate patients prior to colonoscopies was superior to face-to-face education.¹⁰ In addition, video education may free up time for office staff to accomplish other tasks.

As a specialty, dermatology has not been a leader in the implementation of social networking for collaboration and training purposes. Every dermatologist is an educator. To maintain a successful practice, dermatologists must keep up-to-date on their own clinical knowledge, provide training to their staff, and educate their patients. Although there are numerous educational resources available to dermatologists, an informal survey of 30 dermatology faculty members revealed a practice gap in awareness and utilization of these expanding electronic resources.¹¹

To better understand the needs of the specialty as a whole, we chose to focus on one aspect of dermatology education: resident training. The goal of our study was to survey dermatology residents and faculty to gain a better understanding of how they currently provide education and what online resources and social networking sites they currently use or would be willing to use. The study included 3 central hypotheses: First, residents would be less satisfied with their current curriculum and residents would report greater contributions to the curriculum relative to faculty. Second, both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Lastly, residents would be more willing than faculty to participate in social networking for educational purposes.

Methods

This study was granted institutional review board exemption. Two surveys were developed by the authors to assess the current structure and satisfaction of dermatology residency curriculum and the willingness to participate in social networking to use and share educational materials. The surveys were evaluated for relevance by the survey evaluation team of the Association of Professors of Dermatology (APD). The instrument was not pilot tested.

The surveys were electronically distributed using an online service to dermatology faculty via the APD listserve, which comprised the entirety of the APD membership in 2014. The resident survey was distributed to the dermatology residents via the American Society for Dermatologic Surgery listserve, which included all residents in training (2013-2014 academic year). Second and third invitations to complete the surveys were distributed 3 and 5 weeks later, respectively.

Resident and faculty responses were compared. Additionally, responses were stratified for large (>9 residents) and small programs (≤9 residents) for comparison. Descriptive statistics including means and medians for continuous variables and frequency tables for categorical variables were generated using research and spreadsheet software.

Results

There were 137 survey respondents; 52 of 426 (12.2%) dermatology faculty and 85 of 1539 (5.5%) dermatology residents responded to the survey. Small programs accounted for 24% of total survey responses and 76% were from large programs.

Current Curriculum

The majority of dermatology faculty (44%) and residents (35%) identified 1 to 2 faculty members as contributing to the creation and organization of their respective curricula; however, a notable percentage of residents (9%) reported that no faculty contributed to the organization of the curriculum. Residents noted that senior residents carry twice the responsibility for structuring the curriculum compared to faculty (61% vs 32% of the workload), but faculty described an even split between senior residents and faculty (47% vs 49% of the workload). Faculty believed their residents spend a similar amount of time in resident- and faculty-led instruction (38% vs 35% of their time); however, the majority of residents reported spending too little time in faculty-led instruction (53%). When residents ranked their preference for learning modes, faculty-led and self-study learning were ranked first and second by 48% and 45% of residents, respectively. Resident-led instruction was ranked last by 66% of residents. Likewise, a majority of residents (53%) described their amount of time in faculty-led instruction as too little.

When asked what subjects in dermatology were lacking at their programs, residents reported clinical trials (47%), skin of color (46%), cosmetic dermatology (34%), and aggressive skin cancer/multidisciplinary tumor board (32%). Although 11% of residents reported lacking inpatient dermatology in their curriculum, 0% of faculty reported the same. A notable percentage of faculty reported nothing was lacking compared to residents (25% vs 7%). Despite these different views between residents and faculty on their contributions to and structure of their curriculums, both faculty and residents claimed overall satisfaction (satisfied or very satisfied) with their program’s ability to optimally cover the field of dermatology in 3 years (100% and 91%, respectively).

Large Versus Small Residency Programs

When stratifying the resident responses for small versus large programs, both program sizes reported more time in resident-led instruction than faculty-led instruction. Likewise, residents in both program sizes equally preferred self-study or faculty-led instruction to resident-led instruction. Residents at small programs more often reported lacking instruction in rheumatology, immunobullous diseases, and basic science/skin biology compared to large-program residents. Compared to large-program faculty, small-program faculty reported lacking instruction in cosmetic dermatology.

Faculty at small programs reported spending too little time preparing for their faculty-led instruction compared to faculty at large programs (44% vs 12%). All (100%) of the faculty at small programs were likely to seek out study materials shared by top educators, while 77% of faculty at large programs were likely to do the same. When asked if faculty would translate what their program does well into an electronic format for sharing, 30% of large-program faculty were likely to do so compared to 11% of small-program faculty (Figure 1).

Use of Online Educational Materials and Interest in Collaboration

A majority of faculty and residents stated that they use online educational materials as supplements to traditional classroom lecture and print materials (81% vs 86%); however, almost twice as many residents stated that online educational materials were essential to their current study routines compared to faculty (39% vs 21%).

The majority of faculty (92%) and residents (84%) were either interested or very interested in a collaborative online curriculum. Both residents (85%) and faculty (81%) stated they would be likely to seek out online educational materials shared by top educators. Although both residents and faculty reported many aspects of their curriculums they thought could be beneficial to other dermatology programs (Table 1), only 27% of faculty and 19% of residents were likely to translate those strengths into a shareable electronic format. Several reasons were reported for not contributing to an online curriculum, with lack of time being the most common reason (Table 2).

Eighty percent of residents and 88% of faculty reported they were either interested or very interested in being more connected/interactive with their dermatology peers nationally (Figure 2). Likewise, 94% of residents and 87% of faculty agreed that the dermatology community could benefit from a social networking site for educational collaboration. Four times as many residents versus faculty currently use social networking sites (eg, Facebook, LinkedIn, Google Groups) as a primary mode of communication with distant professional peers. The majority of residents (52%) reported they would be likely to participate in a professional social networking site, while the majority of faculty (50%) stated they were neutral on their likelihood of participating. Both residents and faculty reported lack of time as a common reason for being unlikely to utilize a professional social networking site. Other barriers to participation are listed in Table 3.

Comment

This study showed how dermatology faculty and residents currently provide training and what online resources and social networking sites they currently use or would be willing to use. The generalizability of the conclusions is limited by the low response rate for the surveys. The results demonstrated the different views between faculty and residents and between large and small residency programs on various topics. This microcosm of dermatology training can likely be applied to other training scenarios in dermatology, including patient education; training of nurses, physician extenders, and office staff; continuing medical education for physicians; and peer-to-peer collaboration.

Hypothesis 1: Partially Proven

We hypothesized that residents would report less satisfaction with their current curriculum and would report greater resident contributions to the curriculum relative to faculty. Overall, residents and faculty reported satisfaction with their curriculums to provide up-to-date information and breadth in the field of dermatology. Despite their overall satisfaction, more residents reported lacking instruction in several dermatology subtopics compared to faculty. Additionally, residents believed they spend twice as much time structuring their curriculum compared to faculty, with some residents reporting no faculty involvement. Although residents preferred faculty-led instruction, a majority of residents reported they do not have enough faculty-led didactics. The preference for faculty-led training is likely due to the expertise of faculty compared to residents.

Hypothesis 2: Partially Proven

We also hypothesized that both residents and faculty of smaller programs would be more interested in collaborative educational resources relative to larger programs. Although there was no difference in interest between residents at small versus large programs, there was a difference between faculty at small versus large programs. Small-program faculty were more interested in using shared materials than larger programs, while large-program faculty were more likely to share their educational materials. Small-program faculty reported spending too little time preparing their lectures, which is possibly due to a lack of time for preparation. Additionally, residents and faculty at smaller programs report their curriculum was lacking specific dermatology topics compared to large programs. These disparities between program sizes indicate a need for a social networking site for training collaboration in dermatology. Large programs have the ability to share what they do well, which small programs are eager to utilize.

Hypothesis 3: Not Proven

We hypothesized that residents would be more willing than faculty to participate in social networking for educational purposes. The majority of faculty and residents were interested in participating in a collaborative online curriculum and using the shared materials from top educators; however, even though such large majorities favored collaboration and sharing, only 27% of faculty and 19% of residents were likely to translate their own materials into a shareable format. Although lack of time was the most common reason for not sharing materials, electronic methods may have the potential to ultimately save time and remove the burden of content creation. The time it would take to translate selected personal training materials into a shareable form would be made up for by the time saved using another educators’ materials. Updating and customizing shared online educational materials can be much quicker and easier than educators creating materials on their own. Dermatologists would be more efficient facilitators of training via high-quality shared materials while decreasing the time burden associated with resident education.⁵ Another concern for not sharing or participating in a social networking site was skepticism of information security on such a network. The poor organization and information overload of online resources can compound the already existing time constraints on dermatologists, which may limit their ability to utilize such valuable resources. In addition, quality of online resources is not always guaranteed, and determining the sources that are high quality is sometimes a difficult task.⁶ For online materials to remain useful, there should be a peer-review process to evaluate quality and assess satisfaction.⁵

Solution: Create a Dermatology Task Force

A dermatology task force could facilitate the resolution of these challenges of online materials. In addition, a task force could cover the administrative support needed to ensure security and provide maintenance on social networks.

The main limitation to implementing a social network is the presence of the administrative infrastructure to jumpstart its creation. A task force incorporating the essential stakeholders in dermatology training is the first step. With inclusive representation from all of the smaller professional dermatology societies, the American Academy of Dermatology is optimally positioned to create this task force. With existing information technologies, a task force could address the concerns revealed in our survey as well as any future concerns that may arise.

The goal is a single social network for dermatologists that has the capability of improving communication and collaboration between professional peers regardless of their practice setting. Such a network is ideal for the practicing dermatologist for the purposes of staff training, patient education, and obtaining continuing medical education credit. Additionally, peer group collaboration would facilitate the understanding and completion of the evolving requirements for Maintenance of Certification from the American Board of Dermatology. The availability of quality shared materials would save time and increase efficiency of an entire dermatology practice. Materials that aid in patient education would allow office staff to dedicate their time to other tasks, thereby increasing productivity. Shared training materials would decrease the burden of staff education, providing more time for advanced hands-on training. This method of collaborative effort is capable of advancing the field of dermatology as a whole. It can overcome geographical and institutional barriers to connect dermatologists with similar interests worldwide; disseminate advances in diagnosis and treatment; and improve the quality of dermatology training of dermatologists, staff, and patients.

I understand that you as an ObGyn do not have the time or bandwidth to “vet” the available mobile apps for your practice. However, that does not mean you need to forgo using apps that could make your clinical life a little easier if possible. In this continuation of my “APP review” series, I focus on drug reference apps, which generally include the names of drugs, their indications, dosages, pharmacology, drug-drug interactions, contraindications, cost, and identifying characteristics.¹ Drug reference apps, along with medical calculator and disease diagnosis apps, are reported as most useful by health care professionals and medical or nursing students.¹ Drug reference apps are particularly popular among residents and medical students as the apps allow for rapid decision making.²

I have selected 2 drug reference apps—Epocrates and Medscape—to report here as both of these apps are free and are the only apps that appear in independent comprehensive studies.^1,3 I particularly like Epocrates’ pill identification function for those patients who have forgotten the name of the medication they use but have the actual pill with them. I find Medscape’s additional information on diseases, conditions, and medical procedures especially useful for the times I have forgotten the condition that the medication is indicated for.

The recommended apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ Visit the OBG Management website to download the apps featured.

Watch for my next column in which I will recommend, according to APPLI, the top apps for patients to use to track their menstrual cycles.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

I understand that you as an ObGyn do not have the time or bandwidth to “vet” the available mobile apps for your practice. However, that does not mean you need to forgo using apps that could make your clinical life a little easier if possible. In this continuation of my “APP review” series, I focus on drug reference apps, which generally include the names of drugs, their indications, dosages, pharmacology, drug-drug interactions, contraindications, cost, and identifying characteristics.¹ Drug reference apps, along with medical calculator and disease diagnosis apps, are reported as most useful by health care professionals and medical or nursing students.¹ Drug reference apps are particularly popular among residents and medical students as the apps allow for rapid decision making.²

I have selected 2 drug reference apps—Epocrates and Medscape—to report here as both of these apps are free and are the only apps that appear in independent comprehensive studies.^1,3 I particularly like Epocrates’ pill identification function for those patients who have forgotten the name of the medication they use but have the actual pill with them. I find Medscape’s additional information on diseases, conditions, and medical procedures especially useful for the times I have forgotten the condition that the medication is indicated for.

The recommended apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ Visit the OBG Management website to download the apps featured.

Watch for my next column in which I will recommend, according to APPLI, the top apps for patients to use to track their menstrual cycles.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

I understand that you as an ObGyn do not have the time or bandwidth to “vet” the available mobile apps for your practice. However, that does not mean you need to forgo using apps that could make your clinical life a little easier if possible. In this continuation of my “APP review” series, I focus on drug reference apps, which generally include the names of drugs, their indications, dosages, pharmacology, drug-drug interactions, contraindications, cost, and identifying characteristics.¹ Drug reference apps, along with medical calculator and disease diagnosis apps, are reported as most useful by health care professionals and medical or nursing students.¹ Drug reference apps are particularly popular among residents and medical students as the apps allow for rapid decision making.²

I have selected 2 drug reference apps—Epocrates and Medscape—to report here as both of these apps are free and are the only apps that appear in independent comprehensive studies.^1,3 I particularly like Epocrates’ pill identification function for those patients who have forgotten the name of the medication they use but have the actual pill with them. I find Medscape’s additional information on diseases, conditions, and medical procedures especially useful for the times I have forgotten the condition that the medication is indicated for.

The recommended apps are listed in the TABLE alphabetically and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, and important special features).⁴ Visit the OBG Management website to download the apps featured.

Watch for my next column in which I will recommend, according to APPLI, the top apps for patients to use to track their menstrual cycles.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Ota nevus is a dermal melanocytosis that is typically characterized by blue, gray, or brown pigmented patches in the periorbital region.¹ The condition has a prevalence of 0.04% in a Philadelphia study of 6915 patients and is most notable in patients with skin of color, affecting up to 0.6% of Asians,² 0.038% of white individuals, and 0.014% of black individuals.^3,4 The appearance of an Ota nevus often imparts a negative psychosocial impact on the patient, prompting requests for treatment and/or removal.⁵ Laser treatment of Ota nevi must be carefully implemented, especially in Fitzpatrick skin types IV through VI. Although 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,^5,6 typically only moderate improvement is seen; further treatment at higher fluences will only increase the risk for dyspigmentation and scarring.⁶

We report a case of successful treatment of an Ota nevus following 2 treatment sessions with the 532-nm solid-state picosecond laser, which is a novel application in patients with skin of color (Fitzpatrick skin types IV-VI). The Q-switched nanosecond laser has been shown to be moderately effective at treating Ota nevi.⁶ 

Case Report

An 18-year-old woman with Fitzpatrick skin type IV presented for cosmetic removal of an 8×5-cm dark brown-blue patch on the right temple and malar and buccal cheek present since birth that had failed to respond to an unknown laser treatment that was administered outside of the United States (Figure, A). To ascertain the diagnosis, a biopsy was performed, showing histology consistent with Ota nevus. Initially, the 755-nm Q-switched nanosecond laser was recommended for treatment. Over the course of 7 months (1 treatment session per month [Table]), the patient saw improvement but not to the desired extent. The patient then underwent 2 treatments at 4-week intervals with the 1064-nm solid-state picosecond and nanosecond lasers; however, no improvement was seen following these 2 sessions (Table).

The next month the patient received treatment with a novel 532-nm solid-state picosecond laser using the following parameters: fluence, 0.5 J/cm²; spot size, 6 mm; repetition rate, 1 Hz; pulse duration, 750 picoseconds; 339 pulses. The end point was whitening. A remarkable clinical response was demonstrated 6 weeks later (Figure, B). A second treatment with the 532-nm solid-state picosecond laser was then performed at 14 months. On a return visit 2 months after the second treatment, the patient showed dramatic improvement, almost to the degree of complete resolution (Figure, C). 

Comment

Pigmentation disorders are more common in patients with skin of color, and those affected may experience psychological effects secondary to these dermatoses, prompting requests for treatment and/or removal.⁷ Although the 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,³ the challenge remains for patients with skin of color, as these lasers work through photothermolysis, which generates heat and may cause thermal damage by targeting melanin. Because more melanin is present in skin of color patients, the threshold for too much heat is lower and these patients are at a higher risk for adverse events such as scarring and hyperpigmentation.^6,8

By delivering energy in shorter pulses, the novel 532-nm solid-state picosecond laser shows greater fragmentation of melanosomes into melanin particles that are eventually phagocytosed.⁸ In our patient, dramatic improvement was noted after only 2 treatments, as evidenced by other picosecond treatments on Ota nevi,^6,8 suggesting that fewer treatments are necessary when using the 532-nm solid-state picosecond laser for Ota nevi.

Although the 532-nm solid-state picosecond laser was cleared by the US Food and Drug Administration for tattoo removal, this laser shows potential use in other pigmentary disorders, particularly in patients with skin of color, as demonstrated in our case. With continued understanding through further studies, this picosecond laser with a shorter pulse duration may prove to be a safer and more effective alternative to the Q-switched nanosecond laser.

Conclusion

As shown in our case, the 532-nm solid-state picosecond laser appears to be a safe and effective modality for treating Ota nevi. This case demonstrates the potential utility of this laser in patients desiring more complete clearing, as it removes pigment more rapidly with lower risk for serious adverse effects. The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

Ota nevus is a dermal melanocytosis that is typically characterized by blue, gray, or brown pigmented patches in the periorbital region.¹ The condition has a prevalence of 0.04% in a Philadelphia study of 6915 patients and is most notable in patients with skin of color, affecting up to 0.6% of Asians,² 0.038% of white individuals, and 0.014% of black individuals.^3,4 The appearance of an Ota nevus often imparts a negative psychosocial impact on the patient, prompting requests for treatment and/or removal.⁵ Laser treatment of Ota nevi must be carefully implemented, especially in Fitzpatrick skin types IV through VI. Although 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,^5,6 typically only moderate improvement is seen; further treatment at higher fluences will only increase the risk for dyspigmentation and scarring.⁶

We report a case of successful treatment of an Ota nevus following 2 treatment sessions with the 532-nm solid-state picosecond laser, which is a novel application in patients with skin of color (Fitzpatrick skin types IV-VI). The Q-switched nanosecond laser has been shown to be moderately effective at treating Ota nevi.⁶ 

Case Report

An 18-year-old woman with Fitzpatrick skin type IV presented for cosmetic removal of an 8×5-cm dark brown-blue patch on the right temple and malar and buccal cheek present since birth that had failed to respond to an unknown laser treatment that was administered outside of the United States (Figure, A). To ascertain the diagnosis, a biopsy was performed, showing histology consistent with Ota nevus. Initially, the 755-nm Q-switched nanosecond laser was recommended for treatment. Over the course of 7 months (1 treatment session per month [Table]), the patient saw improvement but not to the desired extent. The patient then underwent 2 treatments at 4-week intervals with the 1064-nm solid-state picosecond and nanosecond lasers; however, no improvement was seen following these 2 sessions (Table).

The next month the patient received treatment with a novel 532-nm solid-state picosecond laser using the following parameters: fluence, 0.5 J/cm²; spot size, 6 mm; repetition rate, 1 Hz; pulse duration, 750 picoseconds; 339 pulses. The end point was whitening. A remarkable clinical response was demonstrated 6 weeks later (Figure, B). A second treatment with the 532-nm solid-state picosecond laser was then performed at 14 months. On a return visit 2 months after the second treatment, the patient showed dramatic improvement, almost to the degree of complete resolution (Figure, C). 

Comment

Pigmentation disorders are more common in patients with skin of color, and those affected may experience psychological effects secondary to these dermatoses, prompting requests for treatment and/or removal.⁷ Although the 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,³ the challenge remains for patients with skin of color, as these lasers work through photothermolysis, which generates heat and may cause thermal damage by targeting melanin. Because more melanin is present in skin of color patients, the threshold for too much heat is lower and these patients are at a higher risk for adverse events such as scarring and hyperpigmentation.^6,8

By delivering energy in shorter pulses, the novel 532-nm solid-state picosecond laser shows greater fragmentation of melanosomes into melanin particles that are eventually phagocytosed.⁸ In our patient, dramatic improvement was noted after only 2 treatments, as evidenced by other picosecond treatments on Ota nevi,^6,8 suggesting that fewer treatments are necessary when using the 532-nm solid-state picosecond laser for Ota nevi.

Although the 532-nm solid-state picosecond laser was cleared by the US Food and Drug Administration for tattoo removal, this laser shows potential use in other pigmentary disorders, particularly in patients with skin of color, as demonstrated in our case. With continued understanding through further studies, this picosecond laser with a shorter pulse duration may prove to be a safer and more effective alternative to the Q-switched nanosecond laser.

Conclusion

As shown in our case, the 532-nm solid-state picosecond laser appears to be a safe and effective modality for treating Ota nevi. This case demonstrates the potential utility of this laser in patients desiring more complete clearing, as it removes pigment more rapidly with lower risk for serious adverse effects. The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

Ota nevus is a dermal melanocytosis that is typically characterized by blue, gray, or brown pigmented patches in the periorbital region.¹ The condition has a prevalence of 0.04% in a Philadelphia study of 6915 patients and is most notable in patients with skin of color, affecting up to 0.6% of Asians,² 0.038% of white individuals, and 0.014% of black individuals.^3,4 The appearance of an Ota nevus often imparts a negative psychosocial impact on the patient, prompting requests for treatment and/or removal.⁵ Laser treatment of Ota nevi must be carefully implemented, especially in Fitzpatrick skin types IV through VI. Although 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,^5,6 typically only moderate improvement is seen; further treatment at higher fluences will only increase the risk for dyspigmentation and scarring.⁶

We report a case of successful treatment of an Ota nevus following 2 treatment sessions with the 532-nm solid-state picosecond laser, which is a novel application in patients with skin of color (Fitzpatrick skin types IV-VI). The Q-switched nanosecond laser has been shown to be moderately effective at treating Ota nevi.⁶ 

Case Report

An 18-year-old woman with Fitzpatrick skin type IV presented for cosmetic removal of an 8×5-cm dark brown-blue patch on the right temple and malar and buccal cheek present since birth that had failed to respond to an unknown laser treatment that was administered outside of the United States (Figure, A). To ascertain the diagnosis, a biopsy was performed, showing histology consistent with Ota nevus. Initially, the 755-nm Q-switched nanosecond laser was recommended for treatment. Over the course of 7 months (1 treatment session per month [Table]), the patient saw improvement but not to the desired extent. The patient then underwent 2 treatments at 4-week intervals with the 1064-nm solid-state picosecond and nanosecond lasers; however, no improvement was seen following these 2 sessions (Table).

The next month the patient received treatment with a novel 532-nm solid-state picosecond laser using the following parameters: fluence, 0.5 J/cm²; spot size, 6 mm; repetition rate, 1 Hz; pulse duration, 750 picoseconds; 339 pulses. The end point was whitening. A remarkable clinical response was demonstrated 6 weeks later (Figure, B). A second treatment with the 532-nm solid-state picosecond laser was then performed at 14 months. On a return visit 2 months after the second treatment, the patient showed dramatic improvement, almost to the degree of complete resolution (Figure, C). 

Comment

Pigmentation disorders are more common in patients with skin of color, and those affected may experience psychological effects secondary to these dermatoses, prompting requests for treatment and/or removal.⁷ Although the 532- and 755-nm Q-switched nanosecond lasers have been used to treat Ota nevi,³ the challenge remains for patients with skin of color, as these lasers work through photothermolysis, which generates heat and may cause thermal damage by targeting melanin. Because more melanin is present in skin of color patients, the threshold for too much heat is lower and these patients are at a higher risk for adverse events such as scarring and hyperpigmentation.^6,8

By delivering energy in shorter pulses, the novel 532-nm solid-state picosecond laser shows greater fragmentation of melanosomes into melanin particles that are eventually phagocytosed.⁸ In our patient, dramatic improvement was noted after only 2 treatments, as evidenced by other picosecond treatments on Ota nevi,^6,8 suggesting that fewer treatments are necessary when using the 532-nm solid-state picosecond laser for Ota nevi.

Although the 532-nm solid-state picosecond laser was cleared by the US Food and Drug Administration for tattoo removal, this laser shows potential use in other pigmentary disorders, particularly in patients with skin of color, as demonstrated in our case. With continued understanding through further studies, this picosecond laser with a shorter pulse duration may prove to be a safer and more effective alternative to the Q-switched nanosecond laser.

Conclusion

As shown in our case, the 532-nm solid-state picosecond laser appears to be a safe and effective modality for treating Ota nevi. This case demonstrates the potential utility of this laser in patients desiring more complete clearing, as it removes pigment more rapidly with lower risk for serious adverse effects. The 9th Cosmetic Surgery Forum will be held November 29-December 2, 2017, in Las Vegas, Nevada. Get more information at www.cosmeticsurgeryforum.com.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.

An individual’s identity is a learned response to social stimuli, modeling oneself to the expectations of others. Doctors are perceived to be benevolent, knowledgeable, and powerful in matters of life and death. However, a complex concept of reverse hierarchy and role disorientation can take place when a doctor becomes a patient. Because doctors dedicate much of their lives to ensuring the well-being of patients, they may have a skewed perception of their personal health risks and fail to acknowledge that they, too, can fall victim to illness. 

‘Them, not me’

Studies have found that doctors often do not advocate the same treatments for themselves than they would for their patients:

• Although most doctors recommend annual check-ups for their patients, 70% of physicians do not get one themselves.¹ 
• Doctors are more likely to recommend potentially life-saving treatment with severe side effects to their patients than for themselves.²

These studies highlight how objectivity may be absent when doctors make decisions about their own treatment, as well as the complexity associated with treating a doctor as a patient.

A doctor’s sense of identity often is strongest in a health care setting. However, becoming a patient precipitates a drastic change in authority, duty, privacy, and even attire. Earlier this year, a colleague was in the hospital for workup of a cluster of symptoms. On a personal level, she experienced a momentary loss of identity, increased anxiety, and loss of self-esteem, which reduced her ability to connect with those who, in her professional role as “doctor,” were her colleagues. Trust became a matter of contention, especially in the context of understanding the inner workings of the health care system—its limitations, risks, and the possibility of human error. Professionally, she thought some management procedures were objectionable, but quickly assumed the passive role to avoid being labeled as “difficult.”

My colleague relayed 2 interesting viewpoints. First, doctors’ detached communication style seemed to evaporate when she revealed that she also is a physician. Perhaps it was the feeling of pride or competition that comes with being responsible for a colleague’s welfare or the camaraderie that lessened the divide. Slowness to relay clinical information or disregard for transparency—sometimes seen in the inpatient setting—were not apparent during my colleague’s care. However, aspects considered trivial from a doctor’s point of view, such as pre-procedural fasting, lack of privacy, and room changes became acutely intrusive.

Second, my colleague observed that her treatment team was overly solicitous. They wanted her to be pain-free and organized “urgent” tests to minimize waiting time. She recognized that there was an overt obligation to procure excessive investigations and treatment compared with a usual patient, because there was wariness of her vigilance of when things go wrong or are overlooked.

This situation was a reminder that clinicians should be mindful of finding the middle ground between unnecessary treatment for a “doctor as patient” and uninformed treatment for a “standard patient.”

Seek to understand

Role reversal represents the fundamental skill of connecting with others through self-awareness, self-regulation, and empathy.³ Studies have found that doctors who have assumed the patient role show more empathy and possess better communication skills.⁴ The situation for the doctor who becomes a patient may be disconcerting, but the “do no harm” nature of medicine and the generally accepting demeanor of patients render the relationship between empathy and role reversal especially harmonious. Although it is comfortable and convenient to stay on one side of the relationship, grasping an emotional representation of the other side is essential. It is the process of overcoming egocentricity and perceiving the subjective experience of the other role that is rewarding. We all desire to be understood, but to be understood, we must first seek to understand.