COPENHAGEN – Half of patients with ileocecal Crohn’s disease who undergo ileocecal resection within a year of diagnosis remain off drug treatment 5 years post procedure, challenging the current paradigm of reserving surgery for complicated Crohn’s disease, show real-world data comparing outcomes of surgery with anti–tumor necrosis factor inhibitor (TNFi) therapy.

“These data show that resection of inflamed bowel in early ileocecal Crohn’s disease effectively resets the clock,” said Manasi Agrawal, MD, of the department of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and a research associate with the Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, who presented the findings at the annual congress of the European Crohn’s and Colitis Organisation. “These data are in accordance with the LIR!C study data and suggest that ileocecal resection could be a first-line therapeutic option in early ileal or ileocecal Crohn’s disease that could be discussed with our patients.”

While ileocecal resection is accepted as a therapeutic option in early Crohn’s disease, most clinicians reserve it for complicated disease that is refractory or intolerant to medication.

A radical shift in approach might be justified, said Jean-Frederic Colombel, MD, a study coinvestigator and gastroenterologist at Mount Sinai Hospital.

“These data can be transforming. It confirms that there may be a subset of patients with limited ileal Crohn’s disease that is uncomplicated and in whom surgery may be almost ‘curative’ because after follow-up there was no need for drug therapy. We need to reposition surgery as one possible option at diagnosis in patients with limited Crohn’s disease,” he said.

The 2017 LIR!C trial demonstrated comparable 1-year outcomes with ileocecal resection and anti-TNFi therapy in limited, nonstricturing ileocecal Crohn’s disease. A retrospective analysis of 5-year data from this trial, further reinforced ileocecal resection as a first-line option for limited Crohn’s disease, such that of those patients who underwent resection, 26% continued on anti-TNFi therapy, compared with 38% in those patients who took anti-TNFi therapy only. In addition, no patient in the resection group underwent subsequent surgery, whereas 48% of patients on anti-TNF underwent surgery.

Dr. Agrawal and coinvestigators decided that more conclusive, real-world data were needed and would help to determine whether ileocecal resection offered better patient outcomes than staying on anti-TNFi therapy.

The new findings are based on an analysis of 16,443 adults living with ileal Crohn’s disease and were diagnosed between 2003 and 2018. The data is based on an analysis of nationwide Danish registries. It included individuals who underwent

Ileocecal resection or received anti-TNF drugs within 1 year of diagnosis. Of the 16,443 patients diagnosed with Crohn’s disease over the study period, 1,279 had ileal or ileocecal disease and were included with 581 (3.5%) undergoing resection and 698 (4.2%) anti-TNFi index therapy.

Outcomes were compared between the two groups, and the proportions of individuals initiated on immunomodulator, anti-TNFi therapy, or no therapy at 5 years after their ileocecal resection were determined.

The primary outcome was CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. Crohn’s disease–related hospitalization, systemic corticosteroid use, Crohn’s disease–related surgery or perianal Crohn’s disease occurred in 273 versus 318 people in the ileocecal resection and anti-TNFi therapy groups respectively, equating to a 33% lower risk in the resection group. Of those patients who underwent ileocecal resection, 50.3% were on no treatment 5 years later; 47.5% and 17.1% were on immunomodulators and on anti-TNFi therapy respectively.

Resection was found to be associated with a statistically significant reduced risk of systemic corticosteroid use with an adjusted hazard ratio of 0.71 (95% confidence interval, 0.54-0.92). No statistically significant reduced risk was found for Crohn’s disease-related hospitalization (aHR, 0.79; 95% CI, 0.61-1.01) or perianal Crohn’s disease diagnosis (aHR, 0.70; 95% CI, 0.38-1.30). Adjustments were made for demographic and clinical variables, for example, age, sex, year of treatment, number of hospital contacts for an indication all in the year prior to index treatment.

In comparison with the proportion of resection patients at 5 years who were on no treatment, immunomodulators or anti-TNFi therapy, there are no data on the 5-year outcomes of those patients who began on anti-TNFi therapy, but patients typically continue unless they become intolerant or response starts to fail, Dr. Agrawal said.

Willem Bemelmen, MD, a colorectal surgeon from the University of Amsterdam who served as a moderator after the presentation said: “These results could lead to a paradigm shift in the management of patients with Crohn’s disease. Prior studies gave us early signals that surgery in Crohn’s disease might benefit the patients, but now with these larger scale data, with many patients, we might finally convince gastroenterologists to send patients in for early surgery.”

Dr. Agrawal, Dr. Bemelmen, and Dr. Colombel declared no relevant conflicts of interest.

This article was updated 3/7/23.

COPENHAGEN – Half of patients with ileocecal Crohn’s disease who undergo ileocecal resection within a year of diagnosis remain off drug treatment 5 years post procedure, challenging the current paradigm of reserving surgery for complicated Crohn’s disease, show real-world data comparing outcomes of surgery with anti–tumor necrosis factor inhibitor (TNFi) therapy.

“These data show that resection of inflamed bowel in early ileocecal Crohn’s disease effectively resets the clock,” said Manasi Agrawal, MD, of the department of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and a research associate with the Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, who presented the findings at the annual congress of the European Crohn’s and Colitis Organisation. “These data are in accordance with the LIR!C study data and suggest that ileocecal resection could be a first-line therapeutic option in early ileal or ileocecal Crohn’s disease that could be discussed with our patients.”

While ileocecal resection is accepted as a therapeutic option in early Crohn’s disease, most clinicians reserve it for complicated disease that is refractory or intolerant to medication.

A radical shift in approach might be justified, said Jean-Frederic Colombel, MD, a study coinvestigator and gastroenterologist at Mount Sinai Hospital.

“These data can be transforming. It confirms that there may be a subset of patients with limited ileal Crohn’s disease that is uncomplicated and in whom surgery may be almost ‘curative’ because after follow-up there was no need for drug therapy. We need to reposition surgery as one possible option at diagnosis in patients with limited Crohn’s disease,” he said.

The 2017 LIR!C trial demonstrated comparable 1-year outcomes with ileocecal resection and anti-TNFi therapy in limited, nonstricturing ileocecal Crohn’s disease. A retrospective analysis of 5-year data from this trial, further reinforced ileocecal resection as a first-line option for limited Crohn’s disease, such that of those patients who underwent resection, 26% continued on anti-TNFi therapy, compared with 38% in those patients who took anti-TNFi therapy only. In addition, no patient in the resection group underwent subsequent surgery, whereas 48% of patients on anti-TNF underwent surgery.

Dr. Agrawal and coinvestigators decided that more conclusive, real-world data were needed and would help to determine whether ileocecal resection offered better patient outcomes than staying on anti-TNFi therapy.

The new findings are based on an analysis of 16,443 adults living with ileal Crohn’s disease and were diagnosed between 2003 and 2018. The data is based on an analysis of nationwide Danish registries. It included individuals who underwent

Ileocecal resection or received anti-TNF drugs within 1 year of diagnosis. Of the 16,443 patients diagnosed with Crohn’s disease over the study period, 1,279 had ileal or ileocecal disease and were included with 581 (3.5%) undergoing resection and 698 (4.2%) anti-TNFi index therapy.

Outcomes were compared between the two groups, and the proportions of individuals initiated on immunomodulator, anti-TNFi therapy, or no therapy at 5 years after their ileocecal resection were determined.

The primary outcome was CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. Crohn’s disease–related hospitalization, systemic corticosteroid use, Crohn’s disease–related surgery or perianal Crohn’s disease occurred in 273 versus 318 people in the ileocecal resection and anti-TNFi therapy groups respectively, equating to a 33% lower risk in the resection group. Of those patients who underwent ileocecal resection, 50.3% were on no treatment 5 years later; 47.5% and 17.1% were on immunomodulators and on anti-TNFi therapy respectively.

Resection was found to be associated with a statistically significant reduced risk of systemic corticosteroid use with an adjusted hazard ratio of 0.71 (95% confidence interval, 0.54-0.92). No statistically significant reduced risk was found for Crohn’s disease-related hospitalization (aHR, 0.79; 95% CI, 0.61-1.01) or perianal Crohn’s disease diagnosis (aHR, 0.70; 95% CI, 0.38-1.30). Adjustments were made for demographic and clinical variables, for example, age, sex, year of treatment, number of hospital contacts for an indication all in the year prior to index treatment.

In comparison with the proportion of resection patients at 5 years who were on no treatment, immunomodulators or anti-TNFi therapy, there are no data on the 5-year outcomes of those patients who began on anti-TNFi therapy, but patients typically continue unless they become intolerant or response starts to fail, Dr. Agrawal said.

Willem Bemelmen, MD, a colorectal surgeon from the University of Amsterdam who served as a moderator after the presentation said: “These results could lead to a paradigm shift in the management of patients with Crohn’s disease. Prior studies gave us early signals that surgery in Crohn’s disease might benefit the patients, but now with these larger scale data, with many patients, we might finally convince gastroenterologists to send patients in for early surgery.”

Dr. Agrawal, Dr. Bemelmen, and Dr. Colombel declared no relevant conflicts of interest.

This article was updated 3/7/23.

COPENHAGEN – Half of patients with ileocecal Crohn’s disease who undergo ileocecal resection within a year of diagnosis remain off drug treatment 5 years post procedure, challenging the current paradigm of reserving surgery for complicated Crohn’s disease, show real-world data comparing outcomes of surgery with anti–tumor necrosis factor inhibitor (TNFi) therapy.

“These data show that resection of inflamed bowel in early ileocecal Crohn’s disease effectively resets the clock,” said Manasi Agrawal, MD, of the department of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and a research associate with the Center for Molecular Prediction of Inflammatory Bowel Disease, Aalborg University, Copenhagen, who presented the findings at the annual congress of the European Crohn’s and Colitis Organisation. “These data are in accordance with the LIR!C study data and suggest that ileocecal resection could be a first-line therapeutic option in early ileal or ileocecal Crohn’s disease that could be discussed with our patients.”

While ileocecal resection is accepted as a therapeutic option in early Crohn’s disease, most clinicians reserve it for complicated disease that is refractory or intolerant to medication.

A radical shift in approach might be justified, said Jean-Frederic Colombel, MD, a study coinvestigator and gastroenterologist at Mount Sinai Hospital.

“These data can be transforming. It confirms that there may be a subset of patients with limited ileal Crohn’s disease that is uncomplicated and in whom surgery may be almost ‘curative’ because after follow-up there was no need for drug therapy. We need to reposition surgery as one possible option at diagnosis in patients with limited Crohn’s disease,” he said.

The 2017 LIR!C trial demonstrated comparable 1-year outcomes with ileocecal resection and anti-TNFi therapy in limited, nonstricturing ileocecal Crohn’s disease. A retrospective analysis of 5-year data from this trial, further reinforced ileocecal resection as a first-line option for limited Crohn’s disease, such that of those patients who underwent resection, 26% continued on anti-TNFi therapy, compared with 38% in those patients who took anti-TNFi therapy only. In addition, no patient in the resection group underwent subsequent surgery, whereas 48% of patients on anti-TNF underwent surgery.

Dr. Agrawal and coinvestigators decided that more conclusive, real-world data were needed and would help to determine whether ileocecal resection offered better patient outcomes than staying on anti-TNFi therapy.

The new findings are based on an analysis of 16,443 adults living with ileal Crohn’s disease and were diagnosed between 2003 and 2018. The data is based on an analysis of nationwide Danish registries. It included individuals who underwent

Ileocecal resection or received anti-TNF drugs within 1 year of diagnosis. Of the 16,443 patients diagnosed with Crohn’s disease over the study period, 1,279 had ileal or ileocecal disease and were included with 581 (3.5%) undergoing resection and 698 (4.2%) anti-TNFi index therapy.

Outcomes were compared between the two groups, and the proportions of individuals initiated on immunomodulator, anti-TNFi therapy, or no therapy at 5 years after their ileocecal resection were determined.

The primary outcome was CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. Crohn’s disease–related hospitalization, systemic corticosteroid use, Crohn’s disease–related surgery or perianal Crohn’s disease occurred in 273 versus 318 people in the ileocecal resection and anti-TNFi therapy groups respectively, equating to a 33% lower risk in the resection group. Of those patients who underwent ileocecal resection, 50.3% were on no treatment 5 years later; 47.5% and 17.1% were on immunomodulators and on anti-TNFi therapy respectively.

Resection was found to be associated with a statistically significant reduced risk of systemic corticosteroid use with an adjusted hazard ratio of 0.71 (95% confidence interval, 0.54-0.92). No statistically significant reduced risk was found for Crohn’s disease-related hospitalization (aHR, 0.79; 95% CI, 0.61-1.01) or perianal Crohn’s disease diagnosis (aHR, 0.70; 95% CI, 0.38-1.30). Adjustments were made for demographic and clinical variables, for example, age, sex, year of treatment, number of hospital contacts for an indication all in the year prior to index treatment.

In comparison with the proportion of resection patients at 5 years who were on no treatment, immunomodulators or anti-TNFi therapy, there are no data on the 5-year outcomes of those patients who began on anti-TNFi therapy, but patients typically continue unless they become intolerant or response starts to fail, Dr. Agrawal said.

Willem Bemelmen, MD, a colorectal surgeon from the University of Amsterdam who served as a moderator after the presentation said: “These results could lead to a paradigm shift in the management of patients with Crohn’s disease. Prior studies gave us early signals that surgery in Crohn’s disease might benefit the patients, but now with these larger scale data, with many patients, we might finally convince gastroenterologists to send patients in for early surgery.”

Dr. Agrawal, Dr. Bemelmen, and Dr. Colombel declared no relevant conflicts of interest.

This article was updated 3/7/23.

COPENHAGEN – Chronic pain in pediatric inflammatory bowel disease (IBD) is not associated with disease activity but has a significant impact on quality of life, including emotional well-being and social functioning, shows a study on chronic pain in children with IBD.

“A major finding of our small study was the impact of chronic pain on well-being and emotional health which was particularly significant in vulnerable children moving through adolescence towards adulthood,” said Dhamyanthi Thangarajah, MD, a consultant pediatric gastroenterologist at Chelsea and Westminster Hospital, London, in a presentation at the annual congress of the European Crohn’s and Colitis Organisation.

In the study of 41 children between 10 and 17 years old, chronic pain was found in 80% of participants who had established and extensive disease. Most participants had markers for fecal calprotectin, a sensitive marker for inflammation in the gastrointestinal tract, and others had Crohn’s disease and were prescribed biologics.

No relationship was found between chronic pain and IBD activity, but quality of life scores were negatively impacted in children with chronic pain.

“Moving forward, strategies should target screening for chronic pain in children with IBD and provide psychosocial interventions early on,” Dr. Thangarajah said. “We also need to understand more about internalizing pain and explore mood disorders.”

Many children with IBD also present with chronic abdominal pain, which was the impetus for conducting the study. “Essentially, we wondered whether this was a symptom of active disease, or were we missing something? In adult patients, chronic pain is prevalent, but in children we don’t necessarily screen for chronic pain, although it is part of active disease,” she said.

There is considerable patient and parental anxiety around the nature and origins of the chronic pain, Dr. Thangarajah said.

“We need to understand the prevalence and impact of chronic pain in children and adolescents, and as such we wanted to understand and characterize our cohort,” she said.

Dr. Thangarajah said clinicians tend to be very focused on disease activity and that screening for chronic pain is not usually carried out. “When we look at their clinical indices, the patients seem better, but the fact that it affects emotional health, and we don’t screen for it, means we need psychological help for these pediatric patients,” she said. “Patients need to be able to talk about their pain, and we need to understand if these children are having IBD-type symptoms, and this just isn’t asked about. It would be good to extend this study with a psychologist to understand more about this pain.”
 

How the study was conducted

The findings are based on the IMPACT III quality of life questionnaire for IBD. Chronic pain was defined as mild, moderate, or severe according to the van Korff scale.

“Patients had extensive and established disease, as expected in a pediatric cohort, the majority of whom were on immunosuppressant biologic drugs [64%-89%]. Among these patients, analgesic use was low, which is part of the education we give parents, and there was no opiate use in children, which differs from adults with IBD,” Dr. Thangarajah said.

A total of 33/41 (80%) of patients had chronic pain, and of these, abdominal chronic pain was most common in 30/33 (90%), joint pain was present in 2/33 (6%), and headache in 1/33, (3%). The majority 26/33 (79%) were on biologic agents, and analgesia use was low at 15/33 (45%). A total of 42% of children across the spectrum of chronic pain severity were on immunomodulators. Comorbidities were present in 42%-57% of patients with mild, and moderate-severe chronic pain respectively.

IBD disease activity in children with chronic pain was compared with those without chronic pain, as defined by Pediatric Crohn’s Disease Activity Index (PCDAI), Pediatric Ulcerative Colitis Activity Index (PUCAI), C-reactive protein (CRP), and faecal calprotectin. No difference was found.

Dr. Thangarajah highlighted the significantly lower quality of life score in children with chronic pain (69 and 51 in mild, and moderate-severe pain subgroups respectively, compared with 81 in those children without chronic pain, P < .05). Specifically, body image showed no difference between children with and without chronic pain (59-65 points across no pain, mild, moderate and severe chronic pain).

Chronic pain patients also commonly reported sleep disturbance with around 66% of patients with chronic pain, compared with around 11% in those without. Anemia was reported in 30% versus 21% respectively. However, nearly half of children with chronic pain had comorbidities 16/33 (48%), and 5/16 (31%) had diagnoses that may be associated with comorbid pain.
 

Psychosocial support within gastroenterology unavailable

Christine Norton, PhD, professor of nursing at Kings College London, also spoke at the conference on abdominal pain and the well-being of patients with IBD. She said that pain can still be a problem for some patients in remission from IBD.

“In adults we find pain is related to disease activity, however, 40%-50% of patients with IBD remission still report pain. Abdominal pain is dominant but it can be anywhere in the body. This is really poorly addressed in clinical consultations. It’s a ‘don’t ask, don’t tell’ situation where the nurse or doctor would do something if they could, but they just don’t ask the patients,” she said.

If patients volunteer the information that they still have pain during remission, it might get dismissed as irritable bowel syndrome (IBS), Dr. Norton said. “Some patients do fulfill these criteria for IBS, but it still needs to be managed. Here at ECCO, the focus is on getting patients into deep remission and inflammation under tight control, but what do we do with the jangling pain nerves although there’s nothing apparently triggering them, the gut-brain sensitivity – it’s so hard to live with it. They need support,” she said.

Dr. Norton said clinicians need a better way to validate chronic pain. “Sometimes people don’t feel believed, but even if the doctor believes them, they don’t know what to do anyway. There’s very few places with psychological support within the field of gastroenterology. Do we educate the gastroenterologist in this aspect? Do we develop the skills of IBD nurses?”

Dr. Thangarajah and Dr. Norton have no disclosures to declare.

COPENHAGEN – Chronic pain in pediatric inflammatory bowel disease (IBD) is not associated with disease activity but has a significant impact on quality of life, including emotional well-being and social functioning, shows a study on chronic pain in children with IBD.

“A major finding of our small study was the impact of chronic pain on well-being and emotional health which was particularly significant in vulnerable children moving through adolescence towards adulthood,” said Dhamyanthi Thangarajah, MD, a consultant pediatric gastroenterologist at Chelsea and Westminster Hospital, London, in a presentation at the annual congress of the European Crohn’s and Colitis Organisation.

In the study of 41 children between 10 and 17 years old, chronic pain was found in 80% of participants who had established and extensive disease. Most participants had markers for fecal calprotectin, a sensitive marker for inflammation in the gastrointestinal tract, and others had Crohn’s disease and were prescribed biologics.

No relationship was found between chronic pain and IBD activity, but quality of life scores were negatively impacted in children with chronic pain.

“Moving forward, strategies should target screening for chronic pain in children with IBD and provide psychosocial interventions early on,” Dr. Thangarajah said. “We also need to understand more about internalizing pain and explore mood disorders.”

Many children with IBD also present with chronic abdominal pain, which was the impetus for conducting the study. “Essentially, we wondered whether this was a symptom of active disease, or were we missing something? In adult patients, chronic pain is prevalent, but in children we don’t necessarily screen for chronic pain, although it is part of active disease,” she said.

There is considerable patient and parental anxiety around the nature and origins of the chronic pain, Dr. Thangarajah said.

“We need to understand the prevalence and impact of chronic pain in children and adolescents, and as such we wanted to understand and characterize our cohort,” she said.

Dr. Thangarajah said clinicians tend to be very focused on disease activity and that screening for chronic pain is not usually carried out. “When we look at their clinical indices, the patients seem better, but the fact that it affects emotional health, and we don’t screen for it, means we need psychological help for these pediatric patients,” she said. “Patients need to be able to talk about their pain, and we need to understand if these children are having IBD-type symptoms, and this just isn’t asked about. It would be good to extend this study with a psychologist to understand more about this pain.”
 

How the study was conducted

The findings are based on the IMPACT III quality of life questionnaire for IBD. Chronic pain was defined as mild, moderate, or severe according to the van Korff scale.

“Patients had extensive and established disease, as expected in a pediatric cohort, the majority of whom were on immunosuppressant biologic drugs [64%-89%]. Among these patients, analgesic use was low, which is part of the education we give parents, and there was no opiate use in children, which differs from adults with IBD,” Dr. Thangarajah said.

A total of 33/41 (80%) of patients had chronic pain, and of these, abdominal chronic pain was most common in 30/33 (90%), joint pain was present in 2/33 (6%), and headache in 1/33, (3%). The majority 26/33 (79%) were on biologic agents, and analgesia use was low at 15/33 (45%). A total of 42% of children across the spectrum of chronic pain severity were on immunomodulators. Comorbidities were present in 42%-57% of patients with mild, and moderate-severe chronic pain respectively.

IBD disease activity in children with chronic pain was compared with those without chronic pain, as defined by Pediatric Crohn’s Disease Activity Index (PCDAI), Pediatric Ulcerative Colitis Activity Index (PUCAI), C-reactive protein (CRP), and faecal calprotectin. No difference was found.

Dr. Thangarajah highlighted the significantly lower quality of life score in children with chronic pain (69 and 51 in mild, and moderate-severe pain subgroups respectively, compared with 81 in those children without chronic pain, P < .05). Specifically, body image showed no difference between children with and without chronic pain (59-65 points across no pain, mild, moderate and severe chronic pain).

Chronic pain patients also commonly reported sleep disturbance with around 66% of patients with chronic pain, compared with around 11% in those without. Anemia was reported in 30% versus 21% respectively. However, nearly half of children with chronic pain had comorbidities 16/33 (48%), and 5/16 (31%) had diagnoses that may be associated with comorbid pain.
 

Psychosocial support within gastroenterology unavailable

Christine Norton, PhD, professor of nursing at Kings College London, also spoke at the conference on abdominal pain and the well-being of patients with IBD. She said that pain can still be a problem for some patients in remission from IBD.

“In adults we find pain is related to disease activity, however, 40%-50% of patients with IBD remission still report pain. Abdominal pain is dominant but it can be anywhere in the body. This is really poorly addressed in clinical consultations. It’s a ‘don’t ask, don’t tell’ situation where the nurse or doctor would do something if they could, but they just don’t ask the patients,” she said.

If patients volunteer the information that they still have pain during remission, it might get dismissed as irritable bowel syndrome (IBS), Dr. Norton said. “Some patients do fulfill these criteria for IBS, but it still needs to be managed. Here at ECCO, the focus is on getting patients into deep remission and inflammation under tight control, but what do we do with the jangling pain nerves although there’s nothing apparently triggering them, the gut-brain sensitivity – it’s so hard to live with it. They need support,” she said.

Dr. Norton said clinicians need a better way to validate chronic pain. “Sometimes people don’t feel believed, but even if the doctor believes them, they don’t know what to do anyway. There’s very few places with psychological support within the field of gastroenterology. Do we educate the gastroenterologist in this aspect? Do we develop the skills of IBD nurses?”

Dr. Thangarajah and Dr. Norton have no disclosures to declare.

COPENHAGEN – Chronic pain in pediatric inflammatory bowel disease (IBD) is not associated with disease activity but has a significant impact on quality of life, including emotional well-being and social functioning, shows a study on chronic pain in children with IBD.

“A major finding of our small study was the impact of chronic pain on well-being and emotional health which was particularly significant in vulnerable children moving through adolescence towards adulthood,” said Dhamyanthi Thangarajah, MD, a consultant pediatric gastroenterologist at Chelsea and Westminster Hospital, London, in a presentation at the annual congress of the European Crohn’s and Colitis Organisation.

In the study of 41 children between 10 and 17 years old, chronic pain was found in 80% of participants who had established and extensive disease. Most participants had markers for fecal calprotectin, a sensitive marker for inflammation in the gastrointestinal tract, and others had Crohn’s disease and were prescribed biologics.

No relationship was found between chronic pain and IBD activity, but quality of life scores were negatively impacted in children with chronic pain.

“Moving forward, strategies should target screening for chronic pain in children with IBD and provide psychosocial interventions early on,” Dr. Thangarajah said. “We also need to understand more about internalizing pain and explore mood disorders.”

Many children with IBD also present with chronic abdominal pain, which was the impetus for conducting the study. “Essentially, we wondered whether this was a symptom of active disease, or were we missing something? In adult patients, chronic pain is prevalent, but in children we don’t necessarily screen for chronic pain, although it is part of active disease,” she said.

There is considerable patient and parental anxiety around the nature and origins of the chronic pain, Dr. Thangarajah said.

“We need to understand the prevalence and impact of chronic pain in children and adolescents, and as such we wanted to understand and characterize our cohort,” she said.

Dr. Thangarajah said clinicians tend to be very focused on disease activity and that screening for chronic pain is not usually carried out. “When we look at their clinical indices, the patients seem better, but the fact that it affects emotional health, and we don’t screen for it, means we need psychological help for these pediatric patients,” she said. “Patients need to be able to talk about their pain, and we need to understand if these children are having IBD-type symptoms, and this just isn’t asked about. It would be good to extend this study with a psychologist to understand more about this pain.”
 

How the study was conducted

The findings are based on the IMPACT III quality of life questionnaire for IBD. Chronic pain was defined as mild, moderate, or severe according to the van Korff scale.

“Patients had extensive and established disease, as expected in a pediatric cohort, the majority of whom were on immunosuppressant biologic drugs [64%-89%]. Among these patients, analgesic use was low, which is part of the education we give parents, and there was no opiate use in children, which differs from adults with IBD,” Dr. Thangarajah said.

A total of 33/41 (80%) of patients had chronic pain, and of these, abdominal chronic pain was most common in 30/33 (90%), joint pain was present in 2/33 (6%), and headache in 1/33, (3%). The majority 26/33 (79%) were on biologic agents, and analgesia use was low at 15/33 (45%). A total of 42% of children across the spectrum of chronic pain severity were on immunomodulators. Comorbidities were present in 42%-57% of patients with mild, and moderate-severe chronic pain respectively.

IBD disease activity in children with chronic pain was compared with those without chronic pain, as defined by Pediatric Crohn’s Disease Activity Index (PCDAI), Pediatric Ulcerative Colitis Activity Index (PUCAI), C-reactive protein (CRP), and faecal calprotectin. No difference was found.

Dr. Thangarajah highlighted the significantly lower quality of life score in children with chronic pain (69 and 51 in mild, and moderate-severe pain subgroups respectively, compared with 81 in those children without chronic pain, P < .05). Specifically, body image showed no difference between children with and without chronic pain (59-65 points across no pain, mild, moderate and severe chronic pain).

Chronic pain patients also commonly reported sleep disturbance with around 66% of patients with chronic pain, compared with around 11% in those without. Anemia was reported in 30% versus 21% respectively. However, nearly half of children with chronic pain had comorbidities 16/33 (48%), and 5/16 (31%) had diagnoses that may be associated with comorbid pain.
 

Psychosocial support within gastroenterology unavailable

Christine Norton, PhD, professor of nursing at Kings College London, also spoke at the conference on abdominal pain and the well-being of patients with IBD. She said that pain can still be a problem for some patients in remission from IBD.

“In adults we find pain is related to disease activity, however, 40%-50% of patients with IBD remission still report pain. Abdominal pain is dominant but it can be anywhere in the body. This is really poorly addressed in clinical consultations. It’s a ‘don’t ask, don’t tell’ situation where the nurse or doctor would do something if they could, but they just don’t ask the patients,” she said.

If patients volunteer the information that they still have pain during remission, it might get dismissed as irritable bowel syndrome (IBS), Dr. Norton said. “Some patients do fulfill these criteria for IBS, but it still needs to be managed. Here at ECCO, the focus is on getting patients into deep remission and inflammation under tight control, but what do we do with the jangling pain nerves although there’s nothing apparently triggering them, the gut-brain sensitivity – it’s so hard to live with it. They need support,” she said.

Dr. Norton said clinicians need a better way to validate chronic pain. “Sometimes people don’t feel believed, but even if the doctor believes them, they don’t know what to do anyway. There’s very few places with psychological support within the field of gastroenterology. Do we educate the gastroenterologist in this aspect? Do we develop the skills of IBD nurses?”

Dr. Thangarajah and Dr. Norton have no disclosures to declare.

Etiology

Calcareous soils of central and southwest China are home to Primula obconica¹ (also known as German primrose and Libre Magenta).² Primula obconica was introduced to Europe in the 1880s, where it became a popular ornamental and decorative household plant (Figure).³ It also is a frequent resident of greenhouses.

Primula obconica is a member of the family Primulaceae, which comprises semi-evergreen perennials. The genus name Primula is derived from Latin meaning “first”; obconica refers to the conelike shape of the plant’s vivid, cerise-red flowers.

Allergens From P obconica

The allergens primin (2-methoxy-6-pentyl-1,4-benzoquinone) and miconidin (2-methoxy-6-pentyl-1, 4-dihydroxybenzene) have been isolated from P obconica stems, leaves, and flowers. Allergies to P obconica are much more commonly detected in Europe than in the United States because the plant is part of standard allergen screening in dermatology clinics in Europe.⁴ In a British patch test study of 234 patients with hand dermatitis, 34 displayed immediate or delayed sensitization to P obconica allergens.⁵ However, in another study, researchers who surveyed the incidence of P obconica allergic contact dermatitis (CD) in the United Kingdom found a notable decline in the number of primin-positive patch tests from 1995 to 2000, which likely was attributable to a decrease in the number of plant retailers who stocked P obconica and the availability of primin-free varieties from 50% of suppliers.³ Furthermore, a study in the United States of 567 consecutive patch tests that included primin as part of standard screening found only 1 positive reaction, suggesting that routine patch testing for P obconica in the United States would have a low yield unless the patient has a relevant history.⁴

Cutaneous Presentation

Clinical features of P obconica–induced dermatitis include fingertip dermatitis, as well as facial, hand, and forearm dermatitis.⁶ Patients typically present with lichenification and fissuring of the fingertips; fingertip vesicular dermatitis; or linear erythematous streaks, vesicles, and bullae on the forearms, hands, and face. Vesicles and bullae can be hemorrhagic in patients with pompholyxlike lesions.⁷

Some patients have been reported to present with facial angioedema; the clinical diagnosis of CD can be challenging when facial edema is more prominent than eczema.⁶ Furthermore, in a reported case of P obconica CD, the patient’s vesicular hand dermatitis became pustular and spread to the face.⁸

Allergy Testing

Patch testing is performed with synthetic primin to detect allergens of P obconica in patients who are sensitive to them, which can be useful because Primula dermatitis can have variable presentations and cases can be missed if patch testing is not performed.⁹ Diagnostic mimics—herpes simplex, pompholyx, seborrheic dermatitis, and scabies—should be considered before patch testing.⁷

Prevention and Treatment

Preventive Measures—Ideally, once CD occurs in response to P obconica, handling of and other exposure to the plant should be halted; thus, prevention becomes the mainstay of treatment. Alternatively, when exposure is a necessary occupational hazard, nitrile gloves should be worn; allergenicity can be decreased by overwatering or introducing more primin-free varieties.^3,10

Cultivating the plant outdoors during the winter in milder climates can potentially decrease sensitivity because allergen production is lowest during cold months and highest during summer.¹¹ Because P obconica is commonly grown indoors, allergenicity can persist year-round.

Pharmacotherapy—Drawing on experience treating CD caused by other plants, acute and chronic P obconica CD are primarily treated with a topical steroid or, if the face or genitals are affected, with a steroid-sparing agent, such as tacrolimus.¹² A cool compress of water, saline, or Burow solution (aluminum acetate in water) can help decrease acute inflammation, especially in the setting of vesiculation.¹³

Mild CD also can be treated with a barrier cream and lipid-rich moisturizer. Their effectiveness likely is due to increased hydration and aiding impaired skin-barrier repair.¹⁴

Some success in treating chronic CD also has been reported with psoralen plus UVA and UVB light therapy, which function as local immunosuppressants, thus decreasing inflammation.¹⁵

Final Thoughts

Contact dermatitis caused by P obconica is common in Europe but less common in the United States and therefore often is underrecognized. Avoiding contact with the plant should be strongly recommended to allergic persons. Primula obconica allergic CD can be treated with a topical steroid.

Etiology

Calcareous soils of central and southwest China are home to Primula obconica¹ (also known as German primrose and Libre Magenta).² Primula obconica was introduced to Europe in the 1880s, where it became a popular ornamental and decorative household plant (Figure).³ It also is a frequent resident of greenhouses.

Primula obconica is a member of the family Primulaceae, which comprises semi-evergreen perennials. The genus name Primula is derived from Latin meaning “first”; obconica refers to the conelike shape of the plant’s vivid, cerise-red flowers.

Allergens From P obconica

The allergens primin (2-methoxy-6-pentyl-1,4-benzoquinone) and miconidin (2-methoxy-6-pentyl-1, 4-dihydroxybenzene) have been isolated from P obconica stems, leaves, and flowers. Allergies to P obconica are much more commonly detected in Europe than in the United States because the plant is part of standard allergen screening in dermatology clinics in Europe.⁴ In a British patch test study of 234 patients with hand dermatitis, 34 displayed immediate or delayed sensitization to P obconica allergens.⁵ However, in another study, researchers who surveyed the incidence of P obconica allergic contact dermatitis (CD) in the United Kingdom found a notable decline in the number of primin-positive patch tests from 1995 to 2000, which likely was attributable to a decrease in the number of plant retailers who stocked P obconica and the availability of primin-free varieties from 50% of suppliers.³ Furthermore, a study in the United States of 567 consecutive patch tests that included primin as part of standard screening found only 1 positive reaction, suggesting that routine patch testing for P obconica in the United States would have a low yield unless the patient has a relevant history.⁴

Cutaneous Presentation

Clinical features of P obconica–induced dermatitis include fingertip dermatitis, as well as facial, hand, and forearm dermatitis.⁶ Patients typically present with lichenification and fissuring of the fingertips; fingertip vesicular dermatitis; or linear erythematous streaks, vesicles, and bullae on the forearms, hands, and face. Vesicles and bullae can be hemorrhagic in patients with pompholyxlike lesions.⁷

Some patients have been reported to present with facial angioedema; the clinical diagnosis of CD can be challenging when facial edema is more prominent than eczema.⁶ Furthermore, in a reported case of P obconica CD, the patient’s vesicular hand dermatitis became pustular and spread to the face.⁸

Allergy Testing

Patch testing is performed with synthetic primin to detect allergens of P obconica in patients who are sensitive to them, which can be useful because Primula dermatitis can have variable presentations and cases can be missed if patch testing is not performed.⁹ Diagnostic mimics—herpes simplex, pompholyx, seborrheic dermatitis, and scabies—should be considered before patch testing.⁷

Prevention and Treatment

Preventive Measures—Ideally, once CD occurs in response to P obconica, handling of and other exposure to the plant should be halted; thus, prevention becomes the mainstay of treatment. Alternatively, when exposure is a necessary occupational hazard, nitrile gloves should be worn; allergenicity can be decreased by overwatering or introducing more primin-free varieties.^3,10

Cultivating the plant outdoors during the winter in milder climates can potentially decrease sensitivity because allergen production is lowest during cold months and highest during summer.¹¹ Because P obconica is commonly grown indoors, allergenicity can persist year-round.

Pharmacotherapy—Drawing on experience treating CD caused by other plants, acute and chronic P obconica CD are primarily treated with a topical steroid or, if the face or genitals are affected, with a steroid-sparing agent, such as tacrolimus.¹² A cool compress of water, saline, or Burow solution (aluminum acetate in water) can help decrease acute inflammation, especially in the setting of vesiculation.¹³

Mild CD also can be treated with a barrier cream and lipid-rich moisturizer. Their effectiveness likely is due to increased hydration and aiding impaired skin-barrier repair.¹⁴

Some success in treating chronic CD also has been reported with psoralen plus UVA and UVB light therapy, which function as local immunosuppressants, thus decreasing inflammation.¹⁵

Final Thoughts

Contact dermatitis caused by P obconica is common in Europe but less common in the United States and therefore often is underrecognized. Avoiding contact with the plant should be strongly recommended to allergic persons. Primula obconica allergic CD can be treated with a topical steroid.

Etiology

Calcareous soils of central and southwest China are home to Primula obconica¹ (also known as German primrose and Libre Magenta).² Primula obconica was introduced to Europe in the 1880s, where it became a popular ornamental and decorative household plant (Figure).³ It also is a frequent resident of greenhouses.

Primula obconica is a member of the family Primulaceae, which comprises semi-evergreen perennials. The genus name Primula is derived from Latin meaning “first”; obconica refers to the conelike shape of the plant’s vivid, cerise-red flowers.

Allergens From P obconica

The allergens primin (2-methoxy-6-pentyl-1,4-benzoquinone) and miconidin (2-methoxy-6-pentyl-1, 4-dihydroxybenzene) have been isolated from P obconica stems, leaves, and flowers. Allergies to P obconica are much more commonly detected in Europe than in the United States because the plant is part of standard allergen screening in dermatology clinics in Europe.⁴ In a British patch test study of 234 patients with hand dermatitis, 34 displayed immediate or delayed sensitization to P obconica allergens.⁵ However, in another study, researchers who surveyed the incidence of P obconica allergic contact dermatitis (CD) in the United Kingdom found a notable decline in the number of primin-positive patch tests from 1995 to 2000, which likely was attributable to a decrease in the number of plant retailers who stocked P obconica and the availability of primin-free varieties from 50% of suppliers.³ Furthermore, a study in the United States of 567 consecutive patch tests that included primin as part of standard screening found only 1 positive reaction, suggesting that routine patch testing for P obconica in the United States would have a low yield unless the patient has a relevant history.⁴

Cutaneous Presentation

Clinical features of P obconica–induced dermatitis include fingertip dermatitis, as well as facial, hand, and forearm dermatitis.⁶ Patients typically present with lichenification and fissuring of the fingertips; fingertip vesicular dermatitis; or linear erythematous streaks, vesicles, and bullae on the forearms, hands, and face. Vesicles and bullae can be hemorrhagic in patients with pompholyxlike lesions.⁷

Some patients have been reported to present with facial angioedema; the clinical diagnosis of CD can be challenging when facial edema is more prominent than eczema.⁶ Furthermore, in a reported case of P obconica CD, the patient’s vesicular hand dermatitis became pustular and spread to the face.⁸

Allergy Testing

Patch testing is performed with synthetic primin to detect allergens of P obconica in patients who are sensitive to them, which can be useful because Primula dermatitis can have variable presentations and cases can be missed if patch testing is not performed.⁹ Diagnostic mimics—herpes simplex, pompholyx, seborrheic dermatitis, and scabies—should be considered before patch testing.⁷

Prevention and Treatment

Preventive Measures—Ideally, once CD occurs in response to P obconica, handling of and other exposure to the plant should be halted; thus, prevention becomes the mainstay of treatment. Alternatively, when exposure is a necessary occupational hazard, nitrile gloves should be worn; allergenicity can be decreased by overwatering or introducing more primin-free varieties.^3,10

Cultivating the plant outdoors during the winter in milder climates can potentially decrease sensitivity because allergen production is lowest during cold months and highest during summer.¹¹ Because P obconica is commonly grown indoors, allergenicity can persist year-round.

Pharmacotherapy—Drawing on experience treating CD caused by other plants, acute and chronic P obconica CD are primarily treated with a topical steroid or, if the face or genitals are affected, with a steroid-sparing agent, such as tacrolimus.¹² A cool compress of water, saline, or Burow solution (aluminum acetate in water) can help decrease acute inflammation, especially in the setting of vesiculation.¹³

Mild CD also can be treated with a barrier cream and lipid-rich moisturizer. Their effectiveness likely is due to increased hydration and aiding impaired skin-barrier repair.¹⁴

Some success in treating chronic CD also has been reported with psoralen plus UVA and UVB light therapy, which function as local immunosuppressants, thus decreasing inflammation.¹⁵

Final Thoughts

Contact dermatitis caused by P obconica is common in Europe but less common in the United States and therefore often is underrecognized. Avoiding contact with the plant should be strongly recommended to allergic persons. Primula obconica allergic CD can be treated with a topical steroid.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.

“Where are you really from?”

When I tell patients I am from Casper, Wyoming—wh ere I have lived the majority of my life—it’smet with disbelief. The subtext: YOU can’t be from THERE.

I didn’t used to think much of comments like this, but as I have continued to hear them, I find myself feeling tired—tired of explaining myself, tired of being treated differently than my colleagues, and tired of justifying myself. My experiences as a woman of color sadly are not uncommon in medicine.

Sara Martinez-Garcia, BA

Racial bias and racism are steeped in the culture of medicine—from the medical school admissions process^1,2 to the medical training itself.³ More than half of medical students who identify as underrepresented in medicine (UIM) experience microaggressions.⁴ Experiencing racism and sexism in the learning environment can lead to burnout, and microaggressions promote feelings of self-doubt and isolation. Medical students who experience microaggressions are more likely to report feelings of burnout and impaired learning.⁴ These experiences can leave one feeling as if “You do not belong” and “You are unworthy of being in this position.”

Addressing physician burnout already is complex, and addressing burnout caused by inequity, bias, and racism is even more so. In an ideal world, we would eliminate inequity, bias, and racism in medicine through institutional and individual actions. There has been movement to do so. For example, the Accreditation Council for Graduate Medical Education (ACGME), which oversees standards for US resident and fellow training, launched ACGME Equity Matters (https://www.acgme.org/what-we-do/diversity-equity-and-inclusion/ACGME-Equity-Matters/), an initiative aimed to improve diversity, equity, and antiracism practices within graduate medical eduation. However, we know that education alone isn’t enough to fix this monumental problem. Traditional diversity training as we have known it has never been demonstrated to contribute to lasting changes in behavior; it takes much more extensive and complex interventions to meaningfully reduce bias.⁵ In the meantime, we need action. As a medical community, we need to be better about not turning the other way when we see these things happening in our classrooms and in our hospitals. As individuals, we must self-reflect on the role that we each play in contributing to or combatting injustices and seek out bystander training to empower us to speak out against acts of bias such as sexism or racism. Whether it is supporting a fellow colleague or speaking out against an inappropriate interaction, we can all do our part. A very brief list of actions and resources to support our UIM students and colleagues are listed in the Table; those interested in more in-depth resources are encouraged to explore the Association of American Medical Colleges Diversity and Inclusion Toolkit (https://www.aamc.org/professional-development/affinity-groups/cfas/diversity-inclusion-toolkit/resources).

We can’t change the culture of medicine quickly or even in our lifetime. In the meantime, those who are UIM will continue to experience these events that erode our well-being. They will continue to need support. Discussing mental health has long been stigmatized, and physicians are no exception. Many physicians are hesitant to discuss mental health issues out of fear of judgement and perceived or even real repercussions on their careers.¹⁰ However, times are changing and evolving with the current generation of medical students. It’s no secret that medicine is stressful. Most medical schools provide free counseling services, which lowers the barrier for discussions of mental health from the beginning. Making talk about mental health just as normal as talking about other aspects of health takes away the fear that “something is wrong with me” if someone seeks out counseling and mental health services. Faculty should actively check in and maintain open lines of communication, which can be invaluable for UIM students and their training experience. Creating an environment where trainees can be real and honest about the struggles they face in and out of the classroom can make everyone feel like they are not alone.

Addressing burnout in medicine is going to require an all-hands-on-deck approach. At an institutional level, there is a lot of room for improvement—improving systems for physicians so they are able to operate at their highest level (eg, addressing the burdens of prior authorizations and the electronic medical record), setting reasonable expectations around productivity, and creating work structures that respect work-life balance.¹¹ But what can we do for ourselves? We believe that one of the most important ways to protect ourselves from burnout is to remember why. As a medical student, there is enormous pressure—pressure to learn an enormous volume of information, pass examinations, get involved in extracurricular activities, make connections, and seek research opportunities, while also cooking healthy food, grocery shopping, maintaining relationships with loved ones, and generally taking care of oneself. At times it can feel as if our lives outside of medical school are not important enough or valuable enough to make time for, but the pieces of our identity outside of medicine are what shape us into who we are today and are the roots of our purpose in medicine. Sometimes you can feel the most motivated, valued, and supported when you make time to have dinner with friends, call a family member, or simply spend time alone in the outdoors. Who you are and how you got to this point in your life are your identity. Reminding yourself of that can help when experiencing microaggressions or when that voice tries to tell you that you are not worthy. As you progress further in your career, maintaining that relationship with who you are outside of medicine can be your armor against burnout.

“Where are you really from?”

When I tell patients I am from Casper, Wyoming—wh ere I have lived the majority of my life—it’smet with disbelief. The subtext: YOU can’t be from THERE.

I didn’t used to think much of comments like this, but as I have continued to hear them, I find myself feeling tired—tired of explaining myself, tired of being treated differently than my colleagues, and tired of justifying myself. My experiences as a woman of color sadly are not uncommon in medicine.

Sara Martinez-Garcia, BA

Racial bias and racism are steeped in the culture of medicine—from the medical school admissions process^1,2 to the medical training itself.³ More than half of medical students who identify as underrepresented in medicine (UIM) experience microaggressions.⁴ Experiencing racism and sexism in the learning environment can lead to burnout, and microaggressions promote feelings of self-doubt and isolation. Medical students who experience microaggressions are more likely to report feelings of burnout and impaired learning.⁴ These experiences can leave one feeling as if “You do not belong” and “You are unworthy of being in this position.”

Addressing physician burnout already is complex, and addressing burnout caused by inequity, bias, and racism is even more so. In an ideal world, we would eliminate inequity, bias, and racism in medicine through institutional and individual actions. There has been movement to do so. For example, the Accreditation Council for Graduate Medical Education (ACGME), which oversees standards for US resident and fellow training, launched ACGME Equity Matters (https://www.acgme.org/what-we-do/diversity-equity-and-inclusion/ACGME-Equity-Matters/), an initiative aimed to improve diversity, equity, and antiracism practices within graduate medical eduation. However, we know that education alone isn’t enough to fix this monumental problem. Traditional diversity training as we have known it has never been demonstrated to contribute to lasting changes in behavior; it takes much more extensive and complex interventions to meaningfully reduce bias.⁵ In the meantime, we need action. As a medical community, we need to be better about not turning the other way when we see these things happening in our classrooms and in our hospitals. As individuals, we must self-reflect on the role that we each play in contributing to or combatting injustices and seek out bystander training to empower us to speak out against acts of bias such as sexism or racism. Whether it is supporting a fellow colleague or speaking out against an inappropriate interaction, we can all do our part. A very brief list of actions and resources to support our UIM students and colleagues are listed in the Table; those interested in more in-depth resources are encouraged to explore the Association of American Medical Colleges Diversity and Inclusion Toolkit (https://www.aamc.org/professional-development/affinity-groups/cfas/diversity-inclusion-toolkit/resources).

We can’t change the culture of medicine quickly or even in our lifetime. In the meantime, those who are UIM will continue to experience these events that erode our well-being. They will continue to need support. Discussing mental health has long been stigmatized, and physicians are no exception. Many physicians are hesitant to discuss mental health issues out of fear of judgement and perceived or even real repercussions on their careers.¹⁰ However, times are changing and evolving with the current generation of medical students. It’s no secret that medicine is stressful. Most medical schools provide free counseling services, which lowers the barrier for discussions of mental health from the beginning. Making talk about mental health just as normal as talking about other aspects of health takes away the fear that “something is wrong with me” if someone seeks out counseling and mental health services. Faculty should actively check in and maintain open lines of communication, which can be invaluable for UIM students and their training experience. Creating an environment where trainees can be real and honest about the struggles they face in and out of the classroom can make everyone feel like they are not alone.

Addressing burnout in medicine is going to require an all-hands-on-deck approach. At an institutional level, there is a lot of room for improvement—improving systems for physicians so they are able to operate at their highest level (eg, addressing the burdens of prior authorizations and the electronic medical record), setting reasonable expectations around productivity, and creating work structures that respect work-life balance.¹¹ But what can we do for ourselves? We believe that one of the most important ways to protect ourselves from burnout is to remember why. As a medical student, there is enormous pressure—pressure to learn an enormous volume of information, pass examinations, get involved in extracurricular activities, make connections, and seek research opportunities, while also cooking healthy food, grocery shopping, maintaining relationships with loved ones, and generally taking care of oneself. At times it can feel as if our lives outside of medical school are not important enough or valuable enough to make time for, but the pieces of our identity outside of medicine are what shape us into who we are today and are the roots of our purpose in medicine. Sometimes you can feel the most motivated, valued, and supported when you make time to have dinner with friends, call a family member, or simply spend time alone in the outdoors. Who you are and how you got to this point in your life are your identity. Reminding yourself of that can help when experiencing microaggressions or when that voice tries to tell you that you are not worthy. As you progress further in your career, maintaining that relationship with who you are outside of medicine can be your armor against burnout.

“Where are you really from?”

When I tell patients I am from Casper, Wyoming—wh ere I have lived the majority of my life—it’smet with disbelief. The subtext: YOU can’t be from THERE.

I didn’t used to think much of comments like this, but as I have continued to hear them, I find myself feeling tired—tired of explaining myself, tired of being treated differently than my colleagues, and tired of justifying myself. My experiences as a woman of color sadly are not uncommon in medicine.

Sara Martinez-Garcia, BA

Racial bias and racism are steeped in the culture of medicine—from the medical school admissions process^1,2 to the medical training itself.³ More than half of medical students who identify as underrepresented in medicine (UIM) experience microaggressions.⁴ Experiencing racism and sexism in the learning environment can lead to burnout, and microaggressions promote feelings of self-doubt and isolation. Medical students who experience microaggressions are more likely to report feelings of burnout and impaired learning.⁴ These experiences can leave one feeling as if “You do not belong” and “You are unworthy of being in this position.”

Addressing physician burnout already is complex, and addressing burnout caused by inequity, bias, and racism is even more so. In an ideal world, we would eliminate inequity, bias, and racism in medicine through institutional and individual actions. There has been movement to do so. For example, the Accreditation Council for Graduate Medical Education (ACGME), which oversees standards for US resident and fellow training, launched ACGME Equity Matters (https://www.acgme.org/what-we-do/diversity-equity-and-inclusion/ACGME-Equity-Matters/), an initiative aimed to improve diversity, equity, and antiracism practices within graduate medical eduation. However, we know that education alone isn’t enough to fix this monumental problem. Traditional diversity training as we have known it has never been demonstrated to contribute to lasting changes in behavior; it takes much more extensive and complex interventions to meaningfully reduce bias.⁵ In the meantime, we need action. As a medical community, we need to be better about not turning the other way when we see these things happening in our classrooms and in our hospitals. As individuals, we must self-reflect on the role that we each play in contributing to or combatting injustices and seek out bystander training to empower us to speak out against acts of bias such as sexism or racism. Whether it is supporting a fellow colleague or speaking out against an inappropriate interaction, we can all do our part. A very brief list of actions and resources to support our UIM students and colleagues are listed in the Table; those interested in more in-depth resources are encouraged to explore the Association of American Medical Colleges Diversity and Inclusion Toolkit (https://www.aamc.org/professional-development/affinity-groups/cfas/diversity-inclusion-toolkit/resources).

We can’t change the culture of medicine quickly or even in our lifetime. In the meantime, those who are UIM will continue to experience these events that erode our well-being. They will continue to need support. Discussing mental health has long been stigmatized, and physicians are no exception. Many physicians are hesitant to discuss mental health issues out of fear of judgement and perceived or even real repercussions on their careers.¹⁰ However, times are changing and evolving with the current generation of medical students. It’s no secret that medicine is stressful. Most medical schools provide free counseling services, which lowers the barrier for discussions of mental health from the beginning. Making talk about mental health just as normal as talking about other aspects of health takes away the fear that “something is wrong with me” if someone seeks out counseling and mental health services. Faculty should actively check in and maintain open lines of communication, which can be invaluable for UIM students and their training experience. Creating an environment where trainees can be real and honest about the struggles they face in and out of the classroom can make everyone feel like they are not alone.

Addressing burnout in medicine is going to require an all-hands-on-deck approach. At an institutional level, there is a lot of room for improvement—improving systems for physicians so they are able to operate at their highest level (eg, addressing the burdens of prior authorizations and the electronic medical record), setting reasonable expectations around productivity, and creating work structures that respect work-life balance.¹¹ But what can we do for ourselves? We believe that one of the most important ways to protect ourselves from burnout is to remember why. As a medical student, there is enormous pressure—pressure to learn an enormous volume of information, pass examinations, get involved in extracurricular activities, make connections, and seek research opportunities, while also cooking healthy food, grocery shopping, maintaining relationships with loved ones, and generally taking care of oneself. At times it can feel as if our lives outside of medical school are not important enough or valuable enough to make time for, but the pieces of our identity outside of medicine are what shape us into who we are today and are the roots of our purpose in medicine. Sometimes you can feel the most motivated, valued, and supported when you make time to have dinner with friends, call a family member, or simply spend time alone in the outdoors. Who you are and how you got to this point in your life are your identity. Reminding yourself of that can help when experiencing microaggressions or when that voice tries to tell you that you are not worthy. As you progress further in your career, maintaining that relationship with who you are outside of medicine can be your armor against burnout.

Teledermatology is an effective patient care model for the delivery of high-quality dermatologic care.¹ Teledermatology can occur using synchronous, asynchronous, and hybrid models of care. In asynchronous visits (AVs), patients or health professionals submit photographs and information for dermatologists to review and provide treatment recommendations. With synchronous visits (SVs), patients have a visit with a dermatology health professional in real time via live video conferencing software. Hybrid models incorporate asynchronous strategies for patient intake forms and skin photograph submissions as well as synchronous methods for live video consultation in a single visit.¹ However, remarkable inequities in internet access limit telemedicine usage among medically marginalized patient populations, including racialized, elderly, and low socioeconomic status groups.²

Synchronous visits, a relatively newer teledermatology format, allow for communication with dermatology professionals from the convenience of a patient’s selected location. The live interaction of SVs allows dermatology professionals to answer questions, provide treatment recommendations, and build therapeutic relationships with patients. Concerns for dermatologist reimbursement, malpractice/liability, and technological challenges stalled large-scale uptake of teledermatology platforms.³ The COVID-19 pandemic led to a drastic increase in teledermatology usage of approximately 587.2%, largely due to public safety measures and Medicaid reimbursement parity between SV and in-office visits (IVs).^3,4

With the implementation of SVs as a patient care model, we investigated the demographics of patients who utilized SVs, AVs, or IVs, and we propose strategies to promote equity in dermatologic care access.

Methods

This study was approved by the University of Pittsburgh institutional review board (STUDY20110043). We performed a retrospective electronic medical record review of deidentified data from the University of Pittsburgh Medical Center, a tertiary care center in Allegheny County, Pennsylvania, with an established asynchronous teledermatology program. Hybrid SVs were integrated into the University of Pittsburgh Medical Center patient care visit options in March 2020. Patients were instructed to upload photographs of their skin conditions prior to SV appointments. The study included visits occurring between July and December 2020. Visit types included SVs, AVs, and IVs.

We analyzed the initial dermatology visits of 17,130 patients aged 17.5 years and older. Recorded data included diagnosis, age, sex, race, ethnicity, and insurance type for each visit type. Patients without a reported race (990 patients) or ethnicity (1712 patients) were excluded from analysis of race/ethnicity data. Patient zip codes were compared with the zip codes of Allegheny County municipalities as reported by the Allegheny County Elections Division.

Statistical Analysis—Descriptive statistics were calculated; frequency with percentage was used to report categorical variables, and the mean (SD) was used for normally distributed continuous variables. Univariate analysis was performed using the χ² test for categorical variables. One-way analysis of variance was used to compare age among visit types. Statistical significance was defined as P<.05. IBM SPSS Statistics for Windows, Version 24 (IBM Corp) was used for all statistical analyses.

Results

In our study population, 81.2% (13,916) of patients were residents of Allegheny County, where 51.6% of residents are female and 81.4% are older than 18 years according to data from 2020.⁵ The racial and ethnic demographics of Allegheny County were 13.4% African American/Black, 0.2% American Indian/Alaska Native, 4.2% Asian, 2.3% Hispanic/Latino, and 79.6% White. The percentage of residents who identified as Native Hawaiian/Pacific Islander was reported to be greater than 0% but less than 0.5%.⁵

In our analysis, IVs were the most utilized visit type, accounting for 71.5% (12,240) of visits, followed by 15.0% (2577) for SVs and 13.5% (2313) for AVs. The mean age (SD) of IV patients was 51.0 (18.8) years compared with 39.9 (16.9) years for SV patients and 37.5 (14.3) years for AV patients (eTable). The majority of patients for all visits were female: 62.1% (7599) for IVs, 71.4% (1652) for AVs, and 72.8% (1877) for SVs. The largest racial or ethnic group for all visit types included White patients (83.8% [13,524] of all patients), followed by Black (12.4% [2007]), Hispanic/Latino (1.4% [209]), Asian (3.4% [555]), American Indian/Alaska Native (0.2% [35]), and Native Hawaiian/Other Pacific Islander patients (0.1% [19]).

Asian patients, who comprised 4.2% of Allegheny County residents,⁵ accounted for 2.7% (334) of IVs, 4.9% (113) of AVs, and 4.2% (108) of SVs. Black patients, who were reported as 13.4% of the Allegheny County population,⁵ were more likely to utilize SVs (19% [490])compared with AVs (7.5% [174]) and IVs (11% [1343]). Hispanic/Latino patients had a disproportionally lower utilization of dermatologic care in all settings, comprising 1.4% (209) of all patients in our study compared with 2.3% of Allegheny County residents.⁵ White patients, who comprised 79.6% of Allegheny County residents, accounted for 81.1% (9928) of IVs, 67.4% (1737) of SVs, and 80.4% (1859) of AVs. There was no significant difference in the percentage of American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander patients among visit types.

The 3 most common diagnoses for IVs were skin cancer screening, seborrheic keratosis, and melanocytic nevus (Table 1). Skin cancer screening was the most common diagnosis, accounting for 12.2% (8530) of 69,812 IVs. The 3 most common diagnoses for SVs were acne vulgaris, dermatitis, and psoriasis. The 3 most common diagnoses for AVs were acne vulgaris, dermatitis, and perioral dermatitis.

Private insurance was the most common insurance type among all patients (71.4% [12,224])(Table 2). A higher percentage of patients with Medicaid insurance (17.9% [461]) utilized SVs compared with AVs (10.1% [233]) and IVs (11.3% 1385]). Similarly, a higher percentage of patients with no insurance or no insurance listed were seen via SVs (12.5% [322]) compared with AVs (5.1% [117]) and IVs (1.7% [203]). Patients with Medicare insurance used IVs (15.4% [1886]) more than SVs (6.0% [155]) or AVs (2.6% [60]). There was no significant difference among visit type usage for patients with public insurance.

Comment

Teledermatology Benefits—In this retrospective review of medical records of patients who obtained dermatologic care after the implementation of SVs at our institution, we found a proportionally higher use of SVs among Black patients, patients with Medicaid, and patients who are underinsured. Benefits of teledermatology include decreases in patient transportation and associated costs, time away from work or home, and need for childcare.⁶ The SV format provides the additional advantage of direct live interaction and the development of a patient-physician or patient–physician assistant relationship. Although the prerequisite technology, internet, and broadband connectivity preclude use of teledermatology for many vulnerable patients,² its convenience ultimately may reduce inequities in access.

Disparities in Dermatologic Care—Hispanic ethnicity and male sex are among described patient demographics associated with decreased rates of outpatient dermatologic care.⁷ We reported disparities in dermatologic care utilization across all visit types among Hispanic patients and males. Patients identifying as Hispanic/Latino composed only 1.4% (n=209) of our study population compared with 2.3% of Allegheny County residents.⁵ During our study period, most patients seen were female, accounting for 62.1% to 72.8% of visits, compared with 51.6% of Allegheny County residents.⁵ These disparities in dermatologic care use may have implications for increased skin-associated morbidity and provide impetus for dermatologists to increase engagement with these patient groups.

Characteristics of Patients Using Teledermatology—Patients using SVs and AVs were significantly younger (mean age [SD], 39.9 [16.9] years and 37.5 [14.3] years, respectively) compared with those using IVs (51.0 [18.8] years). This finding reflects known digital knowledge barriers among older patients.^8,9 The synchronous communication format of SVs simulates the traditional visit style of IVs, which may be preferable for some patients. Continued patient education and advocacy for broadband access may increase teledermatology use among older patients and patients with limited technology resources.⁸

Teledermatology visits were used most frequently for acne and dermatitis, while IVs were used for skin cancer screenings and examination of concerning lesions. This usage pattern is consistent with a previously described consensus among dermatologists on the conditions most amenable to teledermatology evaluation.³

Medicaid reimbursement parity for SVs is in effect nationally until the end of the COVID-19 public health emergency declaration in the United States.¹⁰ As of February 2023, the public health emergency declaration has been renewed 12 times since January 2020, with the most recent renewal on January 11, 2023.¹¹ As of January 2023, 21 states have enacted legislation providing permanent reimbursement parity for SV services. Six additional states have some payment parity in place, each with its own qualifying criteria, and 23 states have no payment parity.¹² Only 25 Medicaid programs currently provide reimbursement for AV services.¹³

Study Limitations—Our study was limited by lack of data on patients who are multiracial and those who identify as nonbinary and transgender. Because of the low numbers of Hispanic patients associated with each race category and a high number of patients who did not report an ethnicity or race, race and ethnicity data were analyzed separately. For SVs, patients were instructed to upload photographs prior to their visit; however, the percentage of patients who uploaded photographs was not analyzed.

Conclusion

Expansion of teledermatology services, including SVs and AVs, patient outreach and education, advocacy for broadband access, and Medicaid payment parity, may improve dermatologic care access for medically marginalized groups. Teledermatology has the potential to serve as an effective health care option for patients who are racially minoritized, older, and underinsured. To further assess the effectiveness of teledermatology, we plan to analyze the number of SVs and AVs that were referred to IVs. Future studies also will investigate the impact of implementing patient education and patient-reported outcomes of teledermatology visits.

Teledermatology is an effective patient care model for the delivery of high-quality dermatologic care.¹ Teledermatology can occur using synchronous, asynchronous, and hybrid models of care. In asynchronous visits (AVs), patients or health professionals submit photographs and information for dermatologists to review and provide treatment recommendations. With synchronous visits (SVs), patients have a visit with a dermatology health professional in real time via live video conferencing software. Hybrid models incorporate asynchronous strategies for patient intake forms and skin photograph submissions as well as synchronous methods for live video consultation in a single visit.¹ However, remarkable inequities in internet access limit telemedicine usage among medically marginalized patient populations, including racialized, elderly, and low socioeconomic status groups.²

Synchronous visits, a relatively newer teledermatology format, allow for communication with dermatology professionals from the convenience of a patient’s selected location. The live interaction of SVs allows dermatology professionals to answer questions, provide treatment recommendations, and build therapeutic relationships with patients. Concerns for dermatologist reimbursement, malpractice/liability, and technological challenges stalled large-scale uptake of teledermatology platforms.³ The COVID-19 pandemic led to a drastic increase in teledermatology usage of approximately 587.2%, largely due to public safety measures and Medicaid reimbursement parity between SV and in-office visits (IVs).^3,4

With the implementation of SVs as a patient care model, we investigated the demographics of patients who utilized SVs, AVs, or IVs, and we propose strategies to promote equity in dermatologic care access.

Methods

This study was approved by the University of Pittsburgh institutional review board (STUDY20110043). We performed a retrospective electronic medical record review of deidentified data from the University of Pittsburgh Medical Center, a tertiary care center in Allegheny County, Pennsylvania, with an established asynchronous teledermatology program. Hybrid SVs were integrated into the University of Pittsburgh Medical Center patient care visit options in March 2020. Patients were instructed to upload photographs of their skin conditions prior to SV appointments. The study included visits occurring between July and December 2020. Visit types included SVs, AVs, and IVs.

We analyzed the initial dermatology visits of 17,130 patients aged 17.5 years and older. Recorded data included diagnosis, age, sex, race, ethnicity, and insurance type for each visit type. Patients without a reported race (990 patients) or ethnicity (1712 patients) were excluded from analysis of race/ethnicity data. Patient zip codes were compared with the zip codes of Allegheny County municipalities as reported by the Allegheny County Elections Division.

Statistical Analysis—Descriptive statistics were calculated; frequency with percentage was used to report categorical variables, and the mean (SD) was used for normally distributed continuous variables. Univariate analysis was performed using the χ² test for categorical variables. One-way analysis of variance was used to compare age among visit types. Statistical significance was defined as P<.05. IBM SPSS Statistics for Windows, Version 24 (IBM Corp) was used for all statistical analyses.

Results

In our study population, 81.2% (13,916) of patients were residents of Allegheny County, where 51.6% of residents are female and 81.4% are older than 18 years according to data from 2020.⁵ The racial and ethnic demographics of Allegheny County were 13.4% African American/Black, 0.2% American Indian/Alaska Native, 4.2% Asian, 2.3% Hispanic/Latino, and 79.6% White. The percentage of residents who identified as Native Hawaiian/Pacific Islander was reported to be greater than 0% but less than 0.5%.⁵

In our analysis, IVs were the most utilized visit type, accounting for 71.5% (12,240) of visits, followed by 15.0% (2577) for SVs and 13.5% (2313) for AVs. The mean age (SD) of IV patients was 51.0 (18.8) years compared with 39.9 (16.9) years for SV patients and 37.5 (14.3) years for AV patients (eTable). The majority of patients for all visits were female: 62.1% (7599) for IVs, 71.4% (1652) for AVs, and 72.8% (1877) for SVs. The largest racial or ethnic group for all visit types included White patients (83.8% [13,524] of all patients), followed by Black (12.4% [2007]), Hispanic/Latino (1.4% [209]), Asian (3.4% [555]), American Indian/Alaska Native (0.2% [35]), and Native Hawaiian/Other Pacific Islander patients (0.1% [19]).

Asian patients, who comprised 4.2% of Allegheny County residents,⁵ accounted for 2.7% (334) of IVs, 4.9% (113) of AVs, and 4.2% (108) of SVs. Black patients, who were reported as 13.4% of the Allegheny County population,⁵ were more likely to utilize SVs (19% [490])compared with AVs (7.5% [174]) and IVs (11% [1343]). Hispanic/Latino patients had a disproportionally lower utilization of dermatologic care in all settings, comprising 1.4% (209) of all patients in our study compared with 2.3% of Allegheny County residents.⁵ White patients, who comprised 79.6% of Allegheny County residents, accounted for 81.1% (9928) of IVs, 67.4% (1737) of SVs, and 80.4% (1859) of AVs. There was no significant difference in the percentage of American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander patients among visit types.

The 3 most common diagnoses for IVs were skin cancer screening, seborrheic keratosis, and melanocytic nevus (Table 1). Skin cancer screening was the most common diagnosis, accounting for 12.2% (8530) of 69,812 IVs. The 3 most common diagnoses for SVs were acne vulgaris, dermatitis, and psoriasis. The 3 most common diagnoses for AVs were acne vulgaris, dermatitis, and perioral dermatitis.

Private insurance was the most common insurance type among all patients (71.4% [12,224])(Table 2). A higher percentage of patients with Medicaid insurance (17.9% [461]) utilized SVs compared with AVs (10.1% [233]) and IVs (11.3% 1385]). Similarly, a higher percentage of patients with no insurance or no insurance listed were seen via SVs (12.5% [322]) compared with AVs (5.1% [117]) and IVs (1.7% [203]). Patients with Medicare insurance used IVs (15.4% [1886]) more than SVs (6.0% [155]) or AVs (2.6% [60]). There was no significant difference among visit type usage for patients with public insurance.

Comment

Teledermatology Benefits—In this retrospective review of medical records of patients who obtained dermatologic care after the implementation of SVs at our institution, we found a proportionally higher use of SVs among Black patients, patients with Medicaid, and patients who are underinsured. Benefits of teledermatology include decreases in patient transportation and associated costs, time away from work or home, and need for childcare.⁶ The SV format provides the additional advantage of direct live interaction and the development of a patient-physician or patient–physician assistant relationship. Although the prerequisite technology, internet, and broadband connectivity preclude use of teledermatology for many vulnerable patients,² its convenience ultimately may reduce inequities in access.

Disparities in Dermatologic Care—Hispanic ethnicity and male sex are among described patient demographics associated with decreased rates of outpatient dermatologic care.⁷ We reported disparities in dermatologic care utilization across all visit types among Hispanic patients and males. Patients identifying as Hispanic/Latino composed only 1.4% (n=209) of our study population compared with 2.3% of Allegheny County residents.⁵ During our study period, most patients seen were female, accounting for 62.1% to 72.8% of visits, compared with 51.6% of Allegheny County residents.⁵ These disparities in dermatologic care use may have implications for increased skin-associated morbidity and provide impetus for dermatologists to increase engagement with these patient groups.

Characteristics of Patients Using Teledermatology—Patients using SVs and AVs were significantly younger (mean age [SD], 39.9 [16.9] years and 37.5 [14.3] years, respectively) compared with those using IVs (51.0 [18.8] years). This finding reflects known digital knowledge barriers among older patients.^8,9 The synchronous communication format of SVs simulates the traditional visit style of IVs, which may be preferable for some patients. Continued patient education and advocacy for broadband access may increase teledermatology use among older patients and patients with limited technology resources.⁸

Teledermatology visits were used most frequently for acne and dermatitis, while IVs were used for skin cancer screenings and examination of concerning lesions. This usage pattern is consistent with a previously described consensus among dermatologists on the conditions most amenable to teledermatology evaluation.³

Medicaid reimbursement parity for SVs is in effect nationally until the end of the COVID-19 public health emergency declaration in the United States.¹⁰ As of February 2023, the public health emergency declaration has been renewed 12 times since January 2020, with the most recent renewal on January 11, 2023.¹¹ As of January 2023, 21 states have enacted legislation providing permanent reimbursement parity for SV services. Six additional states have some payment parity in place, each with its own qualifying criteria, and 23 states have no payment parity.¹² Only 25 Medicaid programs currently provide reimbursement for AV services.¹³

Study Limitations—Our study was limited by lack of data on patients who are multiracial and those who identify as nonbinary and transgender. Because of the low numbers of Hispanic patients associated with each race category and a high number of patients who did not report an ethnicity or race, race and ethnicity data were analyzed separately. For SVs, patients were instructed to upload photographs prior to their visit; however, the percentage of patients who uploaded photographs was not analyzed.

Conclusion

Expansion of teledermatology services, including SVs and AVs, patient outreach and education, advocacy for broadband access, and Medicaid payment parity, may improve dermatologic care access for medically marginalized groups. Teledermatology has the potential to serve as an effective health care option for patients who are racially minoritized, older, and underinsured. To further assess the effectiveness of teledermatology, we plan to analyze the number of SVs and AVs that were referred to IVs. Future studies also will investigate the impact of implementing patient education and patient-reported outcomes of teledermatology visits.

Teledermatology is an effective patient care model for the delivery of high-quality dermatologic care.¹ Teledermatology can occur using synchronous, asynchronous, and hybrid models of care. In asynchronous visits (AVs), patients or health professionals submit photographs and information for dermatologists to review and provide treatment recommendations. With synchronous visits (SVs), patients have a visit with a dermatology health professional in real time via live video conferencing software. Hybrid models incorporate asynchronous strategies for patient intake forms and skin photograph submissions as well as synchronous methods for live video consultation in a single visit.¹ However, remarkable inequities in internet access limit telemedicine usage among medically marginalized patient populations, including racialized, elderly, and low socioeconomic status groups.²

Synchronous visits, a relatively newer teledermatology format, allow for communication with dermatology professionals from the convenience of a patient’s selected location. The live interaction of SVs allows dermatology professionals to answer questions, provide treatment recommendations, and build therapeutic relationships with patients. Concerns for dermatologist reimbursement, malpractice/liability, and technological challenges stalled large-scale uptake of teledermatology platforms.³ The COVID-19 pandemic led to a drastic increase in teledermatology usage of approximately 587.2%, largely due to public safety measures and Medicaid reimbursement parity between SV and in-office visits (IVs).^3,4

With the implementation of SVs as a patient care model, we investigated the demographics of patients who utilized SVs, AVs, or IVs, and we propose strategies to promote equity in dermatologic care access.

Methods

This study was approved by the University of Pittsburgh institutional review board (STUDY20110043). We performed a retrospective electronic medical record review of deidentified data from the University of Pittsburgh Medical Center, a tertiary care center in Allegheny County, Pennsylvania, with an established asynchronous teledermatology program. Hybrid SVs were integrated into the University of Pittsburgh Medical Center patient care visit options in March 2020. Patients were instructed to upload photographs of their skin conditions prior to SV appointments. The study included visits occurring between July and December 2020. Visit types included SVs, AVs, and IVs.

We analyzed the initial dermatology visits of 17,130 patients aged 17.5 years and older. Recorded data included diagnosis, age, sex, race, ethnicity, and insurance type for each visit type. Patients without a reported race (990 patients) or ethnicity (1712 patients) were excluded from analysis of race/ethnicity data. Patient zip codes were compared with the zip codes of Allegheny County municipalities as reported by the Allegheny County Elections Division.

Statistical Analysis—Descriptive statistics were calculated; frequency with percentage was used to report categorical variables, and the mean (SD) was used for normally distributed continuous variables. Univariate analysis was performed using the χ² test for categorical variables. One-way analysis of variance was used to compare age among visit types. Statistical significance was defined as P<.05. IBM SPSS Statistics for Windows, Version 24 (IBM Corp) was used for all statistical analyses.

Results

In our study population, 81.2% (13,916) of patients were residents of Allegheny County, where 51.6% of residents are female and 81.4% are older than 18 years according to data from 2020.⁵ The racial and ethnic demographics of Allegheny County were 13.4% African American/Black, 0.2% American Indian/Alaska Native, 4.2% Asian, 2.3% Hispanic/Latino, and 79.6% White. The percentage of residents who identified as Native Hawaiian/Pacific Islander was reported to be greater than 0% but less than 0.5%.⁵

In our analysis, IVs were the most utilized visit type, accounting for 71.5% (12,240) of visits, followed by 15.0% (2577) for SVs and 13.5% (2313) for AVs. The mean age (SD) of IV patients was 51.0 (18.8) years compared with 39.9 (16.9) years for SV patients and 37.5 (14.3) years for AV patients (eTable). The majority of patients for all visits were female: 62.1% (7599) for IVs, 71.4% (1652) for AVs, and 72.8% (1877) for SVs. The largest racial or ethnic group for all visit types included White patients (83.8% [13,524] of all patients), followed by Black (12.4% [2007]), Hispanic/Latino (1.4% [209]), Asian (3.4% [555]), American Indian/Alaska Native (0.2% [35]), and Native Hawaiian/Other Pacific Islander patients (0.1% [19]).

Asian patients, who comprised 4.2% of Allegheny County residents,⁵ accounted for 2.7% (334) of IVs, 4.9% (113) of AVs, and 4.2% (108) of SVs. Black patients, who were reported as 13.4% of the Allegheny County population,⁵ were more likely to utilize SVs (19% [490])compared with AVs (7.5% [174]) and IVs (11% [1343]). Hispanic/Latino patients had a disproportionally lower utilization of dermatologic care in all settings, comprising 1.4% (209) of all patients in our study compared with 2.3% of Allegheny County residents.⁵ White patients, who comprised 79.6% of Allegheny County residents, accounted for 81.1% (9928) of IVs, 67.4% (1737) of SVs, and 80.4% (1859) of AVs. There was no significant difference in the percentage of American Indian/Alaska Native and Native Hawaiian/Other Pacific Islander patients among visit types.

The 3 most common diagnoses for IVs were skin cancer screening, seborrheic keratosis, and melanocytic nevus (Table 1). Skin cancer screening was the most common diagnosis, accounting for 12.2% (8530) of 69,812 IVs. The 3 most common diagnoses for SVs were acne vulgaris, dermatitis, and psoriasis. The 3 most common diagnoses for AVs were acne vulgaris, dermatitis, and perioral dermatitis.

Private insurance was the most common insurance type among all patients (71.4% [12,224])(Table 2). A higher percentage of patients with Medicaid insurance (17.9% [461]) utilized SVs compared with AVs (10.1% [233]) and IVs (11.3% 1385]). Similarly, a higher percentage of patients with no insurance or no insurance listed were seen via SVs (12.5% [322]) compared with AVs (5.1% [117]) and IVs (1.7% [203]). Patients with Medicare insurance used IVs (15.4% [1886]) more than SVs (6.0% [155]) or AVs (2.6% [60]). There was no significant difference among visit type usage for patients with public insurance.

Comment

Teledermatology Benefits—In this retrospective review of medical records of patients who obtained dermatologic care after the implementation of SVs at our institution, we found a proportionally higher use of SVs among Black patients, patients with Medicaid, and patients who are underinsured. Benefits of teledermatology include decreases in patient transportation and associated costs, time away from work or home, and need for childcare.⁶ The SV format provides the additional advantage of direct live interaction and the development of a patient-physician or patient–physician assistant relationship. Although the prerequisite technology, internet, and broadband connectivity preclude use of teledermatology for many vulnerable patients,² its convenience ultimately may reduce inequities in access.

Disparities in Dermatologic Care—Hispanic ethnicity and male sex are among described patient demographics associated with decreased rates of outpatient dermatologic care.⁷ We reported disparities in dermatologic care utilization across all visit types among Hispanic patients and males. Patients identifying as Hispanic/Latino composed only 1.4% (n=209) of our study population compared with 2.3% of Allegheny County residents.⁵ During our study period, most patients seen were female, accounting for 62.1% to 72.8% of visits, compared with 51.6% of Allegheny County residents.⁵ These disparities in dermatologic care use may have implications for increased skin-associated morbidity and provide impetus for dermatologists to increase engagement with these patient groups.

Characteristics of Patients Using Teledermatology—Patients using SVs and AVs were significantly younger (mean age [SD], 39.9 [16.9] years and 37.5 [14.3] years, respectively) compared with those using IVs (51.0 [18.8] years). This finding reflects known digital knowledge barriers among older patients.^8,9 The synchronous communication format of SVs simulates the traditional visit style of IVs, which may be preferable for some patients. Continued patient education and advocacy for broadband access may increase teledermatology use among older patients and patients with limited technology resources.⁸

Teledermatology visits were used most frequently for acne and dermatitis, while IVs were used for skin cancer screenings and examination of concerning lesions. This usage pattern is consistent with a previously described consensus among dermatologists on the conditions most amenable to teledermatology evaluation.³

Medicaid reimbursement parity for SVs is in effect nationally until the end of the COVID-19 public health emergency declaration in the United States.¹⁰ As of February 2023, the public health emergency declaration has been renewed 12 times since January 2020, with the most recent renewal on January 11, 2023.¹¹ As of January 2023, 21 states have enacted legislation providing permanent reimbursement parity for SV services. Six additional states have some payment parity in place, each with its own qualifying criteria, and 23 states have no payment parity.¹² Only 25 Medicaid programs currently provide reimbursement for AV services.¹³

Study Limitations—Our study was limited by lack of data on patients who are multiracial and those who identify as nonbinary and transgender. Because of the low numbers of Hispanic patients associated with each race category and a high number of patients who did not report an ethnicity or race, race and ethnicity data were analyzed separately. For SVs, patients were instructed to upload photographs prior to their visit; however, the percentage of patients who uploaded photographs was not analyzed.

Conclusion

Expansion of teledermatology services, including SVs and AVs, patient outreach and education, advocacy for broadband access, and Medicaid payment parity, may improve dermatologic care access for medically marginalized groups. Teledermatology has the potential to serve as an effective health care option for patients who are racially minoritized, older, and underinsured. To further assess the effectiveness of teledermatology, we plan to analyze the number of SVs and AVs that were referred to IVs. Future studies also will investigate the impact of implementing patient education and patient-reported outcomes of teledermatology visits.

Practice Gap

Terbinafine can be used safely and effectively in adult and pediatric patients to treat superficial fungal infections, including onychomycosis.¹ These superficial fungal infections have become increasingly prevalent in children and often require oral therapy²; however, children are frequently unable to swallow a pill.

Until 2016, terbinafine was available as oral granules that could be sprinkled on food, but this formulation has been discontinued.³ In addition, terbinafine tablets have a bitter taste. Therefore, the inability to swallow a pill—typical of young children and other patients with pill dysphagia—is a barrier to prescribing terbinafine.

The Technique

For patients who cannot swallow a pill, a terbinafine tablet can be crushed and mixed with food or a syrup without loss of efficacy. Terbinafine in tablet form has been shown to have relatively unchanged properties after being crushed and mixed in solution, even several weeks after preparation.⁴ Crushing and mixing a terbinafine tablet with food or a syrup therefore is an effective option for patients who cannot swallow a pill but can safely swallow food.

The food or syrup used for this purpose should have a pH of at least 5 because greater acidity reduces absorption of terbinafine. Therefore, avoid mixing it with fruit juices, applesauce, or soda. Given the bitter taste of the terbinafine tablet, mixing it with a sweet food or syrup improves taste and compliance, which makes pudding a particularly good food option for this purpose.

However, because younger patients might not finish an entire serving of pudding or other food into which the tablet has been crushed and mixed, inconsistent dosing might result. Therefore, we recommend mixing the crushed terbinafine tablet with 1 oz (30 mL) of chocolate syrup or corn syrup (Figure). This solution is sweet, easy to prepare and consume, widely available, and affordable (as low as $0.28/oz for corn syrup and as low as $0.10/oz for chocolate syrup, as priced on Amazon).

The tablet can be crushed using a pill crusher ($5–$10 at pharmacies or on Amazon) or by placing it on a piece of paper and crushing it with the back of a metal spoon. For children, the recommended dosing of terbinafine with a 250-mg tablet is based on weight: one-quarter of a tablet for a child weighing 10 to 20 kg; one-half of a tablet for a child weighing 20 to 40 kg; and a full tablet for a child weighing more than 40 kg.⁵ Because terbinafine tablets are not scored, a combined pill splitter–crusher can be used (also available at pharmacies or on Amazon; the price of this device is within the same price range as a pill crusher).

Practical Implication

Use of this method for crushing and mixing the terbinafine tablet allows patients who are unable to swallow a pill to safely and effectively use oral terbinafine.

Practice Gap

Terbinafine can be used safely and effectively in adult and pediatric patients to treat superficial fungal infections, including onychomycosis.¹ These superficial fungal infections have become increasingly prevalent in children and often require oral therapy²; however, children are frequently unable to swallow a pill.

Until 2016, terbinafine was available as oral granules that could be sprinkled on food, but this formulation has been discontinued.³ In addition, terbinafine tablets have a bitter taste. Therefore, the inability to swallow a pill—typical of young children and other patients with pill dysphagia—is a barrier to prescribing terbinafine.

The Technique

For patients who cannot swallow a pill, a terbinafine tablet can be crushed and mixed with food or a syrup without loss of efficacy. Terbinafine in tablet form has been shown to have relatively unchanged properties after being crushed and mixed in solution, even several weeks after preparation.⁴ Crushing and mixing a terbinafine tablet with food or a syrup therefore is an effective option for patients who cannot swallow a pill but can safely swallow food.

The food or syrup used for this purpose should have a pH of at least 5 because greater acidity reduces absorption of terbinafine. Therefore, avoid mixing it with fruit juices, applesauce, or soda. Given the bitter taste of the terbinafine tablet, mixing it with a sweet food or syrup improves taste and compliance, which makes pudding a particularly good food option for this purpose.

However, because younger patients might not finish an entire serving of pudding or other food into which the tablet has been crushed and mixed, inconsistent dosing might result. Therefore, we recommend mixing the crushed terbinafine tablet with 1 oz (30 mL) of chocolate syrup or corn syrup (Figure). This solution is sweet, easy to prepare and consume, widely available, and affordable (as low as $0.28/oz for corn syrup and as low as $0.10/oz for chocolate syrup, as priced on Amazon).

The tablet can be crushed using a pill crusher ($5–$10 at pharmacies or on Amazon) or by placing it on a piece of paper and crushing it with the back of a metal spoon. For children, the recommended dosing of terbinafine with a 250-mg tablet is based on weight: one-quarter of a tablet for a child weighing 10 to 20 kg; one-half of a tablet for a child weighing 20 to 40 kg; and a full tablet for a child weighing more than 40 kg.⁵ Because terbinafine tablets are not scored, a combined pill splitter–crusher can be used (also available at pharmacies or on Amazon; the price of this device is within the same price range as a pill crusher).

Practical Implication

Use of this method for crushing and mixing the terbinafine tablet allows patients who are unable to swallow a pill to safely and effectively use oral terbinafine.

Practice Gap

Terbinafine can be used safely and effectively in adult and pediatric patients to treat superficial fungal infections, including onychomycosis.¹ These superficial fungal infections have become increasingly prevalent in children and often require oral therapy²; however, children are frequently unable to swallow a pill.

Until 2016, terbinafine was available as oral granules that could be sprinkled on food, but this formulation has been discontinued.³ In addition, terbinafine tablets have a bitter taste. Therefore, the inability to swallow a pill—typical of young children and other patients with pill dysphagia—is a barrier to prescribing terbinafine.

The Technique

For patients who cannot swallow a pill, a terbinafine tablet can be crushed and mixed with food or a syrup without loss of efficacy. Terbinafine in tablet form has been shown to have relatively unchanged properties after being crushed and mixed in solution, even several weeks after preparation.⁴ Crushing and mixing a terbinafine tablet with food or a syrup therefore is an effective option for patients who cannot swallow a pill but can safely swallow food.

The food or syrup used for this purpose should have a pH of at least 5 because greater acidity reduces absorption of terbinafine. Therefore, avoid mixing it with fruit juices, applesauce, or soda. Given the bitter taste of the terbinafine tablet, mixing it with a sweet food or syrup improves taste and compliance, which makes pudding a particularly good food option for this purpose.

However, because younger patients might not finish an entire serving of pudding or other food into which the tablet has been crushed and mixed, inconsistent dosing might result. Therefore, we recommend mixing the crushed terbinafine tablet with 1 oz (30 mL) of chocolate syrup or corn syrup (Figure). This solution is sweet, easy to prepare and consume, widely available, and affordable (as low as $0.28/oz for corn syrup and as low as $0.10/oz for chocolate syrup, as priced on Amazon).

The tablet can be crushed using a pill crusher ($5–$10 at pharmacies or on Amazon) or by placing it on a piece of paper and crushing it with the back of a metal spoon. For children, the recommended dosing of terbinafine with a 250-mg tablet is based on weight: one-quarter of a tablet for a child weighing 10 to 20 kg; one-half of a tablet for a child weighing 20 to 40 kg; and a full tablet for a child weighing more than 40 kg.⁵ Because terbinafine tablets are not scored, a combined pill splitter–crusher can be used (also available at pharmacies or on Amazon; the price of this device is within the same price range as a pill crusher).

Practical Implication

Use of this method for crushing and mixing the terbinafine tablet allows patients who are unable to swallow a pill to safely and effectively use oral terbinafine.

A blind comparison between a portable, ultra low-field magnetic resonance imaging (MRI) device and a traditional high-field MRI showed that the portable device performed well in detecting periventricular lesions in pateints with multiple sclerosis (MS), suggesting that it could have potential for use in screening high-risk patients.

Although previous studies had shown that the approach could hold up to high-field MRI, the new study was a blind comparison in which raters did not have access to the high-field images.

In addition to portability, the device has potential advantages over high-field MRI, including low cost and no need for high-field physical shielding. It could be used for point-of-care testing, especially in remote or low-resource areas. It does not produce ionizing radiation, and has been used in intensive care units and pediatric facilities.
 

Advantages and limitations

The device isn’t ready for general use in MS. It performed well in periventricular lesions but less well in other areas. Ongoing research could improve its performance, including multiplanar imaging and image analysis.

“I think it still needs some work, but to me if it’s less expensive it will be particularly better for third-world countries and that sort of place, or possibly for use in the field in the United States or in North America. If something is detected, you can then bring the person in for a better scan, but I don’t know how sensitive it is – how much pathology you might miss. But in countries where there are no MRIs, it’s certainly better than nothing,” said Anne Cross, MD, who comoderated the session at the Americas Committee for Treatment and Research in Multiple Sclerosis, where the study was presented.

She also noted that the device is potentially safer than high-field MRI. “I don’t think it would be something insurance companies or patients would want to pay $1,000 for when they could get a better scan somewhere, but it’ll get better,” said Dr. Cross, who is a professor of neurology and chair of neuroimmunology at Washington University in St. Louis.
 

How reliable are low-field images?

In previous work, in which evaluators compared the two scans side by side, the researchers showed in 36 patients that the device performed well, compared with a 64mT scanner. “When we look at tandem evaluations, we can identify dissemination in space in 80%. When a patient has at least one lesion that is larger than 4 millimeters in its largest diameter, we are able to detect it in the ultralow field MRI with 100% sensitivity. The open question here is, what is the diagnostic utility of these scanners when we don’t have any information about the high-field images?” said Serhat Okar, MD, during his presentation of the study. Dr. Okar is a neurologist and postdoctoral researcher at the National Institutes of Health.

National Institutes of Health

To answer that question, the researchers asked two raters to examine scans from the low-field MRI, but only an independent party evaluator had access to both scans.

The study included 55 MS patients who were seen for either clinical or research purposes. The average age was 41 years, and 43 patients were female. Two neuroradiologists served as scan raters. Rater 1 had 17 years of experience, and rater 2 had 9 years of experience. They each conducted assessments for periventricular, juxtacortical, infratentorial, deep white matter, and deep gray matter lesions, as well as dissemination in space. They marked the scan and filled out an online form with number of observed lesions and whether they observed dissemination in space, with responses checked against a high-field image by an independent neuroradiologist for true positive and false positive findings.

There was significant discordance between raters for observation of dissemination in space, with rater 1 reporting 81% positivity and reader 2, 49%. False positive analyses revealed a difference in their approaches: Rater 1 was more conservative in marking lesions, which led to fewer true positive and fewer false positive findings. Both raters had good performance in the periventricular lesions with similar, low rates of false positives.

Other areas were a different story. Both raters found a greater number of true positive and false positive areas in the juxtacortical, deep white matter, and deep gray matter areas.

The study was funded by Hyperfine. Dr. Okar and Dr. Cross have no relevant financial disclosures.

A blind comparison between a portable, ultra low-field magnetic resonance imaging (MRI) device and a traditional high-field MRI showed that the portable device performed well in detecting periventricular lesions in pateints with multiple sclerosis (MS), suggesting that it could have potential for use in screening high-risk patients.

Although previous studies had shown that the approach could hold up to high-field MRI, the new study was a blind comparison in which raters did not have access to the high-field images.

In addition to portability, the device has potential advantages over high-field MRI, including low cost and no need for high-field physical shielding. It could be used for point-of-care testing, especially in remote or low-resource areas. It does not produce ionizing radiation, and has been used in intensive care units and pediatric facilities.
 

Advantages and limitations

The device isn’t ready for general use in MS. It performed well in periventricular lesions but less well in other areas. Ongoing research could improve its performance, including multiplanar imaging and image analysis.

“I think it still needs some work, but to me if it’s less expensive it will be particularly better for third-world countries and that sort of place, or possibly for use in the field in the United States or in North America. If something is detected, you can then bring the person in for a better scan, but I don’t know how sensitive it is – how much pathology you might miss. But in countries where there are no MRIs, it’s certainly better than nothing,” said Anne Cross, MD, who comoderated the session at the Americas Committee for Treatment and Research in Multiple Sclerosis, where the study was presented.

She also noted that the device is potentially safer than high-field MRI. “I don’t think it would be something insurance companies or patients would want to pay $1,000 for when they could get a better scan somewhere, but it’ll get better,” said Dr. Cross, who is a professor of neurology and chair of neuroimmunology at Washington University in St. Louis.
 

How reliable are low-field images?

In previous work, in which evaluators compared the two scans side by side, the researchers showed in 36 patients that the device performed well, compared with a 64mT scanner. “When we look at tandem evaluations, we can identify dissemination in space in 80%. When a patient has at least one lesion that is larger than 4 millimeters in its largest diameter, we are able to detect it in the ultralow field MRI with 100% sensitivity. The open question here is, what is the diagnostic utility of these scanners when we don’t have any information about the high-field images?” said Serhat Okar, MD, during his presentation of the study. Dr. Okar is a neurologist and postdoctoral researcher at the National Institutes of Health.

National Institutes of Health

To answer that question, the researchers asked two raters to examine scans from the low-field MRI, but only an independent party evaluator had access to both scans.

The study included 55 MS patients who were seen for either clinical or research purposes. The average age was 41 years, and 43 patients were female. Two neuroradiologists served as scan raters. Rater 1 had 17 years of experience, and rater 2 had 9 years of experience. They each conducted assessments for periventricular, juxtacortical, infratentorial, deep white matter, and deep gray matter lesions, as well as dissemination in space. They marked the scan and filled out an online form with number of observed lesions and whether they observed dissemination in space, with responses checked against a high-field image by an independent neuroradiologist for true positive and false positive findings.

There was significant discordance between raters for observation of dissemination in space, with rater 1 reporting 81% positivity and reader 2, 49%. False positive analyses revealed a difference in their approaches: Rater 1 was more conservative in marking lesions, which led to fewer true positive and fewer false positive findings. Both raters had good performance in the periventricular lesions with similar, low rates of false positives.

Other areas were a different story. Both raters found a greater number of true positive and false positive areas in the juxtacortical, deep white matter, and deep gray matter areas.

The study was funded by Hyperfine. Dr. Okar and Dr. Cross have no relevant financial disclosures.

A blind comparison between a portable, ultra low-field magnetic resonance imaging (MRI) device and a traditional high-field MRI showed that the portable device performed well in detecting periventricular lesions in pateints with multiple sclerosis (MS), suggesting that it could have potential for use in screening high-risk patients.

Although previous studies had shown that the approach could hold up to high-field MRI, the new study was a blind comparison in which raters did not have access to the high-field images.

In addition to portability, the device has potential advantages over high-field MRI, including low cost and no need for high-field physical shielding. It could be used for point-of-care testing, especially in remote or low-resource areas. It does not produce ionizing radiation, and has been used in intensive care units and pediatric facilities.
 

Advantages and limitations

The device isn’t ready for general use in MS. It performed well in periventricular lesions but less well in other areas. Ongoing research could improve its performance, including multiplanar imaging and image analysis.

“I think it still needs some work, but to me if it’s less expensive it will be particularly better for third-world countries and that sort of place, or possibly for use in the field in the United States or in North America. If something is detected, you can then bring the person in for a better scan, but I don’t know how sensitive it is – how much pathology you might miss. But in countries where there are no MRIs, it’s certainly better than nothing,” said Anne Cross, MD, who comoderated the session at the Americas Committee for Treatment and Research in Multiple Sclerosis, where the study was presented.

She also noted that the device is potentially safer than high-field MRI. “I don’t think it would be something insurance companies or patients would want to pay $1,000 for when they could get a better scan somewhere, but it’ll get better,” said Dr. Cross, who is a professor of neurology and chair of neuroimmunology at Washington University in St. Louis.
 

How reliable are low-field images?

In previous work, in which evaluators compared the two scans side by side, the researchers showed in 36 patients that the device performed well, compared with a 64mT scanner. “When we look at tandem evaluations, we can identify dissemination in space in 80%. When a patient has at least one lesion that is larger than 4 millimeters in its largest diameter, we are able to detect it in the ultralow field MRI with 100% sensitivity. The open question here is, what is the diagnostic utility of these scanners when we don’t have any information about the high-field images?” said Serhat Okar, MD, during his presentation of the study. Dr. Okar is a neurologist and postdoctoral researcher at the National Institutes of Health.

National Institutes of Health

To answer that question, the researchers asked two raters to examine scans from the low-field MRI, but only an independent party evaluator had access to both scans.

The study included 55 MS patients who were seen for either clinical or research purposes. The average age was 41 years, and 43 patients were female. Two neuroradiologists served as scan raters. Rater 1 had 17 years of experience, and rater 2 had 9 years of experience. They each conducted assessments for periventricular, juxtacortical, infratentorial, deep white matter, and deep gray matter lesions, as well as dissemination in space. They marked the scan and filled out an online form with number of observed lesions and whether they observed dissemination in space, with responses checked against a high-field image by an independent neuroradiologist for true positive and false positive findings.

There was significant discordance between raters for observation of dissemination in space, with rater 1 reporting 81% positivity and reader 2, 49%. False positive analyses revealed a difference in their approaches: Rater 1 was more conservative in marking lesions, which led to fewer true positive and fewer false positive findings. Both raters had good performance in the periventricular lesions with similar, low rates of false positives.

Other areas were a different story. Both raters found a greater number of true positive and false positive areas in the juxtacortical, deep white matter, and deep gray matter areas.

The study was funded by Hyperfine. Dr. Okar and Dr. Cross have no relevant financial disclosures.

Patients with degenerative mitral valve (MV) regurgitation that calls for surgery may, for the most part, safely choose either a standard procedure requiring a midline sternotomy or one performed through a minithoracotomy, suggests a randomized comparison of the two techniques.

Still, the minimally invasive approach showed some advantages in the study. Patients’ quality of recovery was about the same with both procedures at 12 weeks, but those who had the minimally invasive thoracoscopy-guided surgery had shown greater improvement 6 weeks earlier.

Also in the UK Mini Mitral Trial, hospital length of stay (LOS) was significantly shorter for patients who underwent the mini-thoracotomy procedure, and that group spent fewer days in the hospital over the following months.

But neither procedure had an edge in terms of postoperative clinical risk in the study. Rates of clinical events, such as death or hospitalization for heart failure (HHF), were about the same over 1 year.

Patients in this trial had been deemed suitable for either of the two surgeries, which were always performed by surgeons specially chosen by the steering committee for their experience and expertise.

This first randomized head-to-head comparison of the two approaches in such patients should make both patients and clinicians more confident about choosing the minimally invasive surgery for degenerative MV disease, said Enoch Akowuah, MD, Newcastle (England) University, United Kingdom.

Dr. Akowuah presented the UK Mini-Mitral Trial at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

A “main takeaway” for clinical practice from the trial would be that minithoracotomy MV repair “is as safe and effective as conventional sternotomy for degenerative mitral regurgitation,” said discussant Amy E. Simone, PA-C, following Dr. Akowuah’s presentation.

“I think this study is unique in that its focus is on delivering high-quality, cost-efficient care for mitral regurgitation, but also with an emphasis on patients’ goals and wishes,” said Ms. Simone, who directs the Marcus Heart Valve Center of the Piedmont Heart Institute, Atlanta.

Cardiac surgeon Thomas MacGillivray, MD, another discussant, agreed that the data presented from at least this study suggest neither the minithoracotomy nor sternotomy approach is better than the other. But he questioned whether that would hold true if applied to broader clinical practice.

Dr. MacGillivray, of MedStar Washington Hospital Center, Washington, observed that only 330 patients were randomly assigned among a total of 1,167 candidates for candidates for MV repair surgery.

Indeed, he noted, more than 200 declined and about 600 were declared ineligible for the study, “even though it had seemed as if all were appropriate for mitral valve repair. That could be viewed as a significant limitation in terms of scalability in the real world.”

Some of those patients weren’t randomly assigned because they ultimately were not considered appropriate for both procedures, and some expressed a preference for one or the other approach, Dr. Akowuah replied. Those were the most common reasons. Many others did not enter the study, he said, because their mitral regurgitation was functional, not degenerative.

The two randomization groups fared similarly for the primary endpoint reflecting recovery from surgery, so the trial was actually “negative,” Dr. Akowuah said in an interview. However, “I see it as very much a win for minithoracotomy. The outstanding questions for clinicians and patients have been about the clinical efficacy and safety of the technique. And we’ve shown in this trial that minithoracotomy is safe and effective.”

If the minithoracotomy procedure is available, he continued, “and it’s just as clinically effective and safe – and we weren’t sure that was the case until we did this trial – and the repair is almost as durable, then why have a sternotomy?”

The researchers assigned 330 patients with degenerative MV disease who were deemed suitable for either type of surgery to undergo the standard operation via sternotomy or the minithoracotomy procedure at 10 centers in the United Kingdom. The steering committee had hand-selected its 28 experienced surgeons, each of whom performed only one of the two surgeries consistently for the trial’s patients.

The technically more demanding minithoracotomy procedure took longer to perform by a mean of 44 minutes,  it prolonged cross-clamp time by 11 minutes, and it required 30 minutes more cardiopulmonary bypass support, Dr. Akowuah reported.

The two patient groups showed no significant differences in the primary endpoint of physical function and ability to return to usual activity levels at 12 weeks, as assessed by scores on the 36-Item Short Form Survey and wrist-worn accelerometer monitoring. At 6 weeks, however, the mini-thoracotomy patients had shown a significant early but temporary advantage for those recovery measures.

The minithoracotomy group clearly fared better, however, on some secondary endpoints. For example, their median hospital LOS was 5 days, compared with 6 days for the sternotomy group (P = .003), and 33.1% of the mini-thoracotomy patients were discharged within 4 days of the surgery, compared with only 15.3% of patients who had the standard procedure (P < .001).

The minithoracotomy group also had marginally more days alive out of the hospital at both 30 days (23.6 days vs. 22.4 days in the sternotomy group) and 90 days (82.7 days and 80.5 days, respectively) after the surgery (P = .03 for both differences).

Safety outcomes at 12 weeks were similar, with no significant differences in rate of death, strokes, MI, or renal impairment, or in ICU length of stay or need for more than 48 hours of mechanical ventilation, Dr. Akowuah reported.

Safety outcomes at 1 year were also similar. Mortality by then was 2.4% for the minithoracotomy patients and 2.5% for the sternotomy group, nor were there significant differences in HHF rates or need for repeat MV surgical repair.

Dr. Akowuah said the patients will be followed for up to 5 years for the primary outcomes, echocardiographic changes, and clinical events.

The minithoracotomy surgery’s longer operative times and specialized equipment make it more a expensive procedure than the standard surgery, he said. “So we need to work out in a cost-effectiveness analysis whether that is offset by the benefits,” such as shorter hospital stays or perhaps fewer transfusions or readmissions.

The study was funded by the United Kingdom’s National Institute for Health and Care Research. Dr. Akowuah reported no relevant financial relationships with industry.

A version of this article first appeared on Medscape.com.

Patients with degenerative mitral valve (MV) regurgitation that calls for surgery may, for the most part, safely choose either a standard procedure requiring a midline sternotomy or one performed through a minithoracotomy, suggests a randomized comparison of the two techniques.

Still, the minimally invasive approach showed some advantages in the study. Patients’ quality of recovery was about the same with both procedures at 12 weeks, but those who had the minimally invasive thoracoscopy-guided surgery had shown greater improvement 6 weeks earlier.

Also in the UK Mini Mitral Trial, hospital length of stay (LOS) was significantly shorter for patients who underwent the mini-thoracotomy procedure, and that group spent fewer days in the hospital over the following months.

But neither procedure had an edge in terms of postoperative clinical risk in the study. Rates of clinical events, such as death or hospitalization for heart failure (HHF), were about the same over 1 year.

Patients in this trial had been deemed suitable for either of the two surgeries, which were always performed by surgeons specially chosen by the steering committee for their experience and expertise.

This first randomized head-to-head comparison of the two approaches in such patients should make both patients and clinicians more confident about choosing the minimally invasive surgery for degenerative MV disease, said Enoch Akowuah, MD, Newcastle (England) University, United Kingdom.

Dr. Akowuah presented the UK Mini-Mitral Trial at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

A “main takeaway” for clinical practice from the trial would be that minithoracotomy MV repair “is as safe and effective as conventional sternotomy for degenerative mitral regurgitation,” said discussant Amy E. Simone, PA-C, following Dr. Akowuah’s presentation.

“I think this study is unique in that its focus is on delivering high-quality, cost-efficient care for mitral regurgitation, but also with an emphasis on patients’ goals and wishes,” said Ms. Simone, who directs the Marcus Heart Valve Center of the Piedmont Heart Institute, Atlanta.

Cardiac surgeon Thomas MacGillivray, MD, another discussant, agreed that the data presented from at least this study suggest neither the minithoracotomy nor sternotomy approach is better than the other. But he questioned whether that would hold true if applied to broader clinical practice.

Dr. MacGillivray, of MedStar Washington Hospital Center, Washington, observed that only 330 patients were randomly assigned among a total of 1,167 candidates for candidates for MV repair surgery.

Indeed, he noted, more than 200 declined and about 600 were declared ineligible for the study, “even though it had seemed as if all were appropriate for mitral valve repair. That could be viewed as a significant limitation in terms of scalability in the real world.”

Some of those patients weren’t randomly assigned because they ultimately were not considered appropriate for both procedures, and some expressed a preference for one or the other approach, Dr. Akowuah replied. Those were the most common reasons. Many others did not enter the study, he said, because their mitral regurgitation was functional, not degenerative.

The two randomization groups fared similarly for the primary endpoint reflecting recovery from surgery, so the trial was actually “negative,” Dr. Akowuah said in an interview. However, “I see it as very much a win for minithoracotomy. The outstanding questions for clinicians and patients have been about the clinical efficacy and safety of the technique. And we’ve shown in this trial that minithoracotomy is safe and effective.”

If the minithoracotomy procedure is available, he continued, “and it’s just as clinically effective and safe – and we weren’t sure that was the case until we did this trial – and the repair is almost as durable, then why have a sternotomy?”

The researchers assigned 330 patients with degenerative MV disease who were deemed suitable for either type of surgery to undergo the standard operation via sternotomy or the minithoracotomy procedure at 10 centers in the United Kingdom. The steering committee had hand-selected its 28 experienced surgeons, each of whom performed only one of the two surgeries consistently for the trial’s patients.

The technically more demanding minithoracotomy procedure took longer to perform by a mean of 44 minutes,  it prolonged cross-clamp time by 11 minutes, and it required 30 minutes more cardiopulmonary bypass support, Dr. Akowuah reported.

The two patient groups showed no significant differences in the primary endpoint of physical function and ability to return to usual activity levels at 12 weeks, as assessed by scores on the 36-Item Short Form Survey and wrist-worn accelerometer monitoring. At 6 weeks, however, the mini-thoracotomy patients had shown a significant early but temporary advantage for those recovery measures.

The minithoracotomy group clearly fared better, however, on some secondary endpoints. For example, their median hospital LOS was 5 days, compared with 6 days for the sternotomy group (P = .003), and 33.1% of the mini-thoracotomy patients were discharged within 4 days of the surgery, compared with only 15.3% of patients who had the standard procedure (P < .001).

The minithoracotomy group also had marginally more days alive out of the hospital at both 30 days (23.6 days vs. 22.4 days in the sternotomy group) and 90 days (82.7 days and 80.5 days, respectively) after the surgery (P = .03 for both differences).

Safety outcomes at 12 weeks were similar, with no significant differences in rate of death, strokes, MI, or renal impairment, or in ICU length of stay or need for more than 48 hours of mechanical ventilation, Dr. Akowuah reported.

Safety outcomes at 1 year were also similar. Mortality by then was 2.4% for the minithoracotomy patients and 2.5% for the sternotomy group, nor were there significant differences in HHF rates or need for repeat MV surgical repair.

Dr. Akowuah said the patients will be followed for up to 5 years for the primary outcomes, echocardiographic changes, and clinical events.

The minithoracotomy surgery’s longer operative times and specialized equipment make it more a expensive procedure than the standard surgery, he said. “So we need to work out in a cost-effectiveness analysis whether that is offset by the benefits,” such as shorter hospital stays or perhaps fewer transfusions or readmissions.

The study was funded by the United Kingdom’s National Institute for Health and Care Research. Dr. Akowuah reported no relevant financial relationships with industry.

A version of this article first appeared on Medscape.com.

Patients with degenerative mitral valve (MV) regurgitation that calls for surgery may, for the most part, safely choose either a standard procedure requiring a midline sternotomy or one performed through a minithoracotomy, suggests a randomized comparison of the two techniques.

Still, the minimally invasive approach showed some advantages in the study. Patients’ quality of recovery was about the same with both procedures at 12 weeks, but those who had the minimally invasive thoracoscopy-guided surgery had shown greater improvement 6 weeks earlier.

Also in the UK Mini Mitral Trial, hospital length of stay (LOS) was significantly shorter for patients who underwent the mini-thoracotomy procedure, and that group spent fewer days in the hospital over the following months.

But neither procedure had an edge in terms of postoperative clinical risk in the study. Rates of clinical events, such as death or hospitalization for heart failure (HHF), were about the same over 1 year.

Patients in this trial had been deemed suitable for either of the two surgeries, which were always performed by surgeons specially chosen by the steering committee for their experience and expertise.

This first randomized head-to-head comparison of the two approaches in such patients should make both patients and clinicians more confident about choosing the minimally invasive surgery for degenerative MV disease, said Enoch Akowuah, MD, Newcastle (England) University, United Kingdom.

Dr. Akowuah presented the UK Mini-Mitral Trial at the joint scientific sessions of the American College of Cardiology and the World Heart Federation.

A “main takeaway” for clinical practice from the trial would be that minithoracotomy MV repair “is as safe and effective as conventional sternotomy for degenerative mitral regurgitation,” said discussant Amy E. Simone, PA-C, following Dr. Akowuah’s presentation.

“I think this study is unique in that its focus is on delivering high-quality, cost-efficient care for mitral regurgitation, but also with an emphasis on patients’ goals and wishes,” said Ms. Simone, who directs the Marcus Heart Valve Center of the Piedmont Heart Institute, Atlanta.

Cardiac surgeon Thomas MacGillivray, MD, another discussant, agreed that the data presented from at least this study suggest neither the minithoracotomy nor sternotomy approach is better than the other. But he questioned whether that would hold true if applied to broader clinical practice.

Dr. MacGillivray, of MedStar Washington Hospital Center, Washington, observed that only 330 patients were randomly assigned among a total of 1,167 candidates for candidates for MV repair surgery.

Indeed, he noted, more than 200 declined and about 600 were declared ineligible for the study, “even though it had seemed as if all were appropriate for mitral valve repair. That could be viewed as a significant limitation in terms of scalability in the real world.”

Some of those patients weren’t randomly assigned because they ultimately were not considered appropriate for both procedures, and some expressed a preference for one or the other approach, Dr. Akowuah replied. Those were the most common reasons. Many others did not enter the study, he said, because their mitral regurgitation was functional, not degenerative.

The two randomization groups fared similarly for the primary endpoint reflecting recovery from surgery, so the trial was actually “negative,” Dr. Akowuah said in an interview. However, “I see it as very much a win for minithoracotomy. The outstanding questions for clinicians and patients have been about the clinical efficacy and safety of the technique. And we’ve shown in this trial that minithoracotomy is safe and effective.”

If the minithoracotomy procedure is available, he continued, “and it’s just as clinically effective and safe – and we weren’t sure that was the case until we did this trial – and the repair is almost as durable, then why have a sternotomy?”

The researchers assigned 330 patients with degenerative MV disease who were deemed suitable for either type of surgery to undergo the standard operation via sternotomy or the minithoracotomy procedure at 10 centers in the United Kingdom. The steering committee had hand-selected its 28 experienced surgeons, each of whom performed only one of the two surgeries consistently for the trial’s patients.

The technically more demanding minithoracotomy procedure took longer to perform by a mean of 44 minutes,  it prolonged cross-clamp time by 11 minutes, and it required 30 minutes more cardiopulmonary bypass support, Dr. Akowuah reported.

The two patient groups showed no significant differences in the primary endpoint of physical function and ability to return to usual activity levels at 12 weeks, as assessed by scores on the 36-Item Short Form Survey and wrist-worn accelerometer monitoring. At 6 weeks, however, the mini-thoracotomy patients had shown a significant early but temporary advantage for those recovery measures.

The minithoracotomy group clearly fared better, however, on some secondary endpoints. For example, their median hospital LOS was 5 days, compared with 6 days for the sternotomy group (P = .003), and 33.1% of the mini-thoracotomy patients were discharged within 4 days of the surgery, compared with only 15.3% of patients who had the standard procedure (P < .001).

The minithoracotomy group also had marginally more days alive out of the hospital at both 30 days (23.6 days vs. 22.4 days in the sternotomy group) and 90 days (82.7 days and 80.5 days, respectively) after the surgery (P = .03 for both differences).

Safety outcomes at 12 weeks were similar, with no significant differences in rate of death, strokes, MI, or renal impairment, or in ICU length of stay or need for more than 48 hours of mechanical ventilation, Dr. Akowuah reported.

Safety outcomes at 1 year were also similar. Mortality by then was 2.4% for the minithoracotomy patients and 2.5% for the sternotomy group, nor were there significant differences in HHF rates or need for repeat MV surgical repair.

Dr. Akowuah said the patients will be followed for up to 5 years for the primary outcomes, echocardiographic changes, and clinical events.

The minithoracotomy surgery’s longer operative times and specialized equipment make it more a expensive procedure than the standard surgery, he said. “So we need to work out in a cost-effectiveness analysis whether that is offset by the benefits,” such as shorter hospital stays or perhaps fewer transfusions or readmissions.

The study was funded by the United Kingdom’s National Institute for Health and Care Research. Dr. Akowuah reported no relevant financial relationships with industry.

A version of this article first appeared on Medscape.com.

The Diagnosis: Cutaneous Leishmaniasis

A punch biopsy of the skin showed pseudoepitheliomatous hyperplasia of the epidermis with dermal granulomatous and suppurative inflammation; tissue cultures remained sterile. Polymerase chain reaction testing of the skin revealed the presence of Leishmania guyanensis complex. Leishmaniasis is a widespread parasitic disease transmitted via sandflies that often is seen in children and young adults.¹ Although leishmaniasis is endemic to several countries within Southeast Asia, East Africa, and Latin America, an increase in international travel has brought the disease to nonendemic regions. Therefore, it is crucial to obtain a detailed history of travel and exposure to sandflies in patients who have recently returned from endemic regions.

Leishmaniasis may present in 3 forms: cutaneous, mucocutaneous, or visceral. Cutaneous clinical findings vary depending on disease stage, causative species, and host immune activation. Presentation following a sandfly bite typically includes a papule that progresses to an erythematous nodule. Cutaneous leishmaniasis commonly occurs in areas of the body that are easily accessible to sandflies, such as the face, neck, and limbs. Mucocutaneous leishmaniasis presents with nasal or oral involvement several years after the onset of cutaneous leishmaniasis; however, it can coexist with cutaneous involvement. Without treatment, mucocutaneous leishmaniasis may lead to perforation of the nasal septum, destruction of the mouth, and life-threatening airway obstruction.¹ Determining the specific species is important due to the variation in treatment options and prognosis. Because Leishmania organisms are fastidious, obtaining a positive culture often is challenging. Polymerase chain reaction can be utilized for identification, with detection rates of 97%.¹ Systemic treatment is indicated for patients with multiple or large lesions; lesions on the hands, feet, face, or joints; or immunocompromised patients. Antimonial drugs are the first-line treatment for most forms of leishmaniasis, though increasing resistance has led to a decrease in efficacy.¹ Our patient ultimately was treated with 4 weeks of miltefosine 50 mg 3 times daily. She obtained full resolution of the lesions with no further treatment indicated.

Pemphigus vegetans may present with various clinical manifestations that often can lead to a delay in diagnosis. The Hallopeau subtype typically presents as pustular lesions, while the Neumann subtype may present as large vesiculobullous erosive lesions that rupture and form verrucous, crusted, vegetative plaques. The groin, inguinal folds, axillae, thighs, and flexural areas commonly are affected, but reports of nasal, vaginal, and conjunctival involvement also exist.²

Granuloma inguinale is a sexually transmitted ulcerative disease that is caused by infection with Klebsiella granulomatis. It typically is found in tropical and subtropical climates, including Australia, Brazil, India, and South Africa. The initial presentation includes a single papule or multiple papules or nodules in the genital area that progress to a painless ulcer. It can be diagnosed via biopsies or tissue smears, which will demonstrate the presence of inclusion bodies known as Donovan bodies.³

Cutaneous tuberculosis (TB) can have variable clinical presentations and may be acquired exogenously or endogenously. Cutaneous TB can be divided into 2 categories: exogenous TB caused by inoculation and endogenous TB due to direct spread or autoinoculation. Exogenous TB subtypes include tuberculous chancre and TB verrucosa cutis, while endogenous TB includes scrofuloderma, orificial TB, and lupus vulgaris.⁴ Patches and plaques are found in patients with lupus vulgaris and TB verrucosa cutis. Scrofuloderma, tuberculous chancre, and orificial TB can present as ulcerative or erosive lesions. Cutaneous TB infection can be diagnosed through a smear, culture, or polymerase chain reaction.⁴

Deep cutaneous fungal infections most commonly present in immunocompromised individuals, particularly those who are severely neutropenic and are receiving broad-spectrum systemic antimicrobial agents. Deep cutaneous fungal infections initially present as a papule and evolve into a pustule followed by a necrotic ulcer. The lesions typically are accompanied by a fever and/or vital sign abnormalities.⁵

The Diagnosis: Cutaneous Leishmaniasis

A punch biopsy of the skin showed pseudoepitheliomatous hyperplasia of the epidermis with dermal granulomatous and suppurative inflammation; tissue cultures remained sterile. Polymerase chain reaction testing of the skin revealed the presence of Leishmania guyanensis complex. Leishmaniasis is a widespread parasitic disease transmitted via sandflies that often is seen in children and young adults.¹ Although leishmaniasis is endemic to several countries within Southeast Asia, East Africa, and Latin America, an increase in international travel has brought the disease to nonendemic regions. Therefore, it is crucial to obtain a detailed history of travel and exposure to sandflies in patients who have recently returned from endemic regions.

Leishmaniasis may present in 3 forms: cutaneous, mucocutaneous, or visceral. Cutaneous clinical findings vary depending on disease stage, causative species, and host immune activation. Presentation following a sandfly bite typically includes a papule that progresses to an erythematous nodule. Cutaneous leishmaniasis commonly occurs in areas of the body that are easily accessible to sandflies, such as the face, neck, and limbs. Mucocutaneous leishmaniasis presents with nasal or oral involvement several years after the onset of cutaneous leishmaniasis; however, it can coexist with cutaneous involvement. Without treatment, mucocutaneous leishmaniasis may lead to perforation of the nasal septum, destruction of the mouth, and life-threatening airway obstruction.¹ Determining the specific species is important due to the variation in treatment options and prognosis. Because Leishmania organisms are fastidious, obtaining a positive culture often is challenging. Polymerase chain reaction can be utilized for identification, with detection rates of 97%.¹ Systemic treatment is indicated for patients with multiple or large lesions; lesions on the hands, feet, face, or joints; or immunocompromised patients. Antimonial drugs are the first-line treatment for most forms of leishmaniasis, though increasing resistance has led to a decrease in efficacy.¹ Our patient ultimately was treated with 4 weeks of miltefosine 50 mg 3 times daily. She obtained full resolution of the lesions with no further treatment indicated.

Pemphigus vegetans may present with various clinical manifestations that often can lead to a delay in diagnosis. The Hallopeau subtype typically presents as pustular lesions, while the Neumann subtype may present as large vesiculobullous erosive lesions that rupture and form verrucous, crusted, vegetative plaques. The groin, inguinal folds, axillae, thighs, and flexural areas commonly are affected, but reports of nasal, vaginal, and conjunctival involvement also exist.²

Granuloma inguinale is a sexually transmitted ulcerative disease that is caused by infection with Klebsiella granulomatis. It typically is found in tropical and subtropical climates, including Australia, Brazil, India, and South Africa. The initial presentation includes a single papule or multiple papules or nodules in the genital area that progress to a painless ulcer. It can be diagnosed via biopsies or tissue smears, which will demonstrate the presence of inclusion bodies known as Donovan bodies.³

Cutaneous tuberculosis (TB) can have variable clinical presentations and may be acquired exogenously or endogenously. Cutaneous TB can be divided into 2 categories: exogenous TB caused by inoculation and endogenous TB due to direct spread or autoinoculation. Exogenous TB subtypes include tuberculous chancre and TB verrucosa cutis, while endogenous TB includes scrofuloderma, orificial TB, and lupus vulgaris.⁴ Patches and plaques are found in patients with lupus vulgaris and TB verrucosa cutis. Scrofuloderma, tuberculous chancre, and orificial TB can present as ulcerative or erosive lesions. Cutaneous TB infection can be diagnosed through a smear, culture, or polymerase chain reaction.⁴

Deep cutaneous fungal infections most commonly present in immunocompromised individuals, particularly those who are severely neutropenic and are receiving broad-spectrum systemic antimicrobial agents. Deep cutaneous fungal infections initially present as a papule and evolve into a pustule followed by a necrotic ulcer. The lesions typically are accompanied by a fever and/or vital sign abnormalities.⁵

The Diagnosis: Cutaneous Leishmaniasis

A punch biopsy of the skin showed pseudoepitheliomatous hyperplasia of the epidermis with dermal granulomatous and suppurative inflammation; tissue cultures remained sterile. Polymerase chain reaction testing of the skin revealed the presence of Leishmania guyanensis complex. Leishmaniasis is a widespread parasitic disease transmitted via sandflies that often is seen in children and young adults.¹ Although leishmaniasis is endemic to several countries within Southeast Asia, East Africa, and Latin America, an increase in international travel has brought the disease to nonendemic regions. Therefore, it is crucial to obtain a detailed history of travel and exposure to sandflies in patients who have recently returned from endemic regions.

Leishmaniasis may present in 3 forms: cutaneous, mucocutaneous, or visceral. Cutaneous clinical findings vary depending on disease stage, causative species, and host immune activation. Presentation following a sandfly bite typically includes a papule that progresses to an erythematous nodule. Cutaneous leishmaniasis commonly occurs in areas of the body that are easily accessible to sandflies, such as the face, neck, and limbs. Mucocutaneous leishmaniasis presents with nasal or oral involvement several years after the onset of cutaneous leishmaniasis; however, it can coexist with cutaneous involvement. Without treatment, mucocutaneous leishmaniasis may lead to perforation of the nasal septum, destruction of the mouth, and life-threatening airway obstruction.¹ Determining the specific species is important due to the variation in treatment options and prognosis. Because Leishmania organisms are fastidious, obtaining a positive culture often is challenging. Polymerase chain reaction can be utilized for identification, with detection rates of 97%.¹ Systemic treatment is indicated for patients with multiple or large lesions; lesions on the hands, feet, face, or joints; or immunocompromised patients. Antimonial drugs are the first-line treatment for most forms of leishmaniasis, though increasing resistance has led to a decrease in efficacy.¹ Our patient ultimately was treated with 4 weeks of miltefosine 50 mg 3 times daily. She obtained full resolution of the lesions with no further treatment indicated.

Pemphigus vegetans may present with various clinical manifestations that often can lead to a delay in diagnosis. The Hallopeau subtype typically presents as pustular lesions, while the Neumann subtype may present as large vesiculobullous erosive lesions that rupture and form verrucous, crusted, vegetative plaques. The groin, inguinal folds, axillae, thighs, and flexural areas commonly are affected, but reports of nasal, vaginal, and conjunctival involvement also exist.²

Granuloma inguinale is a sexually transmitted ulcerative disease that is caused by infection with Klebsiella granulomatis. It typically is found in tropical and subtropical climates, including Australia, Brazil, India, and South Africa. The initial presentation includes a single papule or multiple papules or nodules in the genital area that progress to a painless ulcer. It can be diagnosed via biopsies or tissue smears, which will demonstrate the presence of inclusion bodies known as Donovan bodies.³

Cutaneous tuberculosis (TB) can have variable clinical presentations and may be acquired exogenously or endogenously. Cutaneous TB can be divided into 2 categories: exogenous TB caused by inoculation and endogenous TB due to direct spread or autoinoculation. Exogenous TB subtypes include tuberculous chancre and TB verrucosa cutis, while endogenous TB includes scrofuloderma, orificial TB, and lupus vulgaris.⁴ Patches and plaques are found in patients with lupus vulgaris and TB verrucosa cutis. Scrofuloderma, tuberculous chancre, and orificial TB can present as ulcerative or erosive lesions. Cutaneous TB infection can be diagnosed through a smear, culture, or polymerase chain reaction.⁴

Deep cutaneous fungal infections most commonly present in immunocompromised individuals, particularly those who are severely neutropenic and are receiving broad-spectrum systemic antimicrobial agents. Deep cutaneous fungal infections initially present as a papule and evolve into a pustule followed by a necrotic ulcer. The lesions typically are accompanied by a fever and/or vital sign abnormalities.⁵