Dermatology

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

WASHINGTON – Smartphone applications that provide advice to people about their skin lesions may provide misleading information that could result in not seeking care from a dermatologist, Suephy C. Chen, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

Even with disclaimers, there are people who want a “quick and easy answer,” and these apps can provide misleading information that “can lead them down a wrong diagnostic pathway,” said Dr. Chen, professor of dermatology and director of the teledermatology service at Emory University, Atlanta. Users not only include lower income or uninsured patients, but busy, high-powered executives.

Apps focused on photo storage are used to help patients track lesions for changes, with some apps dedicated to total body mole mapping. However, while these apps may empower patients to perform regular self skin checks, there is a question of whether they are HIPAA secure, Dr. Chen said. Another issue is that the many different app choices on the market may make it difficult for providers to keep up with which app a particular patient is using, she added. “If you have 10 different patients coming in with 10 different apps, it’s going to be really hard for you to learn all of those and be able to manipulate that easily, especially in the 15-minute slot.”

Smartphone and tablet apps that offer reminders to perform monthly skin checks or apply sunscreen when outdoors are plentiful. Dr. Chen noted that, while the efficacy of these apps are not known, they are similar to less high-tech technology like alarms or calendar reminders. “[They] are really kind of neat and fun. It’s kind of boring to just get a reminder, and you tune it out if you get a reminder on your calendars, so this may be a new way to help people,” she said.


Wearables also track users’ sun exposure, and range from a UV sensor on the thumb that measures sun exposure over a period of months to clip-on wearables and temporary tattoos that tell users when to apply or reapply sunscreen. Some devices allow entry of an individual’s Fitzpatrick skin type and can detect temperature and humidity, she noted.

Risk-calculating apps use images taken from smartphone cameras to determine the risk of melanoma, using algorithms that consider color and pattern recognition, but these apps are not as accurate as dermatologists, she said. In a study published in 2013, the app that sent images directly to a dermatologist was the most effective, compared with apps that relied on an automated algorithm to analyze the images (JAMA Dermatol. 2013 Apr;149[4]:422-6).

One of the conclusions the authors made was that feedback was slow for the one that required the image be sent to a dermatologist. “As opposed to just a minute and spitting out the result, it took 24 hours. My argument is 24 hours is still a lot faster than if you tried to call and get an appointment with a dermatologist,” Dr. Chen commented.

One step above teledermatology is teledermoscopy, or using a mobile, smartphone-attached device to send images to a dermatologist over a secure cloud service for review. “Most of us would agree that it would just take too long to do a live video with a patient,” Dr. Chen pointed out. “They may as well just come in anyway. It’ll take you 40 minutes to be able to take a look at that mole on the video, but to do it in a store-and-forward format can be quite efficient.”

However, she noted that one barrier to entry for teledermoscopy is defining the type of service, such as whether apps will offer provider-to-provider or patient-to-provider services. “That is fraught with its own details and issues, especially with photo quality.”


Another barrier, reimbursement from Centers for Medicare & Medicaid Services for teledermatology, is “the real sticking point,” Dr. Chen continued. Under a 2019 CMS Final Rule, telemedicine is only covered if the patient is already established within the practice, and reimbursement for Healthcare Common Procedure Coding System codes G2010 and G2012 relating to telemedicine ranges between $12 and $14.

Based on her back-of-the-envelope calculation, she added, “I would have to see 180 patients in a half-day session by this method in order to generate my salary, and that would just be impossible.”

Dr. Chen said that teledermatology is the “way of the future” and hopes the CMS Final Rule is reconsidered so the technology can be used to help solve some of the growing issues in the dermatology field. “There’s no way we can meet the demands of an increasingly aging population by an in-person brick and mortar sort of paradigm,” she said, noting that, even in an urban setting, it can be difficult to see a dermatologist.

Dr. Chen reports relationships with BioPharmX, Dermecular Therapeutics, Leo Pharma, Phoenix Tissue Repair, Trevi Therapeutics, and Unilever.

Risankizumab, an interleukin-23 inhibitor, has been approved by the Food and Drug Administration for treating moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy, the manufacturer announced on April 23.

Risankizumab selectively inhibits interleukin-23 (IL-23), a key inflammatory protein, by binding to its p19 subunit. The drug is administered at a dose of 150 mg, in two subcutaneous injections, every 12 weeks, after starting doses at weeks 0 and 4. It will be available in early May, according to an AbbVie press release announcing the approval.

The approval was based in part on data from two phase 3, 2-year studies, In UltIMMA-1 and UltIMMA-2, at 16 weeks, 75% of risankizumab patients in both studies achieved a Psoriasis Area and Severity Index (PASI 90), compared with 5% and 2% of those on placebo, respectively. These results were published in 2018 (Lancet. 2018 Aug 25;392[10148]:650-61).

At 1 year, 82% and 81% of those treated with risankizumab in the two studies achieved a PASI 90, and 56% and 60% achieved a PASI 100, respectively, according to the company.

Approval was also based on additional phase 3 studies, IMMhance and IMMvent.

Upper respiratory infections were among the most common adverse events associated with risankizumab in trials, reported in 13%, according to the company. Other adverse events associated with treatment included headache (3.5 %), fatigue (2.5 %), injection site reactions (1.5%) and tinea infections (1.1%). The AbbVie release states that candidates for treatment should be evaluated for tuberculosis before starting therapy, and patients should be instructed to report signs and symptoms of infection.

Risankizumab, which will be marketed as Skyrizi, was recently approved in Canada for the same indication, and in Japan, for plaque psoriasis, generalized pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis in adults. It currently is under review in Europe.

AbbVie and Boehringer Ingelheim are collaborating on the development of risankizumab, according to an AbbVie press release. Studies of risankizumab for treatment of psoriatic arthritis and Crohn’s disease are underway.

Risankizumab, an interleukin-23 inhibitor, has been approved by the Food and Drug Administration for treating moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy, the manufacturer announced on April 23.

Risankizumab selectively inhibits interleukin-23 (IL-23), a key inflammatory protein, by binding to its p19 subunit. The drug is administered at a dose of 150 mg, in two subcutaneous injections, every 12 weeks, after starting doses at weeks 0 and 4. It will be available in early May, according to an AbbVie press release announcing the approval.

The approval was based in part on data from two phase 3, 2-year studies, In UltIMMA-1 and UltIMMA-2, at 16 weeks, 75% of risankizumab patients in both studies achieved a Psoriasis Area and Severity Index (PASI 90), compared with 5% and 2% of those on placebo, respectively. These results were published in 2018 (Lancet. 2018 Aug 25;392[10148]:650-61).

At 1 year, 82% and 81% of those treated with risankizumab in the two studies achieved a PASI 90, and 56% and 60% achieved a PASI 100, respectively, according to the company.

Approval was also based on additional phase 3 studies, IMMhance and IMMvent.

Upper respiratory infections were among the most common adverse events associated with risankizumab in trials, reported in 13%, according to the company. Other adverse events associated with treatment included headache (3.5 %), fatigue (2.5 %), injection site reactions (1.5%) and tinea infections (1.1%). The AbbVie release states that candidates for treatment should be evaluated for tuberculosis before starting therapy, and patients should be instructed to report signs and symptoms of infection.

Risankizumab, which will be marketed as Skyrizi, was recently approved in Canada for the same indication, and in Japan, for plaque psoriasis, generalized pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis in adults. It currently is under review in Europe.

AbbVie and Boehringer Ingelheim are collaborating on the development of risankizumab, according to an AbbVie press release. Studies of risankizumab for treatment of psoriatic arthritis and Crohn’s disease are underway.

Risankizumab, an interleukin-23 inhibitor, has been approved by the Food and Drug Administration for treating moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy, the manufacturer announced on April 23.

Risankizumab selectively inhibits interleukin-23 (IL-23), a key inflammatory protein, by binding to its p19 subunit. The drug is administered at a dose of 150 mg, in two subcutaneous injections, every 12 weeks, after starting doses at weeks 0 and 4. It will be available in early May, according to an AbbVie press release announcing the approval.

The approval was based in part on data from two phase 3, 2-year studies, In UltIMMA-1 and UltIMMA-2, at 16 weeks, 75% of risankizumab patients in both studies achieved a Psoriasis Area and Severity Index (PASI 90), compared with 5% and 2% of those on placebo, respectively. These results were published in 2018 (Lancet. 2018 Aug 25;392[10148]:650-61).

At 1 year, 82% and 81% of those treated with risankizumab in the two studies achieved a PASI 90, and 56% and 60% achieved a PASI 100, respectively, according to the company.

Approval was also based on additional phase 3 studies, IMMhance and IMMvent.

Upper respiratory infections were among the most common adverse events associated with risankizumab in trials, reported in 13%, according to the company. Other adverse events associated with treatment included headache (3.5 %), fatigue (2.5 %), injection site reactions (1.5%) and tinea infections (1.1%). The AbbVie release states that candidates for treatment should be evaluated for tuberculosis before starting therapy, and patients should be instructed to report signs and symptoms of infection.

Risankizumab, which will be marketed as Skyrizi, was recently approved in Canada for the same indication, and in Japan, for plaque psoriasis, generalized pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis in adults. It currently is under review in Europe.

AbbVie and Boehringer Ingelheim are collaborating on the development of risankizumab, according to an AbbVie press release. Studies of risankizumab for treatment of psoriatic arthritis and Crohn’s disease are underway.

The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)

The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)

The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP considered whether this was a case of metastatic melanoma based on the appearance of the dark lesions, but thought that 22 years was a long time for a primary cancer to metastasize. After obtaining informed consent, the FP performed a 4-mm punch biopsy of one of the lesions on the patient’s trunk. (See the Watch & Learn video on “Punch biopsy.”)

The FP sutured the area closed to minimize postoperative bleeding. The pathology report came back as metastatic melanoma. Unfortunately, melanoma can return even decades after the primary tumor is excised. The FP referred the patient to a medical oncologist who specialized in melanoma treatment. Unfortunately, the patient passed away within a year of the recurrent melanoma diagnosis.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP had never seen a condition like this before, so he used some online resources to come up with a differential diagnosis that included sarcoidosis, leprosy, drug eruption, and mycosis fungoides. Aside from an occasional drug eruption, the other conditions were ones that he had seen in textbooks only.

Based on that differential diagnosis, the FP decided to do a punch biopsy of the largest nodule, which was near the patient’s mouth. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report came back as folliculotropic mycosis fungoides. The FP researched the diagnosis and determined that this was a cutaneous T-cell lymphoma that involved hair follicles and tended to occur on the head and neck. This explained the patient’s hair loss in his beard and right eyebrow. While the prognosis for mycosis fungoides is quite good, the same cannot be said for the folliculotropic variant.

The FP referred the patient to Dermatology for further evaluation and treatment. In consultation with Hematology, the patient was treated with a potent topical steroid, chemotherapy, and narrowband ultraviolet B light therapy. His condition improved, but ongoing treatment and surveillance were needed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1124-1131.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP had never seen a condition like this before, so he used some online resources to come up with a differential diagnosis that included sarcoidosis, leprosy, drug eruption, and mycosis fungoides. Aside from an occasional drug eruption, the other conditions were ones that he had seen in textbooks only.

Based on that differential diagnosis, the FP decided to do a punch biopsy of the largest nodule, which was near the patient’s mouth. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report came back as folliculotropic mycosis fungoides. The FP researched the diagnosis and determined that this was a cutaneous T-cell lymphoma that involved hair follicles and tended to occur on the head and neck. This explained the patient’s hair loss in his beard and right eyebrow. While the prognosis for mycosis fungoides is quite good, the same cannot be said for the folliculotropic variant.

The FP referred the patient to Dermatology for further evaluation and treatment. In consultation with Hematology, the patient was treated with a potent topical steroid, chemotherapy, and narrowband ultraviolet B light therapy. His condition improved, but ongoing treatment and surveillance were needed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1124-1131.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP had never seen a condition like this before, so he used some online resources to come up with a differential diagnosis that included sarcoidosis, leprosy, drug eruption, and mycosis fungoides. Aside from an occasional drug eruption, the other conditions were ones that he had seen in textbooks only.

Based on that differential diagnosis, the FP decided to do a punch biopsy of the largest nodule, which was near the patient’s mouth. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report came back as folliculotropic mycosis fungoides. The FP researched the diagnosis and determined that this was a cutaneous T-cell lymphoma that involved hair follicles and tended to occur on the head and neck. This explained the patient’s hair loss in his beard and right eyebrow. While the prognosis for mycosis fungoides is quite good, the same cannot be said for the folliculotropic variant.

The FP referred the patient to Dermatology for further evaluation and treatment. In consultation with Hematology, the patient was treated with a potent topical steroid, chemotherapy, and narrowband ultraviolet B light therapy. His condition improved, but ongoing treatment and surveillance were needed.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1124-1131.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

A 50-year-old African-American man is referred to dermatology by his primary care provider for evaluation of colored stripes in most of his fingernails. These have been present, without change, for most of his adult life.

The patient has been told these changes probably represent fungal infection, but being dubious of that diagnosis, he declined recommended treatment. Nonetheless, he is interested in knowing exactly what is happening to his nails.

He denies personal or family history of skin cancer and of excessive sun exposure. He reports that several maternal family members have similar nail changes.

EXAMINATION
Seven of the patient’s 10 fingernails demonstrate linear brown streaks that uniformly average 1.5 to 2 mm in width. The streaks run the length of the nail, with no involvement of the adjacent cuticle. Some are darker than others.

The patient has type V skin with no evidence of excessive sun damage.

What’s the diagnosis?

DISCUSSION
Fortunately, this patient’s problem is benign and likely to remain so. Termed longitudinal (or linear) melanonychia (LM), these changes are seen in nearly all African-Americans older than 50 (although it is not uncommon for the condition to develop in the third decade of life). Other populations with dark skin are also at risk for LM, albeit at far lower rates. In white populations, the incidence is around 0.5% to 1%.

LM is caused by activation and proliferation of melanocytes in the nail matrix; they are focally incorporated into the nail plate as onychocytes that grow out with the nail. Typically 1 to 3 mm in uniform width, the streaks of LM range from tan to dark brown and can be solitary or multiple in a given nail.

As mentioned, LM is entirely benign, with almost no potential for malignant transformation. However, two notes of caution are in order: First, although African-American persons generally have very low risk for melanoma, the malignancy tends to manifest in this population in areas with the least pigment (eg, palms, soles, oral cavities, nail beds—unusual locations for most other racial groups). Second, the prognosis for these types of melanomas is poor; most patients and providers are unaware of them until an advanced stage that typically includes metastasis.

Therefore, in patients with skin of color, new or changing lesions in the nail bed must be evaluated by a knowledgeable dermatology provider, who may choose to biopsy the proximal aspect of the lesion to rule out cancer. Of course, any such lesion in a white person needs to be monitored carefully as well, since linear melanonychia is relatively uncommon in this group. Changes in the width, color, or border should cause concern, as should extension of the darker color onto the adjacent cuticle.

The differential for linear discoloration in nails or nail beds includes foreign body, warts, benign tumors (eg, nevi), glomus tumors (which are usually painful), and of course, fungal, mold, or yeast infections.

TAKE-HOME LEARNING POINTS

• Longitudinal (or linear) melanonychia (LM) is quite common in African-Americans, approaching a prevalence of 100% in those older than 50.
• Having multiple LMs in more than one finger is common in this population.
• However, a new or changing subungual lesion bears close monitoring, or even biopsy, by an experienced dermatology provider.
• Although African-Americans rarely develop melanoma, when they do, it’s often in the least pigmented areas (eg, palms, soles, mouth, and nails).
• The prognosis for proven melanoma in African-American patients is poor, making close monitoring a necessity.

A 50-year-old African-American man is referred to dermatology by his primary care provider for evaluation of colored stripes in most of his fingernails. These have been present, without change, for most of his adult life.

The patient has been told these changes probably represent fungal infection, but being dubious of that diagnosis, he declined recommended treatment. Nonetheless, he is interested in knowing exactly what is happening to his nails.

He denies personal or family history of skin cancer and of excessive sun exposure. He reports that several maternal family members have similar nail changes.

EXAMINATION
Seven of the patient’s 10 fingernails demonstrate linear brown streaks that uniformly average 1.5 to 2 mm in width. The streaks run the length of the nail, with no involvement of the adjacent cuticle. Some are darker than others.

The patient has type V skin with no evidence of excessive sun damage.

What’s the diagnosis?

DISCUSSION
Fortunately, this patient’s problem is benign and likely to remain so. Termed longitudinal (or linear) melanonychia (LM), these changes are seen in nearly all African-Americans older than 50 (although it is not uncommon for the condition to develop in the third decade of life). Other populations with dark skin are also at risk for LM, albeit at far lower rates. In white populations, the incidence is around 0.5% to 1%.

LM is caused by activation and proliferation of melanocytes in the nail matrix; they are focally incorporated into the nail plate as onychocytes that grow out with the nail. Typically 1 to 3 mm in uniform width, the streaks of LM range from tan to dark brown and can be solitary or multiple in a given nail.

As mentioned, LM is entirely benign, with almost no potential for malignant transformation. However, two notes of caution are in order: First, although African-American persons generally have very low risk for melanoma, the malignancy tends to manifest in this population in areas with the least pigment (eg, palms, soles, oral cavities, nail beds—unusual locations for most other racial groups). Second, the prognosis for these types of melanomas is poor; most patients and providers are unaware of them until an advanced stage that typically includes metastasis.

Therefore, in patients with skin of color, new or changing lesions in the nail bed must be evaluated by a knowledgeable dermatology provider, who may choose to biopsy the proximal aspect of the lesion to rule out cancer. Of course, any such lesion in a white person needs to be monitored carefully as well, since linear melanonychia is relatively uncommon in this group. Changes in the width, color, or border should cause concern, as should extension of the darker color onto the adjacent cuticle.

The differential for linear discoloration in nails or nail beds includes foreign body, warts, benign tumors (eg, nevi), glomus tumors (which are usually painful), and of course, fungal, mold, or yeast infections.

TAKE-HOME LEARNING POINTS

• Longitudinal (or linear) melanonychia (LM) is quite common in African-Americans, approaching a prevalence of 100% in those older than 50.
• Having multiple LMs in more than one finger is common in this population.
• However, a new or changing subungual lesion bears close monitoring, or even biopsy, by an experienced dermatology provider.
• Although African-Americans rarely develop melanoma, when they do, it’s often in the least pigmented areas (eg, palms, soles, mouth, and nails).
• The prognosis for proven melanoma in African-American patients is poor, making close monitoring a necessity.

A 50-year-old African-American man is referred to dermatology by his primary care provider for evaluation of colored stripes in most of his fingernails. These have been present, without change, for most of his adult life.

The patient has been told these changes probably represent fungal infection, but being dubious of that diagnosis, he declined recommended treatment. Nonetheless, he is interested in knowing exactly what is happening to his nails.

He denies personal or family history of skin cancer and of excessive sun exposure. He reports that several maternal family members have similar nail changes.

EXAMINATION
Seven of the patient’s 10 fingernails demonstrate linear brown streaks that uniformly average 1.5 to 2 mm in width. The streaks run the length of the nail, with no involvement of the adjacent cuticle. Some are darker than others.

The patient has type V skin with no evidence of excessive sun damage.

What’s the diagnosis?

DISCUSSION
Fortunately, this patient’s problem is benign and likely to remain so. Termed longitudinal (or linear) melanonychia (LM), these changes are seen in nearly all African-Americans older than 50 (although it is not uncommon for the condition to develop in the third decade of life). Other populations with dark skin are also at risk for LM, albeit at far lower rates. In white populations, the incidence is around 0.5% to 1%.

LM is caused by activation and proliferation of melanocytes in the nail matrix; they are focally incorporated into the nail plate as onychocytes that grow out with the nail. Typically 1 to 3 mm in uniform width, the streaks of LM range from tan to dark brown and can be solitary or multiple in a given nail.

As mentioned, LM is entirely benign, with almost no potential for malignant transformation. However, two notes of caution are in order: First, although African-American persons generally have very low risk for melanoma, the malignancy tends to manifest in this population in areas with the least pigment (eg, palms, soles, oral cavities, nail beds—unusual locations for most other racial groups). Second, the prognosis for these types of melanomas is poor; most patients and providers are unaware of them until an advanced stage that typically includes metastasis.

Therefore, in patients with skin of color, new or changing lesions in the nail bed must be evaluated by a knowledgeable dermatology provider, who may choose to biopsy the proximal aspect of the lesion to rule out cancer. Of course, any such lesion in a white person needs to be monitored carefully as well, since linear melanonychia is relatively uncommon in this group. Changes in the width, color, or border should cause concern, as should extension of the darker color onto the adjacent cuticle.

The differential for linear discoloration in nails or nail beds includes foreign body, warts, benign tumors (eg, nevi), glomus tumors (which are usually painful), and of course, fungal, mold, or yeast infections.

TAKE-HOME LEARNING POINTS

• Longitudinal (or linear) melanonychia (LM) is quite common in African-Americans, approaching a prevalence of 100% in those older than 50.
• Having multiple LMs in more than one finger is common in this population.
• However, a new or changing subungual lesion bears close monitoring, or even biopsy, by an experienced dermatology provider.
• Although African-Americans rarely develop melanoma, when they do, it’s often in the least pigmented areas (eg, palms, soles, mouth, and nails).
• The prognosis for proven melanoma in African-American patients is poor, making close monitoring a necessity.

Treatment failure and the adverse effects of traditional psoriasis medications increasingly are driving patients to complementary and alternative medicines (CAMs), despite limited documentation supporting their efficacy, reported Emily C. Murphy and her associates, in the department of dermatology, George Washington University, Washington.

They performed a survey-based statistical analysis to identify specific types of commonly used CAMs, and to explore reasons patients increasingly turn to alternative therapies. The survey was distributed in the National Psoriasis Foundation’s (NPF) October 2018 newsletter to its 100,927 members. Their results were published in a letter to the editor of the Journal of the American Academy of Dermatology.

Of the 6,101 NPF members who opened the newsletter, 324 clicked on the survey link. Of the 219 who completed the survey, almost 70% were women. The majority were white (84.1%), compared with Hispanic (6.2%), Asian (3.1%), and black (2.6%) participants. Most of the survey respondents had a dermatologist diagnosis of psoriasis, as well as access to health insurance to cover any prescribed medicines needed.

Of the 41% of respondents who reported using alternative therapies, usage was especially high among those who considered their psoriasis as severe (50% vs. 33.6% of those with nonsevere disease). Among the respondents, women were more likely than were men to use CAMs (45.6% vs. 26.5%, P = .002).

Only 4% cited access to care as a reason for choosing alternative therapies; the majority said they used CAMs because “traditional medications did not help or had side effects.”

While men were more likely than were women to use vitamins (24% vs. 18.9%, respectively), Dead Sea bath salts (17% vs. 7.8%), and cupping (3% vs. 0.8%), women were more likely to use herbals/botanicals (17% vs. 14%) and yoga (9.6% vs. 2%).

Patients with moderate psoriasis were significantly more likely than were those with mild or severe cases of the disease to recommend CAMs, regardless of insurance status (52.4% vs. 35% among those with mild disease and 40.4% for those with severe disease).

For some of the commonly used treatments, such as vitamins D and B₁₂, there is insufficient evidence documenting their efficacy, although Dead Sea treatments have been shown to have therapeutic effects. And while there is efficacy evidence for indigo naturalis and meditation, these were not mentioned or were not commonly reported by respondents, the authors pointed out.

Although just 43% of patients said they would recommend a CAM to other people with psoriasis, its use remains widespread. For this reason, “educational initiatives that enable physicians to discuss evidence-based CAMs may improve patient satisfaction and outcomes,” observed Ms. Murphy, a research fellow, and her associates.

Previous studies have cited rates of CAM usage among patients with psoriasis as high as 62%, but researchers have failed to examine the reasons motivating usage. Not surprisingly, patients often use but misunderstand the benefits of alternative therapies.

“The onus is on us as physicians to not only ask our patients if they are using nonallopathic therapies for their psoriasis, but also to create an accepting environment that enables further discussion regarding said treatments to ensure patient safety and ultimately good outcomes,” senior author Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, said in an interview.

The authors had no financial sources or conflicts of interest to disclose; there was no funding source.

SOURCE: Murphy E et al. J Am Acad Dermatol. 2019 Mar 29. pii: S0190-9622(19)30503-1. doi: 10.1016/j.jaad.2019.03.059.

Treatment failure and the adverse effects of traditional psoriasis medications increasingly are driving patients to complementary and alternative medicines (CAMs), despite limited documentation supporting their efficacy, reported Emily C. Murphy and her associates, in the department of dermatology, George Washington University, Washington.

They performed a survey-based statistical analysis to identify specific types of commonly used CAMs, and to explore reasons patients increasingly turn to alternative therapies. The survey was distributed in the National Psoriasis Foundation’s (NPF) October 2018 newsletter to its 100,927 members. Their results were published in a letter to the editor of the Journal of the American Academy of Dermatology.

Of the 6,101 NPF members who opened the newsletter, 324 clicked on the survey link. Of the 219 who completed the survey, almost 70% were women. The majority were white (84.1%), compared with Hispanic (6.2%), Asian (3.1%), and black (2.6%) participants. Most of the survey respondents had a dermatologist diagnosis of psoriasis, as well as access to health insurance to cover any prescribed medicines needed.

Of the 41% of respondents who reported using alternative therapies, usage was especially high among those who considered their psoriasis as severe (50% vs. 33.6% of those with nonsevere disease). Among the respondents, women were more likely than were men to use CAMs (45.6% vs. 26.5%, P = .002).

Only 4% cited access to care as a reason for choosing alternative therapies; the majority said they used CAMs because “traditional medications did not help or had side effects.”

While men were more likely than were women to use vitamins (24% vs. 18.9%, respectively), Dead Sea bath salts (17% vs. 7.8%), and cupping (3% vs. 0.8%), women were more likely to use herbals/botanicals (17% vs. 14%) and yoga (9.6% vs. 2%).

Patients with moderate psoriasis were significantly more likely than were those with mild or severe cases of the disease to recommend CAMs, regardless of insurance status (52.4% vs. 35% among those with mild disease and 40.4% for those with severe disease).

For some of the commonly used treatments, such as vitamins D and B₁₂, there is insufficient evidence documenting their efficacy, although Dead Sea treatments have been shown to have therapeutic effects. And while there is efficacy evidence for indigo naturalis and meditation, these were not mentioned or were not commonly reported by respondents, the authors pointed out.

Although just 43% of patients said they would recommend a CAM to other people with psoriasis, its use remains widespread. For this reason, “educational initiatives that enable physicians to discuss evidence-based CAMs may improve patient satisfaction and outcomes,” observed Ms. Murphy, a research fellow, and her associates.

Previous studies have cited rates of CAM usage among patients with psoriasis as high as 62%, but researchers have failed to examine the reasons motivating usage. Not surprisingly, patients often use but misunderstand the benefits of alternative therapies.

“The onus is on us as physicians to not only ask our patients if they are using nonallopathic therapies for their psoriasis, but also to create an accepting environment that enables further discussion regarding said treatments to ensure patient safety and ultimately good outcomes,” senior author Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, said in an interview.

The authors had no financial sources or conflicts of interest to disclose; there was no funding source.

SOURCE: Murphy E et al. J Am Acad Dermatol. 2019 Mar 29. pii: S0190-9622(19)30503-1. doi: 10.1016/j.jaad.2019.03.059.

Treatment failure and the adverse effects of traditional psoriasis medications increasingly are driving patients to complementary and alternative medicines (CAMs), despite limited documentation supporting their efficacy, reported Emily C. Murphy and her associates, in the department of dermatology, George Washington University, Washington.

They performed a survey-based statistical analysis to identify specific types of commonly used CAMs, and to explore reasons patients increasingly turn to alternative therapies. The survey was distributed in the National Psoriasis Foundation’s (NPF) October 2018 newsletter to its 100,927 members. Their results were published in a letter to the editor of the Journal of the American Academy of Dermatology.

Of the 6,101 NPF members who opened the newsletter, 324 clicked on the survey link. Of the 219 who completed the survey, almost 70% were women. The majority were white (84.1%), compared with Hispanic (6.2%), Asian (3.1%), and black (2.6%) participants. Most of the survey respondents had a dermatologist diagnosis of psoriasis, as well as access to health insurance to cover any prescribed medicines needed.

Of the 41% of respondents who reported using alternative therapies, usage was especially high among those who considered their psoriasis as severe (50% vs. 33.6% of those with nonsevere disease). Among the respondents, women were more likely than were men to use CAMs (45.6% vs. 26.5%, P = .002).

Only 4% cited access to care as a reason for choosing alternative therapies; the majority said they used CAMs because “traditional medications did not help or had side effects.”

While men were more likely than were women to use vitamins (24% vs. 18.9%, respectively), Dead Sea bath salts (17% vs. 7.8%), and cupping (3% vs. 0.8%), women were more likely to use herbals/botanicals (17% vs. 14%) and yoga (9.6% vs. 2%).

Patients with moderate psoriasis were significantly more likely than were those with mild or severe cases of the disease to recommend CAMs, regardless of insurance status (52.4% vs. 35% among those with mild disease and 40.4% for those with severe disease).

For some of the commonly used treatments, such as vitamins D and B₁₂, there is insufficient evidence documenting their efficacy, although Dead Sea treatments have been shown to have therapeutic effects. And while there is efficacy evidence for indigo naturalis and meditation, these were not mentioned or were not commonly reported by respondents, the authors pointed out.

Although just 43% of patients said they would recommend a CAM to other people with psoriasis, its use remains widespread. For this reason, “educational initiatives that enable physicians to discuss evidence-based CAMs may improve patient satisfaction and outcomes,” observed Ms. Murphy, a research fellow, and her associates.

Previous studies have cited rates of CAM usage among patients with psoriasis as high as 62%, but researchers have failed to examine the reasons motivating usage. Not surprisingly, patients often use but misunderstand the benefits of alternative therapies.

“The onus is on us as physicians to not only ask our patients if they are using nonallopathic therapies for their psoriasis, but also to create an accepting environment that enables further discussion regarding said treatments to ensure patient safety and ultimately good outcomes,” senior author Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, said in an interview.

The authors had no financial sources or conflicts of interest to disclose; there was no funding source.

SOURCE: Murphy E et al. J Am Acad Dermatol. 2019 Mar 29. pii: S0190-9622(19)30503-1. doi: 10.1016/j.jaad.2019.03.059.

WASHINGTON – Patients with spontaneous chronic urticaria treated with the investigational anti-IgE monoclonal antibody ligelizumab experienced up to a year of symptom control in an open-label extension study, Diane Baker, MD, said at the annual meeting of the American Academy of Dermatology.

About 75% of the cohort experienced complete disease control at least once during the study. Novartis is developing ligelizumab (QGE031) as a treatment option for patients with spontaneous chronic urticaria (CSU) whose symptoms are inadequately controlled by H₁-antihistamines. Like omalizumab (Xolair), which is approved in the United States and Europe for treatment of CSU, ligelizumab is a humanized anti-IgE monoclonal antibody. But the investigational agent binds to IgE with greater affinity than omalizumab, said Dr. Baker, a dermatologist who practices in Portland, Ore.

The extension study was a follow-up to a 12-week, phase 2, dose-finding trial of 382 CSU patients. In the study, which was not powered for efficacy endpoints, 51% of those who received 72 mg subcutaneously every 4 weeks had a Hives Severity Score of 0 by week 12, compared with 42% of those who received 240 mg every 4 weeks and 26% of those taking the omalizumab comparator. Additionally, 47% of those in the 72-mg group and 46% of the 240-mg group achieved a score of 0 on another indicator, the Urticaria Activity Score, which measures symptoms over 7 days (UAS7).

The extension study, which evaluated the 240-mg dose, showed the durability of that response, with 52% of those in the 240-mg group maintained a UAS7 of 0 at 1 year, according to Dr. Baker. By the end of the year, most patients (75.8%) had experienced at least one period of complete symptom control, and 84.0% experienced a UAS of 6 or lower at least once.

Adverse events were common in the cohort, with 84% experiencing at least one. But most (78%) were mild or moderate, and there was no clear side effect pattern, Dr. Baker said. Eight patients discontinued treatment because of an adverse event, and another eight dropped out because of lack of efficacy. Other reasons for discontinuation were pregnancy, protocol deviation, and physician or patient decision.

Novartis has launched two 1-year, phase 3 trials randomizing patients to 72 mg or 240 mg of ligelizumab or 300 mg of omalizumab every 4 weeks in a similar patient population, Dr. Baker said. PEARL 1 and PEARL 2, the largest pivotal trials to date in CSU, will enroll more than 2,000 patients, according to a company press release.

Dr. Baker is a clinical trials investigator for Novartis.

msullivan@mdedge.com

SOURCE: Baker D et al. AAD 2019, Session S034.

WASHINGTON – Patients with spontaneous chronic urticaria treated with the investigational anti-IgE monoclonal antibody ligelizumab experienced up to a year of symptom control in an open-label extension study, Diane Baker, MD, said at the annual meeting of the American Academy of Dermatology.

About 75% of the cohort experienced complete disease control at least once during the study. Novartis is developing ligelizumab (QGE031) as a treatment option for patients with spontaneous chronic urticaria (CSU) whose symptoms are inadequately controlled by H₁-antihistamines. Like omalizumab (Xolair), which is approved in the United States and Europe for treatment of CSU, ligelizumab is a humanized anti-IgE monoclonal antibody. But the investigational agent binds to IgE with greater affinity than omalizumab, said Dr. Baker, a dermatologist who practices in Portland, Ore.

The extension study was a follow-up to a 12-week, phase 2, dose-finding trial of 382 CSU patients. In the study, which was not powered for efficacy endpoints, 51% of those who received 72 mg subcutaneously every 4 weeks had a Hives Severity Score of 0 by week 12, compared with 42% of those who received 240 mg every 4 weeks and 26% of those taking the omalizumab comparator. Additionally, 47% of those in the 72-mg group and 46% of the 240-mg group achieved a score of 0 on another indicator, the Urticaria Activity Score, which measures symptoms over 7 days (UAS7).

The extension study, which evaluated the 240-mg dose, showed the durability of that response, with 52% of those in the 240-mg group maintained a UAS7 of 0 at 1 year, according to Dr. Baker. By the end of the year, most patients (75.8%) had experienced at least one period of complete symptom control, and 84.0% experienced a UAS of 6 or lower at least once.

Adverse events were common in the cohort, with 84% experiencing at least one. But most (78%) were mild or moderate, and there was no clear side effect pattern, Dr. Baker said. Eight patients discontinued treatment because of an adverse event, and another eight dropped out because of lack of efficacy. Other reasons for discontinuation were pregnancy, protocol deviation, and physician or patient decision.

Novartis has launched two 1-year, phase 3 trials randomizing patients to 72 mg or 240 mg of ligelizumab or 300 mg of omalizumab every 4 weeks in a similar patient population, Dr. Baker said. PEARL 1 and PEARL 2, the largest pivotal trials to date in CSU, will enroll more than 2,000 patients, according to a company press release.

Dr. Baker is a clinical trials investigator for Novartis.

msullivan@mdedge.com

SOURCE: Baker D et al. AAD 2019, Session S034.

WASHINGTON – Patients with spontaneous chronic urticaria treated with the investigational anti-IgE monoclonal antibody ligelizumab experienced up to a year of symptom control in an open-label extension study, Diane Baker, MD, said at the annual meeting of the American Academy of Dermatology.

About 75% of the cohort experienced complete disease control at least once during the study. Novartis is developing ligelizumab (QGE031) as a treatment option for patients with spontaneous chronic urticaria (CSU) whose symptoms are inadequately controlled by H₁-antihistamines. Like omalizumab (Xolair), which is approved in the United States and Europe for treatment of CSU, ligelizumab is a humanized anti-IgE monoclonal antibody. But the investigational agent binds to IgE with greater affinity than omalizumab, said Dr. Baker, a dermatologist who practices in Portland, Ore.

The extension study was a follow-up to a 12-week, phase 2, dose-finding trial of 382 CSU patients. In the study, which was not powered for efficacy endpoints, 51% of those who received 72 mg subcutaneously every 4 weeks had a Hives Severity Score of 0 by week 12, compared with 42% of those who received 240 mg every 4 weeks and 26% of those taking the omalizumab comparator. Additionally, 47% of those in the 72-mg group and 46% of the 240-mg group achieved a score of 0 on another indicator, the Urticaria Activity Score, which measures symptoms over 7 days (UAS7).

The extension study, which evaluated the 240-mg dose, showed the durability of that response, with 52% of those in the 240-mg group maintained a UAS7 of 0 at 1 year, according to Dr. Baker. By the end of the year, most patients (75.8%) had experienced at least one period of complete symptom control, and 84.0% experienced a UAS of 6 or lower at least once.

Adverse events were common in the cohort, with 84% experiencing at least one. But most (78%) were mild or moderate, and there was no clear side effect pattern, Dr. Baker said. Eight patients discontinued treatment because of an adverse event, and another eight dropped out because of lack of efficacy. Other reasons for discontinuation were pregnancy, protocol deviation, and physician or patient decision.

Novartis has launched two 1-year, phase 3 trials randomizing patients to 72 mg or 240 mg of ligelizumab or 300 mg of omalizumab every 4 weeks in a similar patient population, Dr. Baker said. PEARL 1 and PEARL 2, the largest pivotal trials to date in CSU, will enroll more than 2,000 patients, according to a company press release.

Dr. Baker is a clinical trials investigator for Novartis.

msullivan@mdedge.com

SOURCE: Baker D et al. AAD 2019, Session S034.

The FP was extremely concerned that this was a large melanoma due the lesion’s chaotic appearance, with multiple colors and an irregular border. Going through the ABCDE criteria, he noted that the lesion was Asymmetric, the Border was irregular, the Colors were varied, the Diameter was > 6 mm, and it was Enlarging by history.

With his dermatoscope attached to his smart phone, the FP looked at the lesion and took a photograph (Figure B). The image revealed a pigment network of the original nevus at 5:00 to 6:00 o’clock and extensions of the tumor due to in-transit metastases. Satellites were visible, especially in the top right and left corners. The FP noted the shiny white lines caused by collagen deposition found in growing tumors. (See “Dermoscopy in family medicine: A primer.”)

The FP knew that the mass needed to be biopsied, but because of its size, the best he could do would be to perform a partial biopsy. So on the day of presentation, the FP performed a 6-mm punch biopsy in the most raised area of the lesion to try and get sufficient depth and breadth for diagnosis and prognosis. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report indicated that the lesion was a nodular melanoma with a Breslow depth of 5.5 mm. This melanoma arose in a nevus, which occurs in about 30% of melanomas. Most melanomas arise de novo.

The FP referred the patient to a surgical oncologist for an excision with 2 cm margins and a sentinel lymph node biopsy. The sentinel node was in the right axilla and was remarkably negative despite the local in-transit metastases/satellites. One year after the original diagnosis was made, there was no evidence of metastatic disease and no new melanomas. The patient follows up with the dermatologist for skin and lymph node surveillance every 3 months.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP was extremely concerned that this was a large melanoma due the lesion’s chaotic appearance, with multiple colors and an irregular border. Going through the ABCDE criteria, he noted that the lesion was Asymmetric, the Border was irregular, the Colors were varied, the Diameter was > 6 mm, and it was Enlarging by history.

With his dermatoscope attached to his smart phone, the FP looked at the lesion and took a photograph (Figure B). The image revealed a pigment network of the original nevus at 5:00 to 6:00 o’clock and extensions of the tumor due to in-transit metastases. Satellites were visible, especially in the top right and left corners. The FP noted the shiny white lines caused by collagen deposition found in growing tumors. (See “Dermoscopy in family medicine: A primer.”)

The FP knew that the mass needed to be biopsied, but because of its size, the best he could do would be to perform a partial biopsy. So on the day of presentation, the FP performed a 6-mm punch biopsy in the most raised area of the lesion to try and get sufficient depth and breadth for diagnosis and prognosis. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report indicated that the lesion was a nodular melanoma with a Breslow depth of 5.5 mm. This melanoma arose in a nevus, which occurs in about 30% of melanomas. Most melanomas arise de novo.

The FP referred the patient to a surgical oncologist for an excision with 2 cm margins and a sentinel lymph node biopsy. The sentinel node was in the right axilla and was remarkably negative despite the local in-transit metastases/satellites. One year after the original diagnosis was made, there was no evidence of metastatic disease and no new melanomas. The patient follows up with the dermatologist for skin and lymph node surveillance every 3 months.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP was extremely concerned that this was a large melanoma due the lesion’s chaotic appearance, with multiple colors and an irregular border. Going through the ABCDE criteria, he noted that the lesion was Asymmetric, the Border was irregular, the Colors were varied, the Diameter was > 6 mm, and it was Enlarging by history.

With his dermatoscope attached to his smart phone, the FP looked at the lesion and took a photograph (Figure B). The image revealed a pigment network of the original nevus at 5:00 to 6:00 o’clock and extensions of the tumor due to in-transit metastases. Satellites were visible, especially in the top right and left corners. The FP noted the shiny white lines caused by collagen deposition found in growing tumors. (See “Dermoscopy in family medicine: A primer.”)

The FP knew that the mass needed to be biopsied, but because of its size, the best he could do would be to perform a partial biopsy. So on the day of presentation, the FP performed a 6-mm punch biopsy in the most raised area of the lesion to try and get sufficient depth and breadth for diagnosis and prognosis. (See the Watch & Learn video on “Punch biopsy.”)

The pathology report indicated that the lesion was a nodular melanoma with a Breslow depth of 5.5 mm. This melanoma arose in a nevus, which occurs in about 30% of melanomas. Most melanomas arise de novo.

The FP referred the patient to a surgical oncologist for an excision with 2 cm margins and a sentinel lymph node biopsy. The sentinel node was in the right axilla and was remarkably negative despite the local in-transit metastases/satellites. One year after the original diagnosis was made, there was no evidence of metastatic disease and no new melanomas. The patient follows up with the dermatologist for skin and lymph node surveillance every 3 months.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com